How would you handle the care for these Pts

[Sasha]

I didn't jump on you, there was no hostility in my first post, it was a simple informative post.

 

[MrBrown]

Without getting personal here, the treatment modalities you discuss are horrendously outdated and have long been proven ineffective or shown to increase M&M

IV fluids should be restricted in the context of hypovolaemic shock from uncontrolled bleeding (e.g. an RTA patient with lacerated liver who is bleeding internally) prior to operative control of the bleeding. Our blood pressure target here is ... mm, I think 80mmHg. Somebody else can explain the CPP/MAP thing better than I can.

PASG (MAST) pants autotransfuse about what, maybe a couple hundred CC of blood? We threw them out a decade ago in the face of absolutely no evidence they work and evidence they increase mortality.

There is nothing magic about oxygen, most patients only require 2-3 litres on a nasal cannula. Patients often recieve oxygen that is not clinically indicated nor beneficial and/or in concentrations above what is required. If this patient where acutely hypoxaemic then yes, some oxygen is definately indicated ... I would probably go with 8-10 litres. We rarely (read: never) go above 10lpm here.

With the hospital being 30 minutes away it's still going to be faster to go by land ambulance than a helicopter; HEMS will take 5-10 minutes to depart, say 5-7 minutes flying time each way and say 8-10 minutes to do handover, load and prepare for departure. That's 23 minutes at the least, faster to go by road.

 

[reaper]

This is why I do not like scenarios from a badly written text book!

You can't expect people to answer full questions on this scenario, as there is not a full assessment or vitals given.

The pt is diaphoretic? Is it 100 degrees out or is it from shock?

RR of 30? Is this from shock or because a 20 yo was just in an accident?

Rapid Thready pulse? What is the Pt's normal pulse rate and quality?

We would need a full set of vitals. Most specifically a BP. Whether I start a lock or a line, does not matter. I need an assessment and vitals, before any fluids are given. A lock is fine to start. I can hook a line at any time, as needed. Scenarios are great to do on here, but you have to have all the info for people when they ask. That is how people learn to make the right decisions.

 

[1badassEMT-I]

This is why I do not like scenarios from a badly written text book!

You can't expect people to answer full questions on this scenario, as there is not a full assessment or vitals given.

The pt is diaphoretic? Is it 100 degrees out or is it from shock?

RR of 30? Is this from shock or because a 20 yo was just in an accident?

Rapid Thready pulse? What is the Pt's normal pulse rate and quality?

We would need a full set of vitals. Most specifically a BP. Whether I start a lock or a line, does not matter. I need an assessment and vitals, before any fluids are given. A lock is fine to start. I can hook a line at any time, as needed. Scenarios are great to do on here, but you have to have all the info for people when they ask. That is how people learn to make the right decisions.

You are right! But there again this text book is being used to this day.... I used this for a reason because I wanted to see if anybody would pick this up.... and you did Reaper OUTDATED! However still being taught.

 

[1badassEMT-I]

Without getting personal here, the treatment modalities you discuss are horrendously outdated and have long been proven ineffective or shown to increase M&M

IV fluids should be restricted in the context of hypovolaemic shock from uncontrolled bleeding (e.g. an RTA patient with lacerated liver who is bleeding internally) prior to operative control of the bleeding. Our blood pressure target here is ... mm, I think 80mmHg. Somebody else can explain the CPP/MAP thing better than I can.

PASG (MAST) pants autotransfuse about what, maybe a couple hundred CC of blood? We threw them out a decade ago in the face of absolutely no evidence they work and evidence they increase mortality.

There is nothing magic about oxygen, most patients only require 2-3 litres on a nasal cannula. Patients often recieve oxygen that is not clinically indicated nor beneficial and/or in concentrations above what is required. If this patient where acutely hypoxaemic then yes, some oxygen is definately indicated ... I would probably go with 8-10 litres. We rarely (read: never) go above 10lpm here.

With the hospital being 30 minutes away it's still going to be faster to go by land ambulance than a helicopter; HEMS will take 5-10 minutes to depart, say 5-7 minutes flying time each way and say 8-10 minutes to do handover, load and prepare for departure. That's 23 minutes at the least, faster to go by road.

WOW never over 10lpm that interesting! PASG is never used here either just came from the book that is still being used here is all. However I still have them on my truck.

 

[1badassEMT-I]

This is why I do not like scenarios from a badly written text book!

You can't expect people to answer full questions on this scenario, as there is not a full assessment or vitals given.

The pt is diaphoretic? Is it 100 degrees out or is it from shock?

RR of 30? Is this from shock or because a 20 yo was just in an accident?

Rapid Thready pulse? What is the Pt's normal pulse rate and quality?

We would need a full set of vitals. Most specifically a BP. Whether I start a lock or a line, does not matter. I need an assessment and vitals, before any fluids are given. A lock is fine to start. I can hook a line at any time, as needed. Scenarios are great to do on here, but you have to have all the info for people when they ask. That is how people learn to make the right decisions.

Nobody ask so we didnt play long!

 

[Veneficus]

PASG (MAST) pants autotransfuse about what, maybe a couple hundred CC of blood?

They autotransfuse nothing of consequence.

They can be used to pneumatically cross clamp an abd aorta.

 

[MrBrown]

They autotransfuse nothing of consequence.

They can be used to pneumatically cross clamp an abd aorta.

Aw but its funererer if you do it right there at the roadside!

 

[reaper]

That is a main reason i do not like PHTLS. But, you have to also realize that the instructor books will have more to the scenarios in them. They want the Pt's to ask for that info and then they supply it.

Problem with a lot of text books are they are outdated, even when new. It is up to us to learn more and keep up to date on medicine. EMT books still preach 15lpm by NRB. Anyone with an education knows that is not always needed. These alphabet courses are there just to pick up a little info. They are not the last word or definite treatment for all Pt's.

 

[Sasha]

Anyone with an education knows that is not always needed.

Correction, almost NEVER needed

 

[Veneficus]

Aw but its funererer if you do it right there at the roadside!

Roadside open laparotomy?

I am going to adopt Brown.

 

[Sasha]

Roadside open laparotomy?

I am going to adopt Brown.

Sounds dirty, but what's a little sepsis gonna hurt?

 

[lightsandsirens5]

Sounds dirty, but what's a little sepsis gonna hurt?

Ha ha ha! Great Sasha!

 

[1badassEMT-I]

That is a main reason i do not like PHTLS. But, you have to also realize that the instructor books will have more to the scenarios in them. They want the Pt's to ask for that info and then they supply it.

Problem with a lot of text books are they are outdated, even when new. It is up to us to learn more and keep up to date on medicine. EMT books still preach 15lpm by NRB. Anyone with an education knows that is not always needed. These alphabet courses are there just to pick up a little info. They are not the last word or definite treatment for all Pt's.

You are correct!

 

[1badassEMT-I]

Correction, almost NEVER needed

You are correct also!

 

[1badassEMT-I]

We need to get the OUTDATED books out. Reaper with what you said about books being outdated when they come out so true. How can we bridge that. Because it is still being taught.

 

[Akulahawk]

Late to this one, but...

You have arrived at the scene of a MVC involving a car and an SUV. You recognize a side impact on the drivers side of the car with about 12 inches of intrusion into the passenger compartment and very little damage to the SUV. All other passengers have left the vichiles without injury except the driver of the car, a 20y/o male slumped over the steering wheel with obvious contact of the steering wheel to his anterior chest.

The pt. is awake, anxious, diaphoretic, and breathing rapidly (rr30). He has a weak, thready, rapid radial pulse. There is tenderness and bursing over the left upper quadrant of his ABD.


What injuries do you expect in this Pt.?

How would you manage this Pt.?

You are 30 minutes away from the nearest trauma center. How does this alter your plan of action?

PLEASE ANSWER ALL THE QUESTIONS::::: And have fun with your answers!

Injuries? Well, from the steering wheel marks, I would suspect that he may have sternal/rib fractures, punctured lungs, contused or punctured heart, or (since he's still alive) even an aortic tear that hasn't completely ruptured... the LUQ abdominal pain could mean that any of the internal organs (stomach, spleen, kidney, lots of intestine) could also be damaged in some manner. Since the guy managed to whack the steering wheel so hard, he might have TBI or cervical spine issues... Oh the list is long, and none of which I can definitively treat in the field.

Treatment? Darned near "textbook". Keep him "dry" unless he needs fluid to maintain a SBP of 100.

If I'm 30 minutes from a trauma center, it makes no difference in what I do. An hour? Perhaps. Helicopters are usually a specifically requested resource, and would almost definitely be one within a 30 minute drive time. Unless the helicopter is already on scene, I'm driving the patient in.

 

[Dominion]

Well dont be so quick to JUDGE me. That senario was perfectly written. However you just jump on my question that I was reprimanding a poster over. THAT IS WRONG OF YOU! admit it! When in fact it was a legit question I asked the poster.

It's been said several times but I'll repeat it again. Permissive Hypotension, which I was also taught in my most recent PHTLS course. I dont remember if it was in the book or not but I distinctly remember the instructor telling us to focus on keeping the BP > 85-90 systolic with small boluses IE 250cc - 500cc at the max. A single large bore 16-18 or two 18g IV's are sufficient to achieve this goal.

You gave me no information in the scenario to indicate WHAT the BP or MAP of this patient was so I had no idea what the perfusion status could be in that arena, in my first post I mentioned something about I had no further information to base an appropriate answer on. My bad I didn't directly ask you "What are the other vital signs", then again the scenario asked what I would look for, what my treatment plan was, and how would I manage an extended transport time.

As far as PASG in PHTLS it may be in the book but any educator with a brain is going to make sure the class knows that PASG is not used anymore at all.

 

[1badassEMT-I]

It's been said several times but I'll repeat it again. Permissive Hypotension, which I was also taught in my most recent PHTLS course. I dont remember if it was in the book or not but I distinctly remember the instructor telling us to focus on keeping the BP > 85-90 systolic with small boluses IE 250cc - 500cc at the max. A single large bore 16-18 or two 18g IV's are sufficient to achieve this goal.

You gave me no information in the scenario to indicate WHAT the BP or MAP of this patient was so I had no idea what the perfusion status could be in that arena, in my first post I mentioned something about I had no further information to base an appropriate answer on. My bad I didn't directly ask you "What are the other vital signs", then again the scenario asked what I would look for, what my treatment plan was, and how would I manage an extended transport time.

As far as PASG in PHTLS it may be in the book but any educator with a brain is going to make sure the class knows that PASG is not used anymore at all.

It was directly as it was in the book......we all know PASG are not used anymore last time I used them were late early 90s.... Not saying you are wrong about anything else I did this to see if anybody would notice the outdated PHTLS book that is still being used daily.

 

[jjesusfreak01]

It's not completely awful if the textbooks are slightly outdated, so long as they stay away from medical statements that are fundamentally wrong. Information about MAST systems is tempered by the fact that many systems don't carry them anymore. Also, protocols should serve to keep everyone on track.

That said, my class is using an older version (8th ed) of the Brady textbook, and it is obvious that a good amount of the information is either outdated or plain inapplicable. Almost everything that they teach us about PCRs is inapplicable to our county's system. Also, stuff like use of the PASGs is talked about like it's still in use.