Subarachnoid bleed and hyperventilation

[18G]

But isn't the point this... one way or another a CT scan is gong to be performed. No matter if it's performed at the originating facility or at the destination, someone is going to be ordering a CT scan.

Would a neurosurgeon really open up someones skull without a CT scan?

 

[Veneficus]

But isn't the point this... one way or another a CT scan is gong to be performed. No matter if it's performed at the originating facility or at the destination, someone is going to be ordering a CT scan.

I am not disagreeing with that, I am just disagreeing with the timeing.

Would a neurosurgeon really open up someones skull without a CT scan?

depends on how bad the patient looked and in what circumstances.

 

[Veneficus]

The discussion between you FL Doc turned into something completely off topic from the OP. Seeing how we don't have CTs in the ambulance, I don't have any interest in that discussion but I'm still going to call it like I see it and you and I will have to agree to disagree.

I am curious to hear why somebody who doesn't have a ct would be willing to discount clinical findings and go to a local center that may have to transfer a patient out as opposed to bypassing the local center to go to a more capable one.

Is that not one of the most important things EMS providers can do?

 

[FLdoc2011]

I'll have to reply to the above points when I'm home and have time. But yes, I am a physician and no, I'm not some reincarnate of a previous poster. Only here because I have an interest in some EMS topics and this topics is one I have experience in.

Are you a physician?

I never said "everyone" gets a CT. But in the case of suspected bleed then yes they are getting a scan, even before transfer because, even as I've already pointed out (AND linked to printed guidelines) we need to rule out certain other issues.

And to be clear, I am not talking about blatant obvious trauma or how medicine is practiced in other countries. There are always exceptions and that neurosurgeon giving tx before the scan is an exemption in dire circumstances.

If someone is actively herniating in front of me then they probably aren't stable enough for a scan anyway and there are other immediate issues that need to be addresses such as airway. And in that case they aren't stable enough for transport at that time either.

I'm not really sure how else I can be more clear. It's not about defensive medicine, or legal fear. It IS the test of choice and what is going to be done.

In the example of the preggo with pelvic pain, I get the ultrasound not to drain their wallet but to make sure there's not something life threatening going on. If not then there's no reason to transfer them to an OB facility. I'm actually SAVING healthcare dollars by doing that instead of transferring and spending more time and money on the transfer. And even then another facility is not going to accept my pt if I don't have a reason for them to, they're going to say get the ultrasound and then we'll talk of there's still reason to.


I see your above post and that's a different issue all together.... If you suspect head bleed then just like ischemic stroke you need to transport them to a facility that can receive those pts.... JUST like what we do here with chest pain centers and stroke centers.

I would argue that on clinical findings alone you're not going to be as reliable as you think you might be in differentiating a bleed from something like an ischemic stroke. If at all possible of course you wouldn't transfer to a facility that doesn't have CT, unless the patient was also absolutely crashing and you had to get them the nearest place no matter what. Ex: we don't admit peds but we, fortunately rarely, get critically I'll kids brought in by EMS if we are the absolute closest hospital and the kid is crashing.

 

[Veneficus]

I see your above post and that's a different issue all together.... If you suspect head bleed then just like ischemic stroke you need to transport them to a facility that can receive those pts.... JUST like what we do here with chest pain centers and stroke centers. .

That is the whole point to my argument over all of these pages.

If at all possible of course you wouldn't transfer to a facility that doesn't have CT, unless the patient was also absolutely crashing and you had to get them the nearest place no matter what. Ex: we don't admit peds but we, fortunately rarely, get critically I'll kids brought in by EMS if we are the absolute closest hospital and the kid is crashing.

and in your experience, how much does transporting a crashing patient to the closest facilty actually help?

 

[FLdoc2011]

I am curious to hear why somebody who doesn't have a ct would be willing to discount clinical findings and go to a local center that may have to transfer a patient out as opposed to bypassing the local center to go to a more capable one.

Is that not one of the most important things EMS providers can do?

I think this clears up your stance a little more. You're point is you pick up a pt with suspected bleed, and you have two choices to transport to, Hosp A 15min away with CT but no neuro surg, and Hosp B 30min away with CT AND neurosurg. Is that what you're getting at?

In that instance I would assume EMS protocols vary. Here, outside of trauma, you would go to the nearest stroke center, even if no neurosurg. Clinical exam alone not enough to differentiate ischemic from hemorrhagic.

But if highly suspicious and within protocol I would certainly say reasonable to bypass and go to Hosp B, IF the extra time require for transport wouldn't put you outside window for something like TPA that could've been given at the closer facility

 

[Veneficus]

I think this clears up your stance a little more. You're point is you pick up a pt with suspected bleed, and you have two choices to transport to, Hosp A 15min away with CT but no neuro surg, and Hosp B 30min away with CT AND neurosurg. Is that what you're getting at?

In that instance I would assume EMS protocols vary. Here, outside of trauma, you would go to the nearest stroke center, even if no neurosurg. Clinical exam alone not enough to differentiate ischemic from hemorrhagic.

But if highly suspicious and within protocol I would certainly say reasonable to bypass and go to Hosp B, IF the extra time require for transport wouldn't put you outside window for something like TPA that could've been given at the closer facility

That is exactly what I was trying to say.

I apologize again for mistaking you for somebody else.

 

[FLdoc2011]

and in your experience, how much does transporting a crashing patient to the closest facilty actually help?

If they are truly that bad and crashing then they are already way down on the survivability scale and its already come to heroic measures for the most part, but we can still do things in the ED for that pt that can't be done by EMS, especially if there would be a longer delay in certain interventions from a longer EMS transport.

 

[FLdoc2011]

That is exactly what I was trying to say.

I apologize again for mistaking you for somebody else.

I'm ready for a cigar and beer. :rofl:

 

[systemet]

I wrote an angry response, then decided to tone it down. My apologies to MS Medic who didn't deserve what I posted.

This is a hit the nail on the head moment. Why would someone with MD training spend so much time on an EMS forum telling everyone why they are wrong rather than on a forum with peers where there can be higher level discussions.

Why does it matter? Shouldn't we be happy that two highly educated individuals are discussing the inhospital treatment of a common prehospital presentation.

MS Medic The discussion between you FL Doc turned into something completely off topic from the OP. Seeing how we don't have CTs in the ambulance, I don't have any interest in that discussion but I'm still going to call it like I see it and you and I will have to agree to disagree.

I found it interesting. I don't think our discussion on this site should be limited to discussing only diagnostic techniques that are available prehospitally. Many of us doing interfacility transports, some emergent, in why CT may play a role.

 

[Veneficus]

I'm ready for a cigar and beer. :rofl:

Can we agree on Guiness or do we have to argue again.

 

[FLdoc2011]

Can we agree on Guiness or do we have to argue again.

That'll do just fine.... Ha!

 

[Mex EMT-I]

Hi,

Well i think the subject here (After that very good exchange of system views) is the ETCO2 right? Most of the EMS services around the globe are taking that into account when it is time to treat the patient, and more importantly the TBI and stroke patient.

Does anyone knows of a study relating ICP, ETCO2 and Ventilator parameters (frecuency and volume), or if thats too in the high only ICP and ETCO2?


And by the way, one every 2 seconds is way TOO high. Almost sure (if not contradicted by the study i just asked for) the RT was not doing a good job there.

 

[JakeEMTP]

When you get into critical care transport and ICUs it is a whole different ballgame. They may go by minute volume and will give a higher rate with smaller tidal volumes with each squeeze to protect the lungs and still get the CO2 they want. You might see their vents set at a rate of 30 -40 with the low side for tidal volume setting. Also unless we know what other factors like ph or if the pt was acidotic for some other reason or if they aspirated with lung problems, it is hard to tell what a good rate is for this pt.

Too little information given to form a conclusion if the rate was too fast or even too slow.

 

[EnviroMed]

This has been bugging me since the call a few days ago. We arrived on scene to an elderly female unresponsive following an unwitnessed fall. My parter very quickly said "head bleed" and off we went to the hospital. Within a very short time the ED confirmed a pretty severe subarachnoid hem and the next decision was either medflight to boston or IFT to Providence RI. The family wanted her to go to RI but the problem was that it's hard to get IFT quickly after 11 PM. We happened to still be there doing paperwork and cleaning up and the Dr. asked if we could do the IFT even though we're a 911 truck. We said of course (still have coverage in town) and off we go with a nurse and respiratory therapist.

you did well, under 8 (over 24) herniate, hyperventilate. In cases with increased ICP there runs a risk of a hernia, how do you lower that risk? Hyperventilate. O2 causes blood vessel constriction, means less blow flows of the vessel wall and into the sub arachnoid space, more blood that piles up compresses against the brain and pushes it down. by hyperventilating you are delaying that from happening. In my opinion your call was the right call.

 

[TatuICU]

When you get into critical care transport and ICUs it is a whole different ballgame. They may go by minute volume and will give a higher rate with smaller tidal volumes with each squeeze to protect the lungs and still get the CO2 they want. You might see their vents set at a rate of 30 -40 with the low side for tidal volume setting. Also unless we know what other factors like ph or if the pt was acidotic for some other reason or if they aspirated with lung problems, it is hard to tell what a good rate is for this pt.

Too little information given to form a conclusion if the rate was too fast or even too slow.

Correct. iSTATs would be useful in the field for a long list of reasons.

 

[JakeEMTP]

Correct. iSTATs would be useful in the field for a long list of reasons.

In CCEMT-P class, we learned the ph and some acidosis is usually a later change when the body is decompensating which is why they stress that the guidelines in BCLS and ACLS are generally more for an acute event which is where bagging at only a rate of 8 comes from. I think ETCO2 would be just as good in the field for a new patient. I don't see any advantage of an iSTAT for this especially if you don't know some of the other labs for the type of acidosis or don't carry what you need to treat it. When a pt is on all of the pressors and hypothermia for any length of time, you will see changes but without a bigger picture from lots of labs you can't just treat a ph. Our CCT truck doesn't carry much more than what we do on ALS so unless the hospital initiates it we can't do much. Most of our patients have a base line ABG so the Rt will tell us how to set the vent which is usually are rate of 20 or more and sometimes less than 500 for tidal volume.

 

[TatuICU]

In CCEMT-P class, we learned the ph and some acidosis is usually a later change when the body is decompensating which is why they stress that the guidelines in BCLS and ACLS are generally more for an acute event which is where bagging at only a rate of 8 comes from. I think ETCO2 would be just as good in the field for a new patient. I don't see any advantage of an iSTAT for this especially if you don't know some of the other labs for the type of acidosis or don't carry what you need to treat it. When a pt is on all of the pressors and hypothermia for any length of time, you will see changes but without a bigger picture from lots of labs you can't just treat a ph. Our CCT truck doesn't carry much more than what we do on ALS so unless the hospital initiates it we can't do much. Most of our patients have a base line ABG so the Rt will tell us how to set the vent which is usually are rate of 20 or more and sometimes less than 500 for tidal volume.

I don't mean to call into question the merits of a "CCEMT-P" class, but with all due respect, you will generally see changes in labs, particularly on your ABGs, before you see severe symptoms arise which is why when a pt finally hits the toilet your labs are so whacked out as opposed to just a tad off kilter.

But in all fairness I wasn't offering commentary on this particular scenario, but rather on the sentiment of your previous post regarding the fact that there is "too little info given to form a conclusion." I don't know where you work EMS at, but I worked at a service where we were 45-60 minutes away from even a level IV center, so iSTATs would be very useful for us. I'm also unsure of what you mean by "type" of acidosis. With labs including pH, pO2, CO2, HCO3, and Base excess/deficit, you should be able to pin it down and iSTATS offer all of those labs and more including K+, HCT, Na+.....

And MOST of your patients should have a vT<500.

 

[JakeEMTP]

And MOST of your patients should have a vT<500.

Not really if it is an EMS vent. Alot of protocols are written with a middle of the road tidal volume of 500. EMS vents don't have a way to compensate for their circuits like the ICU vents. The reps should tell you it will vary anywhere from 50 - 100 of volume lost in the circuit. Those single flimsy flex tubes on the ATV are :censored::censored::censored::censored: and the patient probably doesnt get half the volume.

They also taught use ABGs don't give much of the story. We also can't do arterial sticks per the state even on CCT. Only RNs can. You don't just throw bicarb at everyone either. It was discussed that low bicarbs on an ABG doesn't always mean you should give it. If you don't carry blood or potassium, what good do a bunch of labs do. Even that is just a snapshot as ER docs will tell you when they use the istat.

Flight teams and teams like Pedi or neonatal use the istat but they have everything in their bags that they might have in an ICU and their transports are long.

 

[usalsfyre]

Not really if it is an EMS vent. Alot of protocols are written with a middle of the road tidal volume of 500. EMS vents don't have a way to compensate for their circuits like the ICU vents. The reps should tell you it will vary anywhere from 50 - 100 of volume lost in the circuit. Those single flimsy flex tubes on the ATV are :censored::censored::censored::censored: and the patient probably doesnt get half the volume.

They also taught use ABGs don't give much of the story. We also can't do arterial sticks per the state even on CCT. Only RNs can. You don't just throw bicarb at everyone either. It was discussed that low bicarbs on an ABG doesn't always mean you should give it. If you don't carry blood or potassium, what good do a bunch of labs do. Even that is just a snapshot as ER docs will tell you when they use the istat.

Flight teams and teams like Pedi or neonatal use the istat but they have everything in their bags that they might have in an ICU and their transports are long.

An iStat would be extremely useful for formulating things like ventilation stratagies, treating electrolyte derangement, ect. That said, I can't get normal crews to control the effing glucometer....

Whoever taught you ABGs don't tell you a lot doesn't know how to interpret ABGs. ETCO2 is kinda useful by itself. But it doesn't tell you PaCO2 without knowing the gradient. Your ETCO2 may be 35 with a PaCO2 of 80, you won't know till you have an ABG in hand.