Scenario

[Thursday]

Well, seeing as how members are putting up more medical info as of late, I though maybe a little scenario would be in order.

You are called to a person that appears to have a small puncture wound to his left pectoral muscle. There is very little blood comming from the wound site. He states that an explosion went off roughly 100 meters from his location and that he things that a peice of shrapnel may have caught him.

He is complaining of mild difficulty breathing and some chest pain. He is starting to get a little confused. You decide to take his vitals:
HR: 126, strong and regular
RR: 24, mildly labored
BP: 94/86 Left arm 92/86 Right arm

The patient is in the tripod position, trying to get as much air into his lungs as he can. You listed to both lungs, in all fields and hear good air movement in all fields with no irregular sounds. You do note the pt does have JVD starting to appear bilaterally. You re-assess the lung sounds still ok in all fields. You listen to the heart sounds. They sounds muffeled and distant.

The patient is now taking on a bit of a pale complexion and is starting to get a little more confused and drousy.

What is your treatment for this patient and ultimatly, what does this patient need in terms of hospital care? Also, from a civillian ems standpoint, eventhough we dont make a diagnosis in the field, what do you think that this patient might be suffering from?

[Thursday]

But, if you arrive on scene, evaluate your patient, assess signs and listen to symptoms, make a differential decision about the problem and then treat that problem to a successful outcome...you HAVE MADE A DIAGNOSIS.

Doc, I totally agree with you, and even though I did put that in there, it is not how I feel. There are a lot of people that work in-hospital that think that paramedics are still just knuckle dragging ambulance drivers. I was taught to be extremely aggressive and to make a diagnosis. I do and will continue to make a diagnosis, and when I call in my radio report to my resource hospital, I will infact state that we have a patient with <insert: acute MI; thrombotic stroke; pulmonary embolism; etc>

The way that I was trained and the people that trained me taught me that you have to make a diagnosis in order to treat your patient. If we didn't, how would be treat anything? I am in total agreeance with you. But when in hospital personalities come down on prehospital ems for saying that we have an acute MI and not just a patient with chest pain and ekg abnormalaties, I tend to chose my wording with more caution.


Anyways, I'm sure that you already know the answer to my scenario, and I'm sure that you could probably provide others as well (which would be greatly appreciated).

[EvilCouch]

Cardiac tamponade? If so, there's shit I can do, except get his ass to a surgeon fast.

[91W]

Cardiac Tamponade, ABC's, IV, Moniter, Fly to Trauma Center. But while waiting for the bird the Pt goes into PEA and then begines to ART. So once again the Trauma Gods take a big shit and leave it for you to clean up.

On a side note there was a service recently here in Northern Indiana that was doing a Pericardial Centetesis field trial. Scary shit if you ask me.

[ateup25]

This pt is suffering from cardiac tamponade. This can be seen from the JVD, and narrowing pulse pressures. This pt needs a pericardiocentesis, he may also need more extensive surgery such as a pericardiectomy when he gets to the hospital. Pre-hospital I would provide suportive care including high-flow O2, to try and reduce cardiac workload. Depending on the system maybe beta-blockers also.

[KW Driver]

not to shit in anybody's wheeties here, it's good stuff. but y'all wann maybe afterwards, break it down a little for us ex-11B, CLS types, so it gets 'heard' by a larger audience without us having to go buy med dictionaries?

[91W]

Ranger KW Driver,

Your heart is held in a sac called the Pericardium(sp without my dictionary). What happens is the shrapnal has put a hole in the heart itself or one of the vessels that supplies the blood to the heart. When you bleed into that sac and the blood does not leak out you get a pressure equalization outside of the heart working on the heart itself.

When the heart relaxes the chambers expand in volumn. This creats a "low pressure" that pulls blood into the ventricals to fill. With a pericardial tamponade the heart will not relax because of the mechanical pressure working against it. So there is no blood to pump out. A Pericardial Centesis is where a Dr. inserts a needle below the sternum into the sac and removes the blood allowing the heart to pump again.

The Blood Pressure narrows. The top and bottom number start to equal each other. The pt feels like the can't get enough air because their body says they need more oxygen and the heart is not supplying it. And if you listen to heart sound with a stethascope they sound muffled.

In my post I reffered to PEA this is Pulseless Electrical Activity. It is where the electrical system is functioning but there is no blood being pumped. A tamponade is just one thing that causes this. ART is Assuming Room Temperature, Since there is nothing I can do for this person if they are not on a ER table in about 10 min they are dead. So they are dead unless it happens in the ER and they are to the point of PEA.

This is as basic as I can come up with, someone will clean me up if I need correcting. My spelling sucks tonight to much BEAM.

[Phulano]

Depending on the system maybe beta-blockers also.

maybe I'm a hack, but how do beta blockers get rid of blood in the pericardium?[/b]

[ateup25]

Pre-hospital they can be used to decrease the cardiac workload, slow down the heart rate, and in therefore buy a small amount of time before the onset of PEA.

[EvilCouch]

Pre-hospital they can be used to decrease the cardiac workload, slow down the heart rate, and in therefore buy a small amount of time before the onset of PEA.

I'm not a medic, so I'm fully prepared to be wrong, but that sounds like it'd make his blood pressure drop faster.

[ateup25]

It could and I'm definately not saying that it is a common or often used alternative, but I have seen and heard of it. My common treatment for a tamponade, or any other soon to cause death without immediate surgical intervention syndrome is to drive faster.

[Thursday]

It could and I'm definately not saying that it is a common or often used alternative, but I have seen and heard of it. My common treatment for a tamponade, or any other soon to cause death without immediate surgical intervention syndrome is to drive faster.

It's not necessarily an immediate surgical problem. The patient needs pericardialcentisis. It's simmilar to the process of a pnuemothorax. In this case, blood or other fluid has gotten into the paricardial sac and is putting pressure on the heart, making it work a great deal harder to pump much less blood, making the ejection fraction and cardiac output plummet. Once pressure is relieved, the heart will almost immediately go into tachycardia because it is getting signals from the brain that the rest of the body is starving for oxygen rich blood.

If you were to give the patient a beta blocker, it would be extrememly detrimental. The patient is already not pumping enough blood to the rest of the body, so, in later stages, the brain will start telling the vasculature to start shunting all of the preriphereal vessels and only send blood to the core and the brain.

The medications that are indicated are a diuretic like lasix to try and remove some of the excess fluid; an alpha agonist like dopamine or dobutamine to raise his bloodpressure. Morphine is also a good treatment, not because it is going to make him feel a lot less pain (which it is) but because it helps to decrease the patient's anxiety, thus limiting cardiac workload ( the same reason it is given in acute MIs) as well as helping to dilate some cardiac vasculature so the heart is able to get more oxygen.

[Phulano]

Pre-hospital they can be used to decrease the cardiac workload, slow down the heart rate, and in therefore buy a small amount of time before the onset of PEA.

You carry beta blockers on the bus? Maybe..

I think you stepped on your dick on this one little brother.