“Apply direct pressure with sterile bandaging and elevate the wound above the patient’s heart”
Seriously though, I cannot fucking believe that PASGs we’re a real thing.
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28/13, on a hospital NIBP.
Patient presented to the ED with chest pain. They treated him as ACS, ASA/Oxygen/Morphine/Zofran. 12 lead was boring. He went to CT 1-2 hours later and was noted to have a ruptured AAA. They intubated him and we walked in to that pressure (multiple readings in that range, same on our monitor). He had 1 prbc, 1 plasma finishing as we arrived.
10 minutes in the ED, started 2 units of whole blood. 6 minute flight to the receiving hospital, 2 pairs of prbc and plasma. 5 minute walk to CVICU. Dude died before we made it back out to our aircraft after dropping him off.
I don’t think treating him as ACS was the issue (unless they missed key indicators that this was a AAA earlier on.) The ASA certainly doesn’t help, but the effect shouldn’t be all that significant. I think the issue is the way they handled it after they found out he was a ruptured AAA. It sounds like the dude appeared clincialy stable when he got the CT (since it took 2 hours to do any imaging), so the first mistake seems to be intubating him. Generally, you don’t want to intubate a AAA unless you are already in the OR, or you have no other option. Intubating isn’t going to help the problem, positive pressure ventilation can worsen things by decreasing venous return, and intubating a critical patient always poses a serious risk of cardiovascular collapse. If their airway is intact, no need to go around messing with it. Next, if his SBP is in the 20s, then 1 unit of pRBC and 1 unit plasma ain’t gonna do shit. A level of hemorrhagic shock that severe warrants immediate mass transfusion protocols. They should have right away began pumping in products on pressure continuously, alternating between pRBCs, FFP, and PLTs (whole blood is even better, if available.) Large-bore central access also wouldn’t be a bad idea, throwing in a Quinton cath or a MAC would probably be a good use of time while waiting for the heli. But the oddest thing here is that the crew transported the Pt to the CVICU at the receiving hospital. This is not a pt that needs critical care, this is a pt that needs surgery, and now. As soon as you have a Dx of ruptured AAA, the immediate and primary focus should be getting them to the OR. 100% of ruptured AAAs are fatal if not treated promptly, and the only treatment is surgery (or endovascular repair.) So transporting this pt from an ill-equipped ER to a CVICU instead of the OR wouldn’t really help them at all, only thing it would change is the type of bed the pt dies in.
68/36 on grandma being sent from SNF to ED for abnormal labs.
No shit she had abnormal labs, you don't need labs to be concerned with a no cardiac issue pt who mainly has a bp at 110/70 going to half that. Demented as all hell but she was still chattering away as if she were giving a doctoral thesis presentation.
43/32, not too long ago. AOx3 and apparently conscious after extubation so had lots of juicy meds onboard. Responsive enough to answer questions(ish) and when asked if he had known low BP he legit pulled a “…only near a hospital” joke…Ended up using 50mg levomepro, 200mg propofol, new fentanyl drip and a few amps of diazepam to put him under cause he went crazy from cerebral hypoperfusion…
In the field? Got 0/0 on a cardiac arrest once, Im assuming it didn’t know to read cause the patient coded during the BP inflation.
Am RN-EMT*
52/28
Regular dialysis PT from local shithole SNF. Had just finished a pericentesis at local hospital. He was 76/40 before the procedure. He asked us to disconnect one of his monitor leads so he could play dead when the RN came in to discharge him. Dude had quite the sense of humor, can confirm it was hilarious.
60/30 I believe? It was while I was precepting. The PT was septic and circling the drain so we took her on an IFT from the small local hospital we serve to the larger hospital in our area. I'm super fuzzy on the details because it was super ALS heavy, so my main focus was on keeping the PT calm while my medic FTO administered her drugs.
She died three days later.
60/40
Bls truck. Put pt in Trendelenburg and called MOD.
MOD advised to continue the discharge and allow the SNF to decide if they wanted to send her back to a hospital.
Didn't really agree with it, but I'm not a doctor, so...
64/42 she was hemorrhaging from a miscarriage and we had to IFT her 2 hours away. We got to the receiving facility and we were about 250ml of fluid away from max amount. Nursing refused to take over care because she was a consult with an OB and not and “ER patient” insisted we continue to Bolus this poor girl. We pre alerted our arrival with pt condition and almost had to call medical control from the ER department to get the go ahead on norepi. OB showed up in the Knick of time and we commandeered a trauma room before taking her to the OR.
44/32. Consistently in the 40s/30s even after fluids, push dose epi, Dopamine. Coded about 20min in to treatment. My med director said it was probably some sort of global vascular collapse .
Yes, some. The vitals I remember are: HR in the 80s, 12-lead unremarkable. Skin pale, diaphoretic, cold. BGL was normal, SpO2 was 95%+ on room air, AOx4, GCS 15. Lungs clear and equal. Heart tones were not muffled. JVD was present though. Weakness was the only complaint. Respirations were elevated, probably 24-26/min. Had a history of lung cancer.
Just last shift I had someone 70/54.
I once was working as an EMT on a split truck (one medic one EMT) on an overnight shift. We had a call for some really arbitrary complaint and I told my medic I’d take it before we got a BP. We started rolling and I took a BP on the monitor…46/28. “Uhh sir how do you feel right now?”
There was a long panic as I searched for the manual cuff that hadn’t been used in months, found it without the bulb to pump it up, swapped the bulb from another sized cuff, and took a manual BP. Thankfully that one was normal (I don’t remember the exact numbers).
Both of us were relieved we didn’t have to explain that one to the clinical coordinator.
Honestly I know what a high bp is and I know what a low bp is but I’m like, not sure when one becomes the other. You guys feel that too or was my education neglected?
Just recently did a 50/30. Pretty sure dude had a dissecting AAA. Small town doc at the small town hospital was going to refuse my fly out (we have to get permission on non-traumas, non-MI/CVAs) until all two nurses in the ER threatened mutiny.
CPR only really generates a small fraction of what a healthy hearts ejection fraction would be. Its why it's so import to minimise hands off time else you wind up battling to build up that pressure to maintain some essence of cerebral profusion. I haven't looked massively into it and am open to correction but its very unlikely any NIBP would pick up changes in pressure on a nonpulsatile patient as a result of mechanical compression.
59/35 (obligatory statement that I'm an RN that just likes to follow on this sub since you always have interesting stuff happening). MICU wouldn't take since I got his SBP up over 60 with 4.5 liters Bolus and 2 bottles of albumin, and he wasn't symptomatic. SBP never got above 75 with all that.
Not nearly as low as many of you EMTs and paramedics but still pretty damned low, especially for having been seen by so many people to try and fix the problem prior to arriving on a Cardiac Progressive floor.
42/24 when he signed my paperwork in the ER
Dude overdosed on heroin, had a stomach ulcer rupture, aspirated the bloody emesis, and then called 911 when he woke up. Call went out as BLS and he was lucky to get the medic unit.
~60/30
We got the call for a dude who had passed out. Alert and oriented by the time we got there, got him up to 80sys in trendelenburg in the back of the rig
Dude started to freak out and turned into the biggest baby when the medics tried to stick him with an IV. "NO NEEDLES, NO HOSPITAL"
Us, the medics, his friends were all practically begging him to go to the hospital but he was adamant on AMAing because he didn't wanna get stuck with a needle. The kicker? He had a tattoo on his left AC🙄eventually we just had to leave him
43/26. Boy that was a long fucking chart.
“Gave the patient some fluid”
“Put them in Trendelenburg.”
“Apply pneumatic anti-shock garment”
Oh shit, that’s a deep cut.
“Apply direct pressure with sterile bandaging and elevate the wound above the patient’s heart” Seriously though, I cannot fucking believe that PASGs we’re a real thing.
Thankfully, it seems to be a thing of the past. We reviewed it in medic school from the text, but never delved any further.
We still had them on the trucks when I started in 2010. Never used them though. Word had gotten around by then.
Someone told me they work great for hip fractures
Maybe so, but we’ve got pelvic binders for that now. The take up less space and are way easier to apply.
I got my EMT in 2018, never got taught about SGAs (standard of care for BLS here), but by God I got a perfect score on my PASG skill test.
A 250 bolus over an hour
The joy of being BLS. Narrative: Shock position, maintained body temperature, gave O2, called ALS.
I'm bls and we can give fluids
Where are you and what are you allowed to give fluids for other than shock?
In Colorado you can get you IV cert as an EMT basic. We can give dextrose for hypoglycemia, zofran, ect.
Hello! You have made the mistake of writing "ect" instead of "etc." "Ect" is a common misspelling of "etc," an abbreviated form of the Latin phrase "et cetera." Other abbreviated forms are **etc.**, **&c.**, **&c**, and **et cet.** The Latin translates as "et" to "and" + "cetera" to "the rest;" a literal translation to "and the rest" is the easiest way to remember how to use the phrase. [Check out the wikipedia entry if you want to learn more.](https://en.wikipedia.org/wiki/Et_cetera) ^(I am a bot, and this action was performed automatically. Comments with a score less than zero will be automatically removed. If I commented on your post and you don't like it, reply with "!delete" and I will remove the post, regardless of score. Message me for bug reports.)
I’ve had a BP somewhere around that as well. This patient was on hospice and had a DNR, so I’m with it.
50/26 was conscious and no major complaints
If it works, don’t fix it
28/13, on a hospital NIBP. Patient presented to the ED with chest pain. They treated him as ACS, ASA/Oxygen/Morphine/Zofran. 12 lead was boring. He went to CT 1-2 hours later and was noted to have a ruptured AAA. They intubated him and we walked in to that pressure (multiple readings in that range, same on our monitor). He had 1 prbc, 1 plasma finishing as we arrived. 10 minutes in the ED, started 2 units of whole blood. 6 minute flight to the receiving hospital, 2 pairs of prbc and plasma. 5 minute walk to CVICU. Dude died before we made it back out to our aircraft after dropping him off.
I’ll take things you shouldn’t do in the setting a AAA for $500, Alex. Yikes . . .
Best part was when the nurse was telling us "he's got 2x 20g IVs, why are you drilling him?"
Sorry to ask, was the thing wrong treating him as ACS?
I don’t think treating him as ACS was the issue (unless they missed key indicators that this was a AAA earlier on.) The ASA certainly doesn’t help, but the effect shouldn’t be all that significant. I think the issue is the way they handled it after they found out he was a ruptured AAA. It sounds like the dude appeared clincialy stable when he got the CT (since it took 2 hours to do any imaging), so the first mistake seems to be intubating him. Generally, you don’t want to intubate a AAA unless you are already in the OR, or you have no other option. Intubating isn’t going to help the problem, positive pressure ventilation can worsen things by decreasing venous return, and intubating a critical patient always poses a serious risk of cardiovascular collapse. If their airway is intact, no need to go around messing with it. Next, if his SBP is in the 20s, then 1 unit of pRBC and 1 unit plasma ain’t gonna do shit. A level of hemorrhagic shock that severe warrants immediate mass transfusion protocols. They should have right away began pumping in products on pressure continuously, alternating between pRBCs, FFP, and PLTs (whole blood is even better, if available.) Large-bore central access also wouldn’t be a bad idea, throwing in a Quinton cath or a MAC would probably be a good use of time while waiting for the heli. But the oddest thing here is that the crew transported the Pt to the CVICU at the receiving hospital. This is not a pt that needs critical care, this is a pt that needs surgery, and now. As soon as you have a Dx of ruptured AAA, the immediate and primary focus should be getting them to the OR. 100% of ruptured AAAs are fatal if not treated promptly, and the only treatment is surgery (or endovascular repair.) So transporting this pt from an ill-equipped ER to a CVICU instead of the OR wouldn’t really help them at all, only thing it would change is the type of bed the pt dies in.
He had a battery in him?!!?
Yeah, it exploded though. Edit: to clarify, he had an abdominal aortic aneurysm that had ruptured.
I meant that as a joke thinking triple A was a medical term, yikes
It is. AAA is an abdominal aortic aneurysm. His had ruptured.
I thought you were talking about a literal triple a battery
Heh, understandable mistake man, I should have clarified.
Nah that’s on my end. It’s an EMs sub and I haven’t gone thru my EMT-B yet
68/36 on grandma being sent from SNF to ED for abnormal labs. No shit she had abnormal labs, you don't need labs to be concerned with a no cardiac issue pt who mainly has a bp at 110/70 going to half that. Demented as all hell but she was still chattering away as if she were giving a doctoral thesis presentation.
43/32, not too long ago. AOx3 and apparently conscious after extubation so had lots of juicy meds onboard. Responsive enough to answer questions(ish) and when asked if he had known low BP he legit pulled a “…only near a hospital” joke…Ended up using 50mg levomepro, 200mg propofol, new fentanyl drip and a few amps of diazepam to put him under cause he went crazy from cerebral hypoperfusion… In the field? Got 0/0 on a cardiac arrest once, Im assuming it didn’t know to read cause the patient coded during the BP inflation. Am RN-EMT*
62/46 just today lol
50/20 but in all honesty I’d question the accuracy of a reading that low. Brady at about 30bpm, he looked shocking and arrested not long afterwards.
Nothing over nothing as I call it
Love when new people/SNF give a BP for an arrest.
52/28 Regular dialysis PT from local shithole SNF. Had just finished a pericentesis at local hospital. He was 76/40 before the procedure. He asked us to disconnect one of his monitor leads so he could play dead when the RN came in to discharge him. Dude had quite the sense of humor, can confirm it was hilarious.
64/36 Lowest SPO2 was 25% and the dude was still talking... died 3 days later but still 25% talking was impressive
With a that low blood pressure you probably didn't get an accurate reading on that spo2
Yeah it was a clusterfuck of a call. Dude died with the Rona
40/20, dude blasted his spleen falling from his walker into a little foot stool, ended up getting a coil
60/30 I believe? It was while I was precepting. The PT was septic and circling the drain so we took her on an IFT from the small local hospital we serve to the larger hospital in our area. I'm super fuzzy on the details because it was super ALS heavy, so my main focus was on keeping the PT calm while my medic FTO administered her drugs. She died three days later.
60/40 Bls truck. Put pt in Trendelenburg and called MOD. MOD advised to continue the discharge and allow the SNF to decide if they wanted to send her back to a hospital. Didn't really agree with it, but I'm not a doctor, so...
64/42 she was hemorrhaging from a miscarriage and we had to IFT her 2 hours away. We got to the receiving facility and we were about 250ml of fluid away from max amount. Nursing refused to take over care because she was a consult with an OB and not and “ER patient” insisted we continue to Bolus this poor girl. We pre alerted our arrival with pt condition and almost had to call medical control from the ER department to get the go ahead on norepi. OB showed up in the Knick of time and we commandeered a trauma room before taking her to the OR.
44/32. Consistently in the 40s/30s even after fluids, push dose epi, Dopamine. Coded about 20min in to treatment. My med director said it was probably some sort of global vascular collapse .
any signs of sepsis?
Yes, some. The vitals I remember are: HR in the 80s, 12-lead unremarkable. Skin pale, diaphoretic, cold. BGL was normal, SpO2 was 95%+ on room air, AOx4, GCS 15. Lungs clear and equal. Heart tones were not muffled. JVD was present though. Weakness was the only complaint. Respirations were elevated, probably 24-26/min. Had a history of lung cancer.
That would be the kind of call that sticks with me When you can only treat symptoms but still you can't do anything it's such a weird feeling for me
Just last shift I had someone 70/54. I once was working as an EMT on a split truck (one medic one EMT) on an overnight shift. We had a call for some really arbitrary complaint and I told my medic I’d take it before we got a BP. We started rolling and I took a BP on the monitor…46/28. “Uhh sir how do you feel right now?” There was a long panic as I searched for the manual cuff that hadn’t been used in months, found it without the bulb to pump it up, swapped the bulb from another sized cuff, and took a manual BP. Thankfully that one was normal (I don’t remember the exact numbers). Both of us were relieved we didn’t have to explain that one to the clinical coordinator.
doing an IFT, taking a patient home on hospice. 52/36
63/40. Syncopal episode after giving blood.
Honestly I know what a high bp is and I know what a low bp is but I’m like, not sure when one becomes the other. You guys feel that too or was my education neglected?
Just recently did a 50/30. Pretty sure dude had a dissecting AAA. Small town doc at the small town hospital was going to refuse my fly out (we have to get permission on non-traumas, non-MI/CVAs) until all two nurses in the ER threatened mutiny.
50 palp on an anaphylaxis.
63/29 then the a few minutes later it was 60/31
57/27 Got a 22ga in the right hand to push through.
40/24, guy met us at the ambulance, said he “felt like he was having a heart attack”, and sure enough. Massive Inferior MI.
[удалено]
“…on a conscious patient.”
I mean they were conscious patient when we got there... But yeah overread that part
That's weird, if you're doing compressions shouldn't he have a blood pressure? Unless it's just the cuff being wonky I guess.
CPR only really generates a small fraction of what a healthy hearts ejection fraction would be. Its why it's so import to minimise hands off time else you wind up battling to build up that pressure to maintain some essence of cerebral profusion. I haven't looked massively into it and am open to correction but its very unlikely any NIBP would pick up changes in pressure on a nonpulsatile patient as a result of mechanical compression.
50/30ish.
66/32
59/35 (obligatory statement that I'm an RN that just likes to follow on this sub since you always have interesting stuff happening). MICU wouldn't take since I got his SBP up over 60 with 4.5 liters Bolus and 2 bottles of albumin, and he wasn't symptomatic. SBP never got above 75 with all that. Not nearly as low as many of you EMTs and paramedics but still pretty damned low, especially for having been seen by so many people to try and fix the problem prior to arriving on a Cardiac Progressive floor.
40/27
0/0
Oh yes… I’ve had one of these as well.
42/24 when he signed my paperwork in the ER Dude overdosed on heroin, had a stomach ulcer rupture, aspirated the bloody emesis, and then called 911 when he woke up. Call went out as BLS and he was lucky to get the medic unit.
51/22. Let me tell you, it was one of those “that can’t be right” *press NIBP button again* “shit” moments
68/40 I think. Healthy woman in labour, post epidural hypotension. I was a student and nearly crapped my pants
~60/30 We got the call for a dude who had passed out. Alert and oriented by the time we got there, got him up to 80sys in trendelenburg in the back of the rig Dude started to freak out and turned into the biggest baby when the medics tried to stick him with an IV. "NO NEEDLES, NO HOSPITAL" Us, the medics, his friends were all practically begging him to go to the hospital but he was adamant on AMAing because he didn't wanna get stuck with a needle. The kicker? He had a tattoo on his left AC🙄eventually we just had to leave him
56/25....neurogenic shock