Medical Response?

[firedupnursing70]

OK,

Just a general nursing questions. I was attending a training for basic EMT's that a Para medic was protoring. Here is the scenario; A patient found down at the scene 24 yr male patient with head trauma, unconscious, lying supine on the floor, with decordicate posturing, cheyne stokes breathing, Oxygen Saturation 88%, HR 28, thats all the vitals you have. You have an AED, EMT basic bag, 911 is called. No drugs or transcutaneous pacing available. You do have oral adjuncts, 02 and bag valve mask. My questions is would you start CPR with this scenario? I said yes. He said no, not with a palpable pulse!

[HomeBound]

I concur. No CPR with a pulse, but putting someone on pads isn't a crime. Shock won't occur unless you push the button.

As an EMT, we can intubate, sort of. We can put in a King or a Combi. I wouldn't use a BVM with decorticate posturing, due to possible c spone and brain involvement and increased ICP. I would use high flow on a NRB, and possibly an NPA as adjunct.

This does suggest a low GCS, and anything under 8, intubate. If its just BLS and no ALS available, I would contact base and get ready for a king or a combi...then use the BVM. But without a secure airway and neuro deficits, I would supplement O2 with a NRB, load and go.

Just my $0.02.

[That Guy, BSN, RN, EMT-B]

Adult and has pulse, negative on the CPR. Yes its low but they at least have one....until they herniate and die.

[Wuzzie]

I wouldn't use a BVM with decorticate posturing, due to possible c spone and brain involvement and increased ICP. I would use high flow on a NRB, and possibly an NPA as adjunct.

As an EMT you should have been trained how to ventilate a patient while protecting c-spines. It is possible and not that difficult. You want this patient oxygenated BECAUSE they have a brain injury and increased ICP. Supplemental O2 is useless on an apneic patient. Cheyenne-Stokes respirations have an apneic phase. Sometimes prolonged. During this phase your patient will become hypoxic which will further increase ICP and cause even more damage. Can you please expand on your thinking?

[applesxoranges, BSN, RN]

No. Anywy, the guy's blood pressure is going to be through the roof anyway. Better to load and go. Basically, intrcranial pressure is already ******.

[Wuzzie]

Adult and has pulse, negative on the CPR. Yes its low but they at least have one....until they herniate and die.

In about the next 30 minutes. Yikes.

[HomeBound]

Wuzzie. Well, there isn't any information on pupillary response. reason i say don't hyperventilate with a bvm is because of that. i guess i was being a bit conservative. hyperventilation is not warranted in all cases of decorticate posturing post TBI.

and it had nothing to do with "i don't know how to protect the cspine". it had to do with cspine and brain involvement, r/t pending herniation and that there should ALWAYS be an assumption that there is a cervical spine injury. tilting the head to keep the airway open and hyperventilating was, in my judgement, too aggressive for the parameters.

conservative, but definitive. high flow NRB with an NPA, unless I am permitted to put a king in place and THEN use a BVM...and even then, depending on pupillary response, I still won't aggressively hyperventilate.

GCS of

again. my $0.02. But I always, always, always, always, always....enough always? assume there is cspine involvement to the extreme unless I am proven wrong. anything that compromises neutral and secure, better have a damn good reason to do it.

btw. i am a NURSE as well as an EMT. Along with 22 years of experience at both.

[Luchador, CNA, EMT-B]

OK,

ecordicate posturing, cheyne stokes breathing

As an EMT-B I damn near worked this scenario minus the age. 67 year old playing basketball in a gym. Collapses. AED in the gym. People grab it and put it on him. We showed up right after the first shock which brought him back--- sorta.

He was posturing and had the Chenye Stokes. We loaded him and gtfo. He was brain dead, of course. We got him to the hospital alive on a BVM. The ER docs were shaking their heads once we got him on the table.

p.s. his heart rate was something horrible and thready and generally messed up but we did not provide cpr-- but we did leave the AED on. We put in an oral adjunct.

[thoughtful21, BSN, RN]

Love hearing all the different perspectives & ideas from experienced nurses and EMT's. Interesting discussion!

[Wuzzie]

Wuzzie. Well, there isn't any information on pupillary response. reason i say don't hyperventilate with a bvm is because of that. i guess i was being a bit conservative. hyperventilation is not warranted in all cases of decorticate posturing post TBI.

and it had nothing to do with "i don't know how to protect the cspine". it had to do with cspine and brain involvement, r/t pending herniation and that there should ALWAYS be an assumption that there is a cervical spine injury. tilting the head to keep the airway open and hyperventilating was, in my judgement, too aggressive for the parameters.

conservative, but definitive. high flow NRB with an NPA, unless I am permitted to put a king in place and THEN use a BVM...and even then, depending on pupillary response, I still won't aggressively hyperventilate.

GCS of

again. my $0.02. But I always, always, always, always, always....enough always? assume there is cspine involvement to the extreme unless I am proven wrong. anything that compromises neutral and secure, better have a damn good reason to do it.

btw. i am a NURSE as well as an EMT. Along with 22 years of experience at both.

I don't think anybody, including myself, advocated for hyperventilation. In fact in my post I very clearly advised against it. Using a BVM is not automatically hyperventilating and you can ventilate without tilting the head. I've done it hundreds of times. An OA would allow for that and that would be my first choice over an NPA which is not the adjunct of choice with a TBI. You are correct that decorticating posturing is not an indication for BVM ventilation nobody said it was. But the HR of 28 is indicative of Cushing's Triad and that most certainly is an indication for optimizing oxygenation and ventilation which Cheyenne-Stokes breathing will not provide. In addition placing an airway adjunct other than an oral airway without utilizing standard neuro-protection protocols is risky and may be without benefit. I still stand by my opinion that supplemental O2 by mask or NC in the presence of apnea is not beneficial. I also don't recall stating anywhere that you don't know what you're doing. I'm really not trying to be an @$$ but for the sake of discussion I always like to know where the other person is coming from.

I don't doubt your experience and perhaps protocols are different in your locale. At the risk of appearing like I'm pounding my chest (I'm not) I've been a nurse for 31 years (11 of those as a flight nurse) with ED, PICU and NICU experience, a first responder for 40 years and an EMT-P for 11 years. I'm certainly not THE authority on TBI care but I do have a bit of experience with it. :)

[/username, BSN, RN]

As an EMT-B I damn near worked this scenario minus the age. 67 year old playing basketball in a gym. Collapses. AED in the gym. People grab it and put it on him. We showed up right after the first shock which brought him back--- sorta.

He was posturing and had the Chenye Stokes. We loaded him and gtfo. He was brain dead, of course. We got him to the hospital alive on a BVM. The ER docs were shaking their heads once we got him on the table.

p.s. his heart rate was something horrible and thready and generally messed up but we did not provide cpr-- but we did leave the AED on. We put in an oral adjunct.

If he was breathing, he was not brain dead.

If he was posturing, he was not brain dead.

If he was alive when you got him to the hosptial, he was not brain dead.

Brain death is legal and medical death that requires extensive testing to establish. You cannot just say someone is brain dead because they have a poor neurological exam.

[bgxyrnf, MSN, RN]

I always, always, always, always, always....enough always? assume there is cspine involvement to the extreme unless I am proven wrong

In my world, found down generally means c-spine precautions until ruled out by (a) clinical exam of an A&O patient sans distracting injuries, or (b) MRI... most commonly the latter.

[Medic_Murse, BSN, RN, EMT-P]

ABC's always.