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!
EMT basics do not intubate and you would not give a bradycardia head injured hypoxic patient atropine as you would not fix the underlying problem
Airway and breathing folks!
I'll admit I don't know the different levels of EMT. I know our EMTs intubate. I will also say, the EMTs are not diagnosing the extreme amount of head injury here. Only an MRI can do that. Although atropine will not "fix" the problem, it can temporarily get them to the hospital where the appropriate treatment and diagnosis made.
Decorticate posturing does not signal the end. Heck, I've seen those with decerbrite posturing gain some amount of recovery. It happened a couple of weeks ago to me. I scored the guy a 4 all day. One week later, he's having an actual meaningful conversation with the nurse.
We don't know if the posturing is due to hypoxia or say a DAI injury.
I've always been taught in BLS and ACLS that you never do compressions with a palpable pulse. Also, you won't cause any harm by hooking up the pads from the AED just in case.
I'll admit I don't know the different levels of EMT. I know our EMTs intubate.
In general the term "EMT" refers to basics who have a very limited scope for intubating. For instance, in my state they can only intubate a patient with no respirations or pulse. It is unlikely that a basic would be trained to intubate using neuroprotective processes that include the administration of IV medications. A paramedic has a broad scope for intubating including the training to do RSI. You may be confused because the classifications are EMT-B and EMT-P. When I trained there was also an EMT-I (intermediate) but I'm not sure that level exists anymore.
You have lots of good answers already but I'll throw my hat in. Flight nurse and medic here. The priorities are always always always A, B, C. It's nice to note that the patient is posturing and to know the proper terminology for it, but it's not particularly helpful in this scenario.
Is the patient maintaining his/her airway? Yes? Move on to B. No? Open the mouth using a jaw thrust maneuver (c-spine c-spine c-spine) clear the airway with suction (as needed), insert an adjunct if possible, and assist ventilation with a BVM and 100% O2. Rendezvous with an ALS crew and transport rapidly.
Specializes in Adult and Pediatric Vascular Access, Paramedic.
You have lots of good answers already but I'll throw my hat in. Flight nurse and medic here. The priorities are always always always A, B, C. It's nice to note that the patient is posturing and to know the proper terminology for it, but it's not particularly helpful in this scenario.
Is the patient maintaining his/her airway? Yes? Move on to B. No? Open the mouth using a jaw thrust maneuver (c-spine c-spine c-spine) clear the airway with suction (as needed), insert an adjunct if possible, and assist ventilation with a BVM and 100% O2. Rendezvous with an ALS crew and transport rapidly.
I tried explaining this like 20 posts ago, but they still don't get it... The way nurses think and the way a medic think are two different things, which is why I will say it again.. nurses shouldn't bridge to medic.
I tried explaining this like 20 posts ago, but they still don't get it... The way nurses think and the way a medic think are two different things, which is why I will say it again.. nurses shouldn't bridge to medic.
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!
RotorRunner had a very good post at the bottom of page 3.
To answer your question directly (which I know others have), you would not start CPR. I totally hear you with your rationale, but CPR is reserved for those who are pulseless, not just bradycardic (we're talking adults here. Pediatric CPR has different parameters).
And because you do not have a blood pressure in this scenario, you cannot assume this patient is hypotensive. Others have mentioned cushings triad, which this patient is likely experiencing, and that would lead to INCREASED blood pressure.
EMS as a whole is a lot more "down and dirty" than nursing. Especially in the instance of a trauma patient, there aren't many interventions that can happen in the field other than getting the patient to a trauma center and surgical intervention as fast as possible with managing the patient in an A-B-C (airway-breathing-circulation) order. There are plenty of times when you may not be able to get past "A" and that's ok.
EMT basics have less training than paramedics, so you don't have to think about intubating in this situation, but you should be calling for ALS. In this scenario, it's about managing the patient in that same A-B-C order and you don't have to over think it.
Airway - is the airway patent? Do they require suctioning? In this case, a jaw-thrust maneuver would help to open the airway and position your patient for ventilation. You would avoid a head tilt chin lift due to C-spine precautions (a collar should be placed on this patient). You note there are oral adjuncts. An OPA is certainly indicated in this scenario. An NPA is not because of the head trauma. Keep suction nearby as head injury patients frequently vomit.
Breathing - you have a cheyne-stokes pattern and poor O2 sats. Go ahead and start ventilating with the BVM and high-flow O2. Remember, you have your OPA in place.
Circulation - As you've noted, there is are no drugs or pacing available, so you're more or less monitoring for a loss of pulse. If you lose the pulse on this patient, then you start CPR and attach the AED.
So the summation of what they're looking for:
Protect the airway, jaw thrust, OPA, ventilate with the BVM and high-flow O2, start compressions if you lose the pulse. Make sure ALS is on the way and get moving fast to the closest trauma center.
(I am an ICU nurse and a paramedic with 14 years of EMS experience)
LovingLife123
1,592 Posts
I'll admit I don't know the different levels of EMT. I know our EMTs intubate. I will also say, the EMTs are not diagnosing the extreme amount of head injury here. Only an MRI can do that. Although atropine will not "fix" the problem, it can temporarily get them to the hospital where the appropriate treatment and diagnosis made.
Decorticate posturing does not signal the end. Heck, I've seen those with decerbrite posturing gain some amount of recovery. It happened a couple of weeks ago to me. I scored the guy a 4 all day. One week later, he's having an actual meaningful conversation with the nurse.
We don't know if the posturing is due to hypoxia or say a DAI injury.
I've always been taught in BLS and ACLS that you never do compressions with a palpable pulse. Also, you won't cause any harm by hooking up the pads from the AED just in case.