The systolic appears to be 55mmHg by palpation. I raise an eyebrow
at that being considered OK. The abnormal ECG is clearly secondary to the intracranial
catastrophe, but they should have treated as they had no way of knowing that;
this isn’t a clear Cushing’s response so it wasn’t
diagnosable in the field.
The question of their strange exclusion criteria for administration
of atropine are another question altogether – those appear to be
reasonable indications to me, especially in the presence of inferior infarction,
the commonest clinical situation in which they are likely to meet bradycardia
of this scale.
Best Wishes,
Rowley.
From: Accident and Emergency Academic List [mailto:[log in to unmask]]
On Behalf Of Alain Vadeboncoeur
Sent: 02 January 2009 19:50
To: [log in to unmask]
Subject: Re: Pre-hospital scenario
There is no indication to give anything if BP is OK.
Alain
From: Accident
and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of
Jim Connolly
Sent: 2 janvier 2009 14:32
To: [log in to unmask]
Subject: Re: Pre-hospital scenario
give the guy some atropine!!!
working on an ABC basis - you aint going to get the
parenchymal bleed bit till he gets to hospital
interesting exclusion criteria for atropine that dont seem
to corelate with what most of europe do
i would have thought this is exactly the case ( 3rd degree
block - symptomatic ) where atropine was indicated
the outcome however would probably have been the same
jim connolly
newcastle
-----Original Message-----
From: Jason Horan <[log in to unmask]>
To: [log in to unmask]
Sent: Fri, 2 Jan 2009 3:42 pm
Subject: Pre-hospital scenario
First of all, Happy New Year to everybody!!! I've a case up for discussion. You're on shift and an Advanced Paramedic puts this strip in front of you (attached, also at http://www.iemta.ie/imgdump/strip.jpg ) The story is that of a 75 year old male, standing at fence talking to his neighbour when he goes unresponsive and slowly sinks to the ground. Over the next 20 minutes his GCS drops to 5/15. When the APs arrive the HR is 49 =0Aand BP reading about 55/palp. Turns out the gentleman has a parenchymal intracerebral haemorrhage. But anyway, there are 2 APs on-scene debating whether to give the patient atropine for a symptomatic bradycardia. According to their current clinical practice guidelines (Irish guidelines available at http://www.phecit.ie/Documents/Clinical%20Practice%20Guidelines/CPG-A/CPG-Advanced%20Paramedic.pdf refer to CPG-A8 page 10 Adult Symptomatic Bradycardia), atropine can only be given for HR<50 and if 2nd degree type II, and third degree AV block have both been excluded (plus patient symptomatic) The AP in question has come to you saying "What should I do the next time?" There are some areas where P-waves are visible and it appears like a complete AV block but other areas I'm not so sure. A number of us have tried to trash this out but have yet to come to a consensus, so I'm opening it to the list..... Jason HoranSpR Emergency MedicineLimerick, Ireland