Thanks for all your replies. We try to foster a good
relationship with the ambulance service and can say that I think we work pretty
well together, to the extent that I've often asked a crew to stay behind in the
resus room for a few minutes while we get cracking with an arrest or
whatever. The Advanced Paramedics in Ireland have a lot of skills that the
nursing staff and junior doctors don't have so I've no problems in asking
someone to stay back and intubate or get IO access if needed and I'm the only
registrar around. So it's a 2-way street. As for the guy who asked
this question, he's well aware that I'm circulating this and of all the comments
that are coming in.....
To put the case in
context, this gentlemas was picked up in a rural area approximately 35
minutes from the nearest receiving hospital (equivalent to a small DGH
without on-site CT and rudimentary laboratory service out of hours up until
midnight) and another 20 minutes or so to where I work. So to scoop and
run is not really acceptable anymore, especially as my centre will most likely
be taking all acute care for the region in the near future (with a
geographically diverse catchment area currently serviced by 3 such hospitals and
ourselves). There was disagreement between the 2 paramedics (same grade)
as to whether or not to give atropine, so as per SOPs the default
position of not performing the intervention in question was adopted. We
have recently launched a clinical support service based in my ED where the
registrar on duty is on hand to offer advice to any advanced paramedic in the
region who requires it and this case dates from around the launch date. I
think it happened in the week before the service was launched. The service
is radio-based and there is no facility to transmit ECG data as of
yet.
Apologies if some people can't open the Clinical Practice
Guidelines, the full document is online (http://www.phecit.ie/Documents/Clinical%20Practice%20Guidelines/CPG-A/CPG-Advanced%20Paramedic.pdf
adult symptomatic bradycardia is p10) but I think that the link got split up on
my previous mail. This is part of the 2nd edition of Guidelines
(protocols) issued by the pre-hospital regulatory body and define the scope of
practice of all pre-hospital practitioners. The 3rd edition is due out
pretty soon, I think, and should be a much tidier document, tying together all
the different levels or pre-hospital providers. Hopefully we can feed in
the issues surrounding this case to that process. As you can see the
document is not referenced. Also, a rate of <50bpm is
accepted as bradycardia.
As to whether or not Ireland is still in Europe, that's actually
quite a relevant question. In general Ireland follows the American Heart
Association for cardiac life support algorithms. The paramedic CPGs
deviate from this in some areas (eg atropine 3mg bolus for asystole) and the
CPGs are a mixture of the last 2 rounds of guidelines (2002 and 2005). I
suspect that's where the "Type II 2nd degree AV block or 3rd degree AV block
excluded" box comes from.
The rhythm strip I was given was printed out in addition to the
strip included in the clinical notes. The ambulance service has the
capability of printing 12-lead ECGs on the monitor so I'm hoping that this was
done at the time. The machine can also come with a pacing module, but as I
understand it TCP is not within their skill set currently. Neither is an
epinephrine infusion. I need to clarify what their teaching is regarding
identifying 2nd degree Type II and 3rd degree AV blocks, and will feed back to
the list with this in due course.
I agree that the protocol has failed its users in this case.
I would have given atropine, as well as probably pacing and fluids, but I am
allowed to do so. If atropine worked, great! If not, move on.
Nothing is lost by doing so. It is somewhat reassuring for the people
involved that the underlying pathology (intracranial bleed) was not fixable but
this issue needs to be sorted for the next time. This is what we hope to
do, as a result of this discussion.
Many thanks,
Jason
From: Jason Horan ([log in to unmask])
> You're on shift and
an Advanced Paramedic puts this strip in front of you
-->
Great!
I am sure you were able to make the paramedic feel comfortable doing
this. We need MORE of this teamwork!
It would also be ideal, in my opinion,
if you let this paramedic know that you yourself were intending to ask for
advice on this - honest and further encouragement of him/her that he is not
"silly"!
> When the APs arrive the HR is 49 and BP reading about
55/palp
--> I HATE that expression "palp"... So sad that it has
done the "reverse Columbus" and come to us from the Americas...
If
you're going to "palpate", having FAILED to get a reading, then just say radial
pulse palpable or not...
Anyway... HR < 60, hence Bradycardia, so can
use that algorithm from RCUK guidelines...
BP < 90, which is the first
listed indication of the 4 in the initial box, so you go to the left side ad
next thing is to give atropine 500...
(Sorry - I had a hand in re-designing
this particular algorithm into its current simplified form from the old one, so
I do like it)
> According to their current clinical practice
guidelines
--> Sorry, I can't access it...
>
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)
--> I would not be comfortable with that guideline
for pre-hospital use. I would not be comfortable with:
- Attempting to
"exclude" these blocks on the basis of a SINGLE lead
- Spending the time
doing this pre-hospital
- Making this a pre-condition for Atropine. Could you
please let me know what evidence they use to make this
requirement.
> "What should I do the next
time?"
--> Wrong question, I think. "What should I do NOW", is
the question and he has already begun to do it - he asked for advice. Yours (and
ours) might help a bit, but what he needs to do is contact his Medical Director
and get it clarified NOW. Before next time. As it happens, I don't think these 2
blocks are EVIDENLY there. If it were me, I'd get the guideline changed. If it
is a protocol, rather than a guideline, one would have to define what is meant
by "exclude", i.e. what evidence is required? Perhaps it would need to say
"there is no clear 2b or 3rd degree block", which there is not in this case so
they could give Atropine!
The guideline needs fixing now, I think!
I'd bet that if someone fixed those, then this would be the best outcome of this
whole event!
Why don't you bring this up in your M&M
meeting?
As for what to do next time - pacing.
>
There are some areas where P-waves are visible and it appears like a complete AV
block
--> NO. This is not so.
Where there are P-waves, a QRS
ALWAYS follows (i.e. never are there 2 consecutive Ps without a QRS) so it's NOT
a 2b. The QRS which follows is <0.1s and of normal morphology for lead II, so
this is NOT a 3rd degree (complete) block. The PR interval, when it is there, is
ALWAYS >.2s and also variable, so there appears to be a 1st degree block. It
is possible that there is a Wenkebach-type thingie going on behing this, without
enough P-waves to actually show what the AV node could do with them if they
arrived at it more than once every few beats! So one cannot actually CALL this a
Mobitz 2a, I think...
> A number of us have tried to trash this
out
--> You mean "thrash", no? ;-)
From: Alain
Vadeboncoeur ([log in to unmask])
> severe sinusalbradycardia (about 30) most of the time, with most of the
P waves (when theydo occur) conducting, the rest of it being relatively slow
nodal orinfranodal (large) response
-->
Agreed
From: Dunn Matthew ([log in to unmask])
>
...As it stands their protocols do not allow giving drugs in this case. That is
no bad thing...
--> Although I interpret their protocol as
ALLOWING Atropine, I think you may well be right that it is quite likely not to
help AND they should scoop and run. If I were out there, I'd scoop and run and,
in transit, give the Atropine (if I had no pacing), as I think it may well help
on occasion, but will NOT likely harm the paient.
From: Jim
Connolly ([log in to unmask])
> ... interesting exclusion criteria for atropine that dont seem to
corelate with what most of europe do
--> Is Ireland actually IN
Europe?
;-)
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