Safety First: Advanced Circulation


Study Notes:

  1. 1.IVs are for fluid or drugs.

  2. 2.Check RBG in any patients with altered mental status.

  3. 3.Check 3 lead, and 12 lead ECG when required.

“Secondary Circulation”


“Safety First” ... Table of Contents

Safety    Use your BSI - Biological Safety

              F is for Fire - Scene Safety

I                 I is for Incident: MOI/NOI          

R                Determine the numbeR of patients

S                Send for help

T                Trauma to the C-spine?

G                General impression of the patient

E                Estimate LOAs

T                Threats to you or your patient?

1°A             1° Airway

1°B             1° Breathing

1°C             1° Circulation

1°D             1° Decision

2°A             2° Airway

2°B             2° Breathing

2°C             2° Circulation

2°D             2° Decision

Advanced Circulation

In the 2°C step we are going to use advanced life support techniques to support the patients’ circulation.

The first step is to ask yourself if you need to start an intravenous line.  We start IVs for two reasons, either to give drugs, or to give fluids.  So ask yourself, does my patient need fluids?  If so, start a large gauge (big needle) IV and a litre bag. If you think they might need IV drugs, then start a smaller needle with a smaller bag.

In a cardiac arrest, the best IV access is in the external jugular veins.  The site is central, so fluid and drugs go right through the superior vena cava directly into the heart.  Also, the site is easy to access if you are the only paramedic and you are also controlling an intubated airway.

In all cases, it’s best to avoid subdiaphragmatic sites if you at all can.  They aren’t practical, and in cardiac arrest or low flow states the drugs will have trouble getting to the heart.

In any patient that you start an IV on you can use the flashback of blood in the chamber of the needle to assess the patient’s blood sugar.  Use this blood to assess RBG (random blood glucose) in any patient with altered altered mental status.

If you’re having trouble getting the blood to come out, then use a small syringe attached to the needle to push a drop of blood out onto your glucometer strip.

Next you’ll want to attach your ECG monitor.  Any patient that is complaining of pain above the belt should get a cardiac monitor put on them so that you can assess their rhythm. Too aggressive?  I don’t think so.

Specifically, any patient complaining of chest pain, shortness of breath or a change in LOAs must have an ECG monitor placed on them.

Interpreting ECGS is too big a topic to go into on this site, but in my opinion, anyone working on an ambulance should be able to read ECGs.

There are several good books and good sites out there.  Dale Dubin’s book is the long-established classic, but it addresses mostly 12 lead ECGs.   Gail Walraven’s book isn’t bad, but I don’t think it’s great.  Hmmm... maybe I need to add another section to this site?  Gack - I’ll never get my masters degree done!

Along with a standard ECG I think it is hard to argue against paramedics doing 12 lead ECGs in the field.  This used to be a point of discussion, but the research so solidly supports the benefit that I consider it a minimum standard of practice (along with end tidal CO2 for intubated patients).

I especially think that any provider who administers nitroglycerin should be able to acquire and interpret 12 lead ECGs in order to avoid the potentially fatal mistake of giving nitro to a patient with a right ventricular infarction.

Basically, my philosophy is that anyone who works in an ambulance should be able to acquire and interpret a standard ECG, and anyone who administers nitroglycerin to patients with chest pain should be able to acquire and interpret 12 lead ECGs. 

ECGs will help you to understand a patient’s electrical system, but to understand how well their heart is actually pumping you have to check their mechanical system.  How do we do this?

By reviewing what you know of the patient’s vital signs already you will be able to have a good idea of how well their heart is pumping.  You assessed their respiratory rate and you auscultated their lungs already.  When you took a pulse you obtained a rough idea of their heart rate.  (If you attached an ECG monitor, it will tell you their exact heart rate).  You’ve attached an SpO2 and maybe an EtCO2 monitor to help evaluate their gas flows.  And when you started an IV you measured their blood sugar if you had reason to doubt it was abnormal.

All that’s really left is to determine their blood pressure.  If you feel like the patient is pretty stable at this point then you can do a quick systolic blood pressure by palpation. 

If they’re unstable, knowing that they have a radial pulse means that (for now) their brain, heart and lungs are probably getting enough blood to stay alive.

Good enough.  We’ve got all the information we need to make some very important, and complex decisions.  Which leads us to ...