And the winner is...
I rank Epinephrine as my number 1, most essential drug out of the 33 I carry.
Epi has three main uses. For cardiac arrest, for anaphylaxis and for severe asthma.
If I were rating epi only as far as cardiac arrest, I would place it much lower on the list. I have given epi on virtually ever cardiac arrest I have done with the exception of those where my first shock produced a palpable pulse before I was able to get an IV line or shoot the drug down the tube. I have had cardiac arrest saves where the patient was in arrest when I arrived and I rescusitated them with epi and they walked out of the hospital. And I have had many return of spontaneous circulation post epi who made it to hospital admission only to die in the ICU. Do I think epi helped those who walked out of the hospital? Maybe or maybe it was the electricity and the CPR. The science says epi doesn’t make a difference in cardiac arrest, so I am inclined to accept that. I will say I have had many patients who I didn’t get an IV into for awhile, but once I did, and gave them epi, they got pulses back. Now that we have the EZ-IO, as well as a protocol to let us stop resuscitation on patients after twenty minutes without success, I work almost all of my codes where they fell and I get IV assess and epi in much quicker than I did, and I will say I have had a huge increase in my ROSCs. I won’t give up on epi. Maybe if we can improve some of the other aspects of what we do in cardiac arrest, epi may one day be shown to make a difference as the spark that lights a stalled heart, but for now I can only speculate and accept the science.
I have used epi for asthma—There are several limitations on it. The patient must be under 35 and have no hypertension history for use to be able to give it on standing orders. I have had some success, but that may be more attributate to the nebs. I had an asthma code where once I got epi down the tube I was able to save the patient, although unfortunately, she suffered an anoxic injury.
The reason I list epi as my number 1 drug is for anaphylaxis. It is a magic before your eyes life-saver.
When I was precepting many years ago one of my first calls was for a young woman who had just eaten Chinese Food, and almost immediately began to feel sick and have trouble breathing. We were just blocks away, but by the time we arrived, her eyes were closed shut, she was pale, clammy, and we couldn't palpate a pulse. She was dying in front of us. We hit her with the epi, and by the time we reached the ED she looked like any normal teenager, eyes open, warm, dry skin, good BP.
I've done a number of true anaphlyaxis calls over the years, and I can you, I would not want to look in my bag and find the epi gone. Because if it wasn't there, those patients would be dead, and if the epi was missing because I failed to check my gear, then I would deserve life without parole.
Here's an old post Nut Allergy-Sneezing from 2007 about using epi on a child.
***
There are certain calls you get that usually turn out to be nothing — baby choking, person slumped over wheel of car, fall with severe bleeding. In fact, just about every call you get, usually turns out to be nothing much. That’s good. Over time it is a great calmer. I usually say to myself, it’s probably nothing.
We get dispatched to a seven year old having an allergic reaction to some medicine he got at church. We are being dispatched to a local supermarket where the patient will be found in a green SUV. I’m sitting in the back of the ambulance as we have a three person crew today, and my EMT partners have been working for the ambulance each for over twenty-five years so they get the front seats. I think about getting the epi out just in case, but I don’t. Whenever I preprepare, it ends up as a wasted effort. I can’t tell you how many packages of defib pads I opened up on the way to “cardiac arrests” when I first started — “cardiac arrests” where we found the patients alert and talking when we arrived.
We pull up and a cop comes over and asks if I have an epi-pen. I have the house bag over my shoulder as I step out — the med bag is in one of the main pouches. He says the boy ate some nuts or something in a brownie or cookie at a church party and he’s allergic to nuts and he started throwing up, and he got hives and his eyes started swelling, so his parents got him in the car, and drove to the supermarket and got him some liquid benadryl. But they don’t have his epi-pen with them.
The mother is holding the boy and I can see the eyes, still open, but swollen, and I can see some hives on his arms. He looks very pale. The mother says the boy was wheezing so they also gave him some puffs from his inhaler. I sit the med bag down on the hood of the car and take out the epi after asking the boy’s age and weight, I draw up .15 mg of epi 1:1000 in a 1cc syringe. The child starts screaming when he sees the needle. The mother has to give the child to the father to hold so I can hit him with the shot. IM, instead of SQ, as our new protocols dictate. I stick the needle in and dodge a fiercesome kick. One of my partners then says to the child, its okay, no more shots. In the back of my mind, I am thinking, don’t make promises you can’t keep. I hope no more shots. I think they did give him some benadryl syrup so I can at least hold off on the benadryl, which would have meant another needle.
I ask the parents which hospital they want to go to, and they ask which one is closest and then they ask for directions, and then I say, no, he needs to go to the hospital in the ambulance, with us, one parent can ride along. He needs to be monitored, I say, just in case. When you ingest an allergen, the reaction can come back.
***
Many years ago I did a call for a large man who had eaten several brownies with peanuts to which he was allergic, but he said that he had been hungry and they were so good, he went ahead and had them, and hoped he wouldn’t have a reaction. He was dripping with sweat and vomiting. I hit him with the epi and he was doing a whole lot better until we got to triage when I turned around to talk to the nurse and then turned back and he was out — his BP went down to 60 and he was pale diaphoretic and mottled, and they had to hit him with more epi. He crashed again on them later in the shift. I never forgot that.
***
We get in the ambulance and the boy stops crying and the swelling around his eyes subsides, although he is still very pale. I put him on the monitor. He is afraid that the stickers will hurt, but I say no, and he lets me put them on. His heart rate of 144 slowly goes down to 116. His lungs are clear. His SAT on ambient air is 100%. We take off to the hospital, non-priority, and mom and I have a nice chat about the dangers of nut allergies, etc, while I write my report up, but still keeping an eye on the child.
I call the hospital and tell them we are just a couple minutes away with a child allergic to nuts, who had a reaction, didn’t have his epi-pen, I gave epi, and the child is better. They like it short and sweet.
I’m looking at the monitor and I see the heart rate start to rise, which I find very odd. It goes to 140, and then 150, and then 160, and then 170. The SAT starts to drop as well, 96, 92, 90, 85, 80. The child looks the same. Equipment failure? I check the sensor. It is on solidly. The boy isn’t shaking his finger. He sneezes. “Bless you,” his mom and I say together. He sneezes again. “Bless you.”
“Are you okay?” I ask.
He doesn’t say anything. I stimulate him and he at least looks at me, then he sneezes again and again. I look at the SAT — it still reads 80. As I reach for an oxygen mask and try to think how I will explain this to the parent, I notice, he is rubbing his legs. I look at where he is rubbing — I don’t see any hives, but the skin almost in front of me starts to turn red. His face is flushed now as well.
“He’s having another reaction,” I say.
Just like that multiplying hives appear like in some sci-fi movie of a human turning into a creature. I touch his red bumpy skin and when I move my hand off I see my finger prints. He’s mottling. We’re in the ER driveway now.
I have the epi out, draw it up quickly and hit him again. No resistance from him this time. For good measure, I give him some benadryl IM also. No messing around worrying about another needle. He doesn’t even flinch.
Wheeling him down the hall, we navigate through a maze of stretchers, patients, staff and other EMS people and visitors. I tell the triage nurse the patient has had another reaction. The boy is crying and scratching himself. The nurse directs us to a treatment room.
The boy is doing better now, the hives have retreated almost magically, but his skin is still somewhat mottled. His Sat is up to 98%, but that’s with the 02. We get him over onto the bed, and I give my report to the nurse.
They put in an IV and give him Solumedrol, and tell the mother they will have to keep him at least 24 hours for observation.
After I’ve written my run form I go back to the room, where the child, a non-rebreather on, the swelling much subsided around the eyes, no hives visible, sleeps under the watchful eyes of his mom, who signs the back of our run form agreeing to let us bill the insurance company, and she smiles, and thanks us for helping them, for all we did, for helping her son.
***
A couple final points on epi 1:1000 in anaphlyaxis.
Epinephrine 1:1000 should be given Intramuscularly (IM) when used for anaphylaxis as opposed to Subcutaneously (SQ). We use to give it SQ, but IM results in more rapid absorption and higher plasma concentrations than SQ in patients suffering shock.
Never give epinephrine 1:1000 IV. (Unless diluted to make it epi 1:10,000). This will likely put the patient into VT or Vfib and can obviously be fatal. This has happened in our system.
Use the 1:10,000 concentration IV with caution, push 0.1 mg slowly over 3 minutes and only in patients who remain hemodynamically unstable after IM administration. The dose may be repeated as needed every two minutes to a maximum of 0.3 mg. I have never had to give it this way. I know medics who have and their patient have had runs of VT from it.
***
Epinephrine 1:10,000
Class: Natural catecholamine, adrenergic
Action: Stimulates both alpha (a) and beta (ß1 and ß2) receptors.
Indication: Cardiac arrest – Adult
Cardiac arrest - Pediatric
Anaphylaxis with shock
Contraindication: Use in pregnant women should be conservative
Pre-existing tachydysrhythmias
Side effects: Tachydysrhythmias
Hypertension
May induce early labor in pregnancy
Headache, nervousness, decreased level of consciousness
Dose: 0.5 to 1.0 mg (usual)
Route: IV, IO
ET if given this route the dose should be doubled
Pedi Dose: 0.01 mg/kg (0.1 ml/kg)
Epinephrine 1:1,000
Class: Same as Epi 1:10,000
Action: Same as Epi 1:10,000
Indication: Severe allergic reaction, status asthmaticus,
laryngeal or lingual edema
Contraindication: Use with caution in the presence of:
Pre-existing tachydysrhythmias
Hypertension
Significant cardiac history
Pregnancy
Side effect: Same as Epi 1:10,000
Dose: 0.3 mg
Route: IM
Pedi dose: 0.01 mg/kg (0.01 ml/kg) to a max. 0.3 mg (0.3ml)
See PALS guidelines
For croup administer 5mg (5ml) nebulized with 2.5-3ml of NS
I rank Morphine 2nd out of the 33 drugs I carry.
Albert Schweitzer said, “Pain is a more terrible lord of mankind than death himself…. We must all die. But that I can save him from days of torture, that is what I feel as my great and ever new privilege.”
Like many I began in EMS with visions of saving lives everyday and then having grateful reunions filmed by the crew of the old TV show, Rescue 911.
Now over twenty years into my career, I know that true life-saving calls are few and far between. And many of those few life-saving calls you really don't do much more than you are taught:
Show up on scene, find recently collapsed patient, apply defibrillator, shock, feel restored pulse.
Show up on scene, find cool, clammy patient with chest pain, do 12-lead, see obvious STEMI, call hospital to activate cath lab, transport.
Show up on scene, find child in anaphylactic shock, eyes swollen shut, airway closing off, no blood pressure, stick them with epi, and watch them return to their normal self.
Some patients are just waiting there for us to save them.
And on other calls, you can work your tail off, do heroic things and the patient doesn't make it. It was just their day to die.
Today, I see my job not as a lifesaver, but as a comforter.
My EMT instructor told me the emergency ends when you arrive on scene, or at least that's what you have to make the patient believe.
Today, my reinterpretation of her comments is this; once I am on scene, the patient is no longer alone. I am there to care about them, to provide whatever comfort and care I can, and to try to keep them safe from further harm.
I do that hopefully with a calm voice, a caring touch, understandable words, and with if they are in pain, with everything from pillows and ice to morphine.
"My great and ever new privilege," as Schweitzer says, "is to take care of people's pain."
I can do that, in one way or another, on an almost daily basis.
When I started in EMS, I did not give morphine at all my first year. I gave it only twice for trauma in the next two years, and then in doses too small to provide relief. This is working in a busy system doing 400-500 ALS calls a year.
“I have to hurt looking at you for you to get morphine from me,” an old school medic taught me when I started.
It's a new day.
Last year (out of 312 ALS calls) I gave Morphine 37 times, more than any other drug except Zofran.
I gave it for hip fractures, and ankle fractures, and shoulder dislocations and wrist fractures, for amputated fingers, burns, for kidney stones, and for all sorts of abdominal pains. Did I get scammed a time or two by a drug seeker? Likely I did, but you know what? I don't care. I can say I didn't deny anyone in legitimate pain medication for fear they were drug seeking.
Why is pain management important? Because pain is destructive to the human body. Its only purpose is to alert patients to injury to help eliminate the source of the injury and halt damage to the affected tissue. Untreated, pain stresses the body, damages the immune system, hinders wound healing, and can lead to chronic pain. Not to mention the emotional suffering it causes.
"Prompt treatment of acute pain may prevent both short- and long-term deleterious consequences and resultant chronic pain syndromes.” – Pain Management and Sedation: Emergency Department Management, Mace Ducharme Murphy, McGraw Hill – 2006
Nearly ever study ever done on the issue has showed widespread under use of analgesics in EMS systems and emergency departments across the country.
But times are changing.
When I started as a medic, on-line medical control was required to give morphine. Today, for a 220 pound patient, I can give up to 15 mg (over 20 minutes) on standing orders. Morphine for abdominal pain was prohibited. Today I can give it on standing orders.
I may not be able to save a life everyday, but everyday I can treat my patients with respect and dignity, and if they are in pain, I can ease their suffering.
The oldest mission of medical healers is to treat pain. I accept that mission.
***
Morphine Sulfate
Class: Narcotic analgesic
Action: Decreases pain perception and anxiety
Onset of action: Intravenous – immediate with peak effect at 10 – 15 minutes.
Indications: Moderate to severe pain adults
Moderate to severe pain pediatrics
AMI
Pulmonary Edema
Burns adults
Burns pediatrics
Contraindications: Head injury
Decreased mental status
Multiple trauma
COPD/compromised respirations
Hypotension
Allergic to Morphine, Codeine, Percodan
Side effects: Respiratory depression or arrest
Decreased LOC
Hypotension
Increased vagal tone (slowed heart rate)
Nausea/vomiting
Pinpoint pupils
Increased cerebral blood flow
Urticaria
Precautions: Undiagnosed abdominal pain; Continuous patient monitoring after administration of morphine is required including (when physically possible) pulse oximetry, ECG, capnography (when available), vital signs and respiratory effort; Rapid administration increases the likelihood of side effects.
Adult Dose: Analgesia general: Initial dose 0.1 mg/kg (5 – 10 mg) slow IV over 4 to 5 minutes Repeat dose 0.05 mg/kg slow IV after 10 – 15 minutes if needed
ACS: 2 mg slow IV
Pulmonary edema: 2 – 5 mg slow IV
Pedi dose: 0.1mg/kg (usual dose) slow IV or IM
Route: Slow IV; IO push – slow; IM
Okay, so I am not choosing oxygen number 1. I am choosing oxygen number 3 of the 33 drugs we carry. How can I do this? Well, it's my list and I'll do what I want. Say what I want...
Now obviously I give oxygen more than any other drugs. I don't even have a count for the number of times I give it. It is almost a given in any sick patient, but I do give it far less than I used to.
Here's a couple assumptions I am making to justify oxygen as my third choice. I am going to say I can run nebs and CPAP on regular air. If you won't give me that, I am going to say, the first responders will have oxygen at the scene and if I need it , I will take theirs.
The reason I don't want to take oxygen as my number 1 drug is it is an over-rated drug, a misused drug, and a drug with little evidence-based research behind it. Also, as I said before, it is my list and I want to make statements with my number 2 and number 1 drugs that are more powerful if they are number 1 and number 2, instead of being number 2 and number 3.
The reasons I might want to put oxygen number one is if I have a cyanotic, hypoxic patient I would like to give them oxygen. And I would rather have CPAP and my nebs run on oxygen power. And as far as little scientific evidence, there is just no money in researching oxygen, so I shouldn't hold that against oxygen.
But the number 3 pick is my decision and I'm sticking to it.
I now rerun an earlier post called Oxygen Heresy that further elaborates my thoughts on oxygen in EMS.
***
Oxygen has long been considered the mother’s milk of medicine, particularly in EMS.
The first thing many patients get on arrival of EMS responders is a nonrebreather oxygen mask over their face cranked at 15 lpm whether they are hypoxic or not.
The thinking is it can’t hurt and can only help.
Journal Review
But check out the conclusion of a recent article in the noted British medical journal Heart, Routine use of oxygen in the treatment of myocardial infarction: systematic review, which examined the only randomized placebo-controlled trials of oxygen therapy in MI.
Conclusion: The limited evidence that does exist suggests that the routine use of high-flow oxygen in uncomplicated MI may result in a greater infarct size and possibly increase the risk of mortality.
The authors postulate that high flow oxygen may vasoconstrict the coronary arteries as well as possibly causing increased reperfusion injury.
In an accompanying editorial, Challenging doctors’ lifelong habits may be good for their patients: oxygen therapy in acute myocardial infarction, the editorial writers begin with the following observation:
“Medical history is filled with widely applied therapeutic habits that replicate longstanding practices based upon theories that have no true scientific background.” They note “the extraordinary discrepancy between the high incidence of myocardial infarction, affecting millions of people each year, and the paucity of scientific data on one of its most widely used methods of treatment.”
Their conclusion:
"The case against routine use of oxygen therapy which is presented in the paper from Wijesinghe et al is barely sufficient to formally rule out this technique; it should rather be considered, as the authors state in their conclusion, an incentive to design future trials to assess whether this treatment as used in contemporary practice (ie, guided by arterial oxygen saturation monitoring) is truly useful."
And in a September 2009 article Systematic review of studies of the effect of hyperoxia on coronary blood flow in the American Heart Journal, the authors of the previous article are at it again. This time, in a literature review looking specifically at coronary blood flow and oxygen, they conclude :
CONCLUSIONS: Hyperoxia from high-concentration oxygen therapy causes a marked reduction in coronary blood flow and myocardial oxygen consumption. These physiologic effects may have the potential to cause harm and are relevant to the use of high-concentration oxygen therapy in the treatment of cardiac and other disorders.
Bryan Bledsoe
Bryan Bledsoe, the noted EMS physician and educator, wrote a article in March of this year that also questioned the routine use of oxygen by EMS in The Oxygen Myth. He summarizes research on the use of oxygen in stroke, cardiac arrest, MI, trauma, and neonates, and concludes:
“If the patient’s oxygen saturation and ventilation are adequate, supplemental oxygen is probably not required. ”
American Heart Association
Here’s what the American Heart Association has to say about 02 and MI in the chapter Stabilization of the Patient With Acute Coronary Syndromes, which explains the science behind their 2005 guidelines.
EMS providers may administer oxygen to all patients. If the patient is hypoxemic, providers should titrate therapy based on monitoring of oxyhemoglobin saturation (Class I).
And
Administer oxygen to all patients with overt pulmonary congestion or arterial oxygen saturation _90% (Class I). It is also reasonable to administer supplementary oxygen to all patients with ACS for the first 6 hours of therapy (Class IIa). Supplementary oxygen limited ischemic myocardial injury in animals, and oxygen therapy in patients with STEMI reduced the amount of ST-segment elevation. Although a human trial of supplementary oxygen versus room air failed to show a long-term benefit of supplementary oxygen therapy for patients with MI, short-term oxygen administration is beneficial for the patient with unrecognized hypoxemia or unstable pulmonary function.
Regional Guidelines
My regional oxygen guidelines are confusing. In our appendix, the indication for oxygen is listed as:
Indications: Any hypoxic patient or patient who may have increased oxygen demands for any reason.
Dose: Patient dependent 1 liter/minute via Nasal Prongs to 100% via rebreather face mask.
Under Acute Coronary Syndrome, it says the following:
Oxygen: Oxygen Therapy (90-100%)
Is that 90%-100% referring to the patient’s oxygen saturation or that they should be given a 90-100% mixture of oxygen?
I sit on the protocol committee and would vote for the saturation interpretation, but it needs to be made clearer.
The Future
While we should all continue to follow our own EMS systems current medical guidelines, we may consider that in the future, we may talk about the old days when we gave everyone oxygen.
***
The comment section of my recent STEMI Redux post produded a discussion about the use of high-flow oxygen in the setting of an MI, thus spuring this post.
I previously addressed the issue of changing views on oxygen in a December 2007 post titled Oxygen).
***
Oxygen
Class: Gas
Action: Odorless, tasteless, colorless gas that that is necessary for life. Brought into the body via the respiratory system and delivered to each cell via the hemoglobin found in RBCs.
Indications: Any hypoxic patient or patient who may have increased oxygen demands for any reason.
Contraindications: None for field use
Precautions: If has COPD avoid rebreather or >50% oxygen. However O2 should never be withheld from any severely hypoxic patient (O2 sat <90%) In which case provide oxygen without reservations.
Side effects: Hypercarbia and somnolence in COPD patients who retain CO2
Dose: Patient dependent 1 liter/minute via Nasal Prongs to 100% via rebreather face mask. Note if
mouth breathing only nasal prongs still work.
Route: Inhaled, or delivered via supplemental respiratory drive.
I rank Ativan 4th out of the 33 drugs I carry. I don’t use Ativan very much. I only used it three times last year, but when I use it, you can be sure I need it.
Our indications for Ativan are seizure and anxiety. We can also use it for postintubation sedation if the patient starts bucking the tube, but Versed is preferred.
When I started we carried Valium as our anti-seizure med, and we required on-line medical control to give it due to a quirk in Connecticut’s EMS statutes which required “simultaneous” communication with medical control in order to give a controlled substance. Fortunately, we were able to change the law and enable controlled substances to be given under written standing orders. Eventually our Valium was replaced with Versed and then Ativan was added. Standing orders for seizures only was expanded to standing orders for violent psychiatric patients, and finally, standing orders for general anxiety.
I want to first talk about the use of Ativan for anxiety. Great drug. For violent psychs we use it in combination with Haldol. It takes a little while to work, but if you are patient, it does the trick. If you are not patient and keep the patient agitated, it takes more Ativan and more time.
Ativan for general anxiety also works well. By general anxiety, I am talking about the stressed out housewife whose world is coming undone and she can’t stop crying and won’t get out of bed, and basically has lost all ability to function. Another example would be the jittery man who is pacing back and forth smoking one cigarette after the other, afraid of what will happen to him if he leaves his tiny apartment, and no amount of persuasion can get him leave, including the PEC signed by a mental health doctor. These patients aren't violent, but you just can't get them out of there and they need help.
Ativan is also good for certain patients with respiratory distress who are freaking out because they can’t breathe, which just excacerbates their condition and makes breathing worse. A frantic dsypnic patient is one of my worst nightmares. I hate a sick patient who I can’t get to cooperate with me.
Now as a medic you can get by in these cases without the Ativan. Your powers of persuasion will be tested and you may end up having to physically pick up the patient and carry them kicking to your stretcher. Not the best way to get them to go, but you do what you have to do. And for the frantic breathless patient, same thing, you just have to manage.
Ativan earns it place on the Essential Eight list and its spot as my number 4 drug for it use in seizure. In particular, status epilepticus where the seizure is unremitting and the patient’s airway is impaired.
Your patient is a ten-year old boy in status epilepticus. His entire body is convulsing. His face is blue because as long as he is seizing, he is not breathing. If you have Ativan, you can make this end. Sure, you have to get an IV. While Ativan can be given IM (For us, if you can’t get an IV, we use Versed IM), it takes much longer to work. Now with the EZ-IO, you fail with a peripheral line, you can drill the boy. While I haven’t done an IO in an actively seizing patient and suspect it is somewhat challenging, I think it is probably easier than placing an IV in a seizing patient, something I have done many times.
While “seizure” is a common call, status epilepticus is not a common call. In just about all seizure calls I go to, the patient has stopped seizing prior to my arrival. Typically they are epileptics who haven’t taken their Dilantin or other seizure med and they have a 3 minute gran mal seizure, and are postictal for awhile, and that is about it. But when a patient is still seizing when you come through the door (figure the time to call 911, dispatch you, drive to the scene, get out of the ambulance and walk up the stairs to the apartment seven or eight minutes have elapsed) and that seizure is unrelenting, you have to have your Ativan.
When you do have this scenario, be sure and either be prepared to bag the patient or have your intubation kit at the ready. You can stop the seizure and knock out the patient’s respiratory drive at the same time. It isn’t a bad idea to intubate these patients because they can start back seizing again and you want that airway protected.
I cannot imagine being on a call, and facing a continual seizing patient and not having Ativan or an anti-seizure drug available, I would feel completely powerless.
Here's an excerpt from a post I wrote a couple years ago called Richter Scale
The patient, normally verbal, was very restless in bed, moving from side to side of the bed, unable to focus or answer questions. We got him moved over onto the stretcher and then out to our ambulance. I stayed and waited for the nursing supervisor to finish the paperwork. I asked for the med sheet, but the nurse said the man, who had a history of HTN and NIDDM, oddly wasn’t on anything. I asked how long the patient had been restless and she said it started an hour earlier when the patient was found on the floor incontinent of stool and urine. That didn’t sound like hyperglycemia, it sounded more like a seizure. I noticed on the paperwork the patient was a DNR, so I asked for a copy of that official paperwork as well, which the nurse reluctantly dug out for me.
Out in the ambulance, as my preceptee sunk an IV in the patient’s forearm, I relayed the new information, which was different from what my preceptee had gotten from the other nurse. We put an ETCO2 cannula on the patient, but he kept grabbing at it with his left hand and yanking it off. We held his arm down long enough to get a reading – 35 – normal. There was no Kussmal breathing, no fruity acetone smell to his breath. Our blood sugar came up HI, which means greater than 500. We switched the ETCO2 cannula to a regular nasal cannula thinking the mouth piece was what was bothering him. He reached again and yanked it out of his nose. I was sitting in the right hand seat, and noticed that the patient kept looking at my preceptee on the left bench, but I couldn’t get him to turn and look at me. It was apparent there was something neurological going on. When my preceptee held down his left hand, the patient reached with the right hand to try to yank the cannula out, but he kept hitting his nose and eyes. By now we were going lights and sirens to the hospital, and calling in a possible stroke alert.
To stop him from hitting himself, I held his right arm down. If I was alone in the back I would have been busy doing the 12 lead or making the radio patch, but I was able to just sit there and watch the patient. I felt a little tremor in the patient’s arm. “Get the Ativan,” I said. I felt like a technician watching a Richter Scale needle start to go crazy as the tremor gained in intensity. Run for the hills! The big ones coming! The seizure now apparent to the eye progressed in intensity until it was rocking the stretcher full blown. We were in the parking lot of the ED now. We managed to get the ETCO2 back on the patient and while it showed he continued to breath during the early part of his seizure, his ETCO2 was rising steadily all the way up to 69, by which time we had the ambu bag out and were trying to ventilate him in between suctioning him as secretions frothed from his mouth. The Ativan took effect and the seizure broke finally. He began to breathe effectively on his own again and his ETCO2 came back to normal.
***
Lorazepam (Ativan)
Class: Benzodiazepine
Action: Decreases cerebral irritability; sedation
Effect: Stops generalized seizures; produces sedation
Indications: Status Epilepticus
Sedation for TCP or synchronized cardioversion
Anxiety relief
Delirium tremens (i.e. alcohol withdrawal resulting in tremors, anxiety,
hypertension, tachycardia, hallucinations and/or seizures)
Contraindications: Hypersensitivity to benzodiazepines or benzyl alcohol
Adult Dose: Status Epilepticus: 2 mg slow IV (<2 mg/min) or IM; Repeat if condition persists every 5 minutes.
Agitation / Anxiety Relief: 0.5 – 2 mg slow IV (<2 mg/min) or IM
Pediatric Dose: Status Epilepticus: 0.1 mg / kg (max 2 mg per dose) slow IV (<2 mg/min) or IM
Route: Slow IV (< 2 mg/min) diluted in at least an equal volume of NS; IM (undiluted)
Side Effects: CNS and respiratory depressant
Precautions: Continuous patient monitoring after administration of Lorazepam is required including
(when physically possible) pulse oximetry, ECG, capnography (when available), vital signs and respiratory effort; Rapid administration increases the
likelihood of side effects. IV Lorazepam must be diluted in at least an equal volume of saline and administered no faster than 2 mg/minute.I rank duonebs (albuterol/atrovent) 5th out of the 33 drugs we carry.
We use these drugs together in a nebulizer for wheezing related to asthma , COPD or anaphylaxis. Last year I used these drugs together 11 times and Albuterol alone 10 times. When I worked full-time in the city, during the three years I reviewed (1995-1997), I used Albuterol 36, 42, and 37 times. We did not have Atrovent back then. There is a lot more asthma in the inner-city than there is in the town I work in, although there is more COPD out here. One small difference that may attribute to a lower number this past year is I am more careful about giving a breathing treatment to patients with cardiac asthma -- wheezes likely caused by fluid in the lungs. There is considerable debate about the merit of giving breathing treatments to people in CHF. I have heard much pro and con. I have a few anecdotal calls where I gave a breathing treatment to someone with CHF who then flashed on me, but there are doctors who I respect who say a breathing treatment is okay for CHF. While I await a definitive study, I will continue to use nebs with caution in these patients.
I was initially surprised when I first conceived this list that I ultimately rated duonebs (combivents) as high as I did. I think I sometimes take for granted what breathing treatments do. Someone is having a hard time breathing, lots of wheezes, you give them a treatment, they start breathing better. Pretty routine.
Consider for a moment where the patients might end up if you didn't have the treatments for them. They don't get better, they don’t stay the same, they get worse. Breathing treatments can keep moderate dsypneas from becoming respiratory failures.
My least favorite calls are severe dsypneas where I can see the panic in the patient's eyes (and I hope they can't see mine) as they struggle to get air. The very worse are asthmas, particularly in young people. Anything that can stave off their respiratory arrest is gold in my book.
On a curious note, the OPALS trials (large and well-respected clinical trials in Canada) which showed that the introduction of ALS (to areas that previously were only BLS) made no difference in mortality for cardiac arrest or trauma, but did make a difference in respiratory emergencies, suggested that the difference in respiratory mortality was not subject to advanced life-support techniques, but to the introduction of nitro and nebulized breathing treatments.
The most substantial change in therapeutic intervention was the marked increase in the use of medications for symptom relief; this intervention is not a component of advanced life support, and it was implemented as part of a separate program. Thus, the benefit of the intervention in this trial may have been primarily due not to the availability of advanced-life-support techniques but to the use of nebulized salbutamol and sublingual nitroglycerin.
Check out the Article here:
Advanced Life Support for Out-of-Hospital Respiratory Distress
As a side note, we were recently approved to use CPAP in asthma and COPD. I haven’t used it yet for these indications.
***
Ipratropium (Atrovent)
Class: Anticholinergic Bronchodilator
Action: Relaxes bronchial smooth muscle
Effect: Bronchodilation
Indication: For use in severe COPD and Asthma cases after Albuterol
Contraindication: Hypersensitivity to ipratropium
Dose: 0.5 mg (2.5ml)
Route: Nebulized updraft
Side effects: Tachycardia, palpitations, headache
Albuterol (Ventolin, Proventil)
Class: ß2 Agonist
Synthetic sympathomimetic
Bronchodilator
Action: Stimulates ß2 receptors in the smooth muscle of the bronchial tree.
Indication: Relief of bronchospasm.
Contraindication: None for field use.
Precaution: Patient with tachycardia.
Side effect: Tachycardia
Dose: 2.5mg (0.5ml of the 0.5% solution diluted to 3ml NS) for nebulized updraft.
May repeat in 10-20 minutes.
Route: Inhaled as a mist via nebulizer.
Pediatric Dose: 2.5mg nebulized updraft. May repeat in 10-20 minutes.
I rank duonebs (albuterol/atrovent) 5th out of the 33 drugs we carry.
We use these drugs together in a nebulizer for wheezing related to asthma , COPD or anaphylaxis. Last year I used these drugs together 11 times and Albuterol alone 10 times. When I worked full-time in the city, during the three years I reviewed (1995-1997), I used Albuterol 36, 42, and 37 times. We did not have Atrovent back then. There is a lot more asthma in the inner-city than there is in the town I work in, although there is more COPD out here. One small difference that may attribute to a lower number this past year is I am more careful about giving a breathing treatment to patients with cardiac asthma -- wheezes likely caused by fluid in the lungs. There is considerable debate about the merit of giving breathing treatments to people in CHF. I have heard much pro and con. I have a few anecdotal calls where I gave a breathing treatment to someone with CHF who then flashed on me, but there are doctors who I respect who say a breathing treatment is okay for CHF. While I await a definitive study, I will continue to use nebs with caution in these patients.
I was initially surprised when I first conceived this list that I ultimately rated duonebs (combivents) as high as I did. I think I sometimes take for granted what breathing treatments do. Someone is having a hard time breathing, lots of wheezes, you give them a treatment, they start breathing better. Pretty routine.
Consider for a moment where the patients might end up if you didn't have the treatments for them. They don't get better, they don’t stay the same, they get worse. Breathing treatments can keep moderate dsypneas from becoming respiratory failures.
My least favorite calls are severe dsypneas where I can see the panic in the patient's eyes (and I hope they can't see mine) as they struggle to get air. The very worse are asthmas, particularly in young people. Anything that can stave off their respiratory arrest is gold in my book.
On a curious note, the OPALS trials (large and well-respected clinical trials in Canada) which showed that the introduction of ALS (to areas that previously were only BLS) made no difference in mortality for cardiac arrest or trauma, but did make a difference in respiratory emergencies, suggested that the difference in respiratory mortality was not subject to advanced life-support techniques, but to the introduction of nitro and nebulized breathing treatments.
The most substantial change in therapeutic intervention was the marked increase in the use of medications for symptom relief; this intervention is not a component of advanced life support, and it was implemented as part of a separate program. Thus, the benefit of the intervention in this trial may have been primarily due not to the availability of advanced-life-support techniques but to the use of nebulized salbutamol and sublingual nitroglycerin.
Check out the Article here:
Advanced Life Support for Out-of-Hospital Respiratory Distress
As a side note, we were recently approved to use CPAP in asthma and COPD. I haven’t used it yet for these indications.
***
Ipratropium (Atrovent)
Class: Anticholinergic Bronchodilator
Action: Relaxes bronchial smooth muscle
Effect: Bronchodilation
Indication: For use in severe COPD and Asthma cases after Albuterol
Contraindication: Hypersensitivity to ipratropium
Dose: 0.5 mg (2.5ml)
Route: Nebulized updraft
Side effects: Tachycardia, palpitations, headache
Albuterol (Ventolin, Proventil)
Class: ß2 Agonist
Synthetic sympathomimetic
Bronchodilator
Action: Stimulates ß2 receptors in the smooth muscle of the bronchial tree.
Indication: Relief of bronchospasm.
Contraindication: None for field use.
Precaution: Patient with tachycardia.
Side effect: Tachycardia
Dose: 2.5mg (0.5ml of the 0.5% solution diluted to 3ml NS) for nebulized updraft.
May repeat in 10-20 minutes.
Route: Inhaled as a mist via nebulizer.
Pediatric Dose: 2.5mg nebulized updraft. May repeat in 10-20 minutes.
I rank Normal Saline 6 out of the 33 drugs we carry.
When I started as a paramedic the goal for every major trauma patient was to have two large bore IVs running wide open. The mark of a stud paramedic was getting your shooting victim to the trauma room in world record time while also getting bilateral 14s on the way and showing up with the bags at least half empty. 2 14s meant nothing if you only ran in 100 cc in each. Of course, we eventually learned that while trying to stay ahead of the blood pressure curve, we were actually accelerating it by pushing oxygen carrying blood out of the leaky circulatory system with replacement water and harming the body's ability to clot the holes.
I remember one shooting I responded to while backing up another medic. While he tried to intubate, I slammed a 14 into the AC and I never saw the fluid run like it did. It ran through the drip chamber like Niagra Falls. It seemed like in only a minute the bag was empty. It was then we noticed a spreading wet pinkish damp on the man’s tee-shirt near the arm pit. In addition to multiple torso wounds, he had also been shot in the upper humerous and the bullet had evidently severed the vein the fluid was running through as it gushed out of his shoulder as fast as it gushed into his AC. Another street fatality in that hot gang-fed summer.
Now, while all of my major trauma patients get two large bore IVs (if I have spare time and always enroute), instead of hanging IV bags, even at KVO, I just pop in locks. Locks have the added benefit of not getting snagged when we transfer the patient over to the trauma bed, causing the IVs to be torn out (How I hated that!).
So why is Saline on my Essential Eight list? It can still be a life-saving drug to support blood pressure and hydration, in addition to being a great comfort drug. Hypotensive septic patients get the large bore wide-open treatment. Patients in DKA get a liter over an hour, and more if they are also hypotensive. Syncopes with resulting hypotension get boluses until their pressure stabilizes. And all those dehydrated vomiting old ladies get nice fluid boluses.
Now I am not saying it is me, let’s say it is a paramedic friend I know. We’ll call him Ernie. Anytime Ernie gets the flu, he either gives himself or gets one of his partners to give him a bag of Saline IV over an hour. He is pretty adept at sticking himself – the hard part is holding pressure on the vein while he pulls the needle out and attaches the IV drip set to the remaining catheter. Ernie uses his chin. So sometimes he spills a little blood in the exchange, but not too much. Ernie feels so much better after awards. He is truly a new man, so Ernie likes to bolus his sick patients and when they say they are feeling better after the fluid, he knows what they mean. A little Zofran and some fluid, along with a gentle ride and some caring words and we are at the heart of what paramedicine is all about.
We also carry Lactaed Ringers, although as of the last year we are no longer required to carry it. There are subtle differences between Saline and Ringers (and those differences are subject to debate and MD preference), but perhaps not important enough for our transport times. I usually reach for the Saline.
We also use Saline (sometimes with Morgan Lenses) to flush chemicals out of eyes.
And while not a direct use of the drug, the outer packaging of Saline bags when wrapped around a flashlight makes an excellent lantern in dark rooms without working light bulbs.
I rate Dextrose (D50) 7 out of the 33 Drugs we carry.
We use D50 for altered mental status due to hypoglycemia (where the patient is too altered to drink juice).
I live in a big diabetic town. I gave D50 19 times last year. I sometimes joke that I am known as King Sugar to the diabetic ladies in my town.
If I didn't have D50, a few of these patients I might be able to arouse with oral glucose, but certainly not all of them. Some would probably be all right on the transport into the hospital with just supportive care until the hospital could give the D50, but some clearly would not. There are the seizing diabetics, the combative diabetics, the out cold gurlging diabetics and the three-hundred pound plus dead weight out cold diabetics all with sugars way below the level needed to keep their brain mentating.
An IV, some D50 (or as I have been doing more and more often, either D25 or D10 to cut down on vein injury and to make their post D50 hangover less severe. Also, some of my patients I can only get a 24 in, and pushing D50 through a 24 in a tiny hand vein is a workout - D25 goes easier), and a few moments of waiting and their eyes are open, and they look around and apolgize for inconviniencing us.
When we arrive, a first responder may say, "You are going to need the stair chair." I say, "No, I'm just going to wake them up."
Here's one of my favorite diabetic stories I posted in February of 2006:
Snow
The snow is coming down in near white out conditions. At one point we lose the road the snow bank kicking up snow that completely obliterates our view through the windshield. We arrive at a townhouse apartment complex where we have been called for an unresponsive diabetic. Carrying our blue house bag, heart monitor, and 02 tank, we wade through drifts up to our waist to get to the door.
An old Jamaican woman meets us at the door in her bathrobe and says her sister is upstairs on the bed. We have been to this house many times before. The sister is in her eighties. She is supine across the bed, snoring, her skin cool and clammy. We check her sugar. Our glucometer reads “LO” which means less than 20. I get a line and push in an amp of D50. She opens her eyes to a sternal rub now, but is still mostly out of it. I give her another half an amp and she now has her eyes fully open and looks around at us quizzically. “What hap’en?” she asks.
“Your sugar was low,” I say. “Less than 20.”
“No, my sugar is high,” she says, “I write it right down dere in de book.”
“No, it was less than twenty.”
“No, it isn’t low. Me write it down in de book before me go to bed.”
“You sugar went down. You must not have eaten.”
She listens seemingly intently to what I say. I think I am getting through, but then she says again, “My sugar high. I write it down in de book.”
Finally her sister says, “Dis is anothder day now dear.”
We finally got her straightened out and have her sitting at the kitchen table eating a big Jamaican meal of stew chicken and rice and peas.
“What do you think of the snow storm?” I ask.
She looks at me with one eye cocked, uncertain what I am saying.
“Look outside,” I say.
My partner opens the door for her to see.
It is a winter wonderland outside, nothing but white powder.
Her eyes widen. Her mouth opens, but no words come out. She looks like a little five-year old Jamaican girl seeing snow for the first time.
***
I always try to talk the now alert patients into going to the hospital, but if they have a good story why their sugar dropped (forgot to eat), they live with someone else, they are on insulin, and this has happened to them before, then as long as their friend or family member agrees to watch them, they agree to follow up with their doctor, and I watch them eat something, taking a refusal is okay. It is the noninsulin dependent diabetics, the first time hypoglycemic shock patients, the people with no reason for their sugar to have dropped and the person who lives alone, you need to be careful about.
On quite a few occasions I have gotten a person back with D50, persuaded them to go to the hospital, and had them crash again on me in the ambulance. You can never be too careful.
I don't really know at what point having low blood sugar starts to cause irreversable harm, but I have worked cardiac arrests and presumed a number of patients who were diabetics and had low blood sugar at the time of their death.
This is the account of one such death:
I rank Narcan 9 out of the 33 drugs we carry.
We give it for suspected opiate overdose where the patient is breathing less than 8 times a minute or is otherwise hypoventilating.
I only gave Narcan once last year. True, I no longer work in the inner-city where I gave it a fair amount more, but I also give it far less routinely than I once did.
The following is excerpted from a post "That Narcan Shit" from December of 2008.
When I was in paramedic school one of my instructors boasted of fellow medics bringing junkies into ERs with a loaded narcan syringe in the junkie's IV, and slamming the Narcan as they'd go through the ED door so the junkie would sit up and puke all over the medic's nemesis -- the evil nurse at triage. We all thought that was funny in class, and while I have heard versions of this story told by many people from many parts of the country, I never did it and never saw anyone do it or even heard of it really truly happening.
I did, however, slam Narcan into lots of junkies and wake them up. When I say slam, I'm not taking about pushing the Narcan in like I push Adenosine, but I probably pushed it as fast as I would push a routine flush. In other words, too fast for narcan.
I'd slam it. They'd puke, curse, rip their IV out and stalk off. One guy I found in an abandoned building. His brother had flagged us down. The man had been missing for a day until his brother discovered him. He was out cold, but he was still breathing. I was real new and excited and so I am sure I pushed the Narcan way too fast. I probably gave the full 2.0 dose all at once as well. The next thing I knew the man who was now semi-awake was in such severae pulmonary edema that I was hitting him with Lasix (a drug for another blog post). The sudden pulmonary edema was completely unexpected. I asked a doctor at the ED about it, and she said, it can happen when you push Narcan. I'd had no idea.
Over the years my practice has changed. Maybe I was improperly instructed at the beginning, but I went from putting an IV into every junky and slamming the Narcan to doing it IM or SQ and pushing it very slowly and just a small amount (0.4 mg) at a time. Just enough to get their respirations going and not even wake them up fully.
Slamming a full dose of Narcan is not a good thing to do. Its puts them into sudden withdrawal and that is not good. Nor is the violence that may ensue.
It used to be if I was called for an OD and the patient had used Heroin, they got Narcan even if they were breathing okay. As long as they were slightly altered, I'd hit them with it. Even if they were talking to me. I thought that was what I was supposed to do.
"Did you do drugs?"
"No."
"Then why do you keep dropping asleep?"
"I didn't do drugs."
I'd push the Narcan. They are wide awake and puking. Stupid. Them and me.
"Did you do drugs?"
"No."
"Then why are you wide awake now and puking?"
I don't give narcan now as much as I used too because I don't work in the city nearly as much, plus now, like I said, I only give Narcan if I suspect an opiate overdose and the patient's respirations are extremely depressed. Sometimes I bring Heroin users in to the hospital and the first thing the hospital staff does is give the patient Narcan. Wake them up and make them puke. I shake my head. That's just no way to treat people. Put them in a hallway and let them sleep it off -- as long as they are breathing okay.
We also used to give Narcan as a diagnostic for coma of unknown etiology. That was an indication listed in our protocols. We removed that indication several years ago, and I think it is a good thing.
Here's two cases where I gave narcan to coma of unknown origin with bad consequences.
1. I had just started as a medic and found a paraplegic unresponsive in bed. He was a young guy who had been shot a few years before and ended up like he did -- living in a small room with a bed, a big screen TV and stacks and stacks of DVDs. He was stuporous when I found him. I should also point out he had a bad fever. Knucklehead that I was, seeing his pin point pupils and all the prescription pain pills -- opiates -- I zapped him with Narcan. So now I went from a patient in a semi-coma due to a fever to a patient in a semi-coma due to a fever in excruciating pain. He became extremely agitated with good reason. I'd just zapped all the pain medicine he needed to tolerate living into the ether. My bad.
2. Called for a possible stroke, I found an 80-year-old female with altered mental status of sudden onset, unable to speak or respond. I loaded her quick, raced toward the hospital, calling in a stroke alert. I then happened to notice her pupils were pinpoint so, as a stab in the dark, I gave her Narcan. Amazingly she woke up within a minute. I told the driver to slow down and called the hospital back to say never mind about that stroke alert. I had woken granny up with narcan. The odd thing about it was I couldn't find any opiates on her list of meds and she denied taking any drugs or even having a secret stash of cough syrup. Strange. At the hospital, her whole family was gathered around laughing with her when suddenly she gorked out again. She had a head bleed and her waking up (her lucid interval) had just happened to correspond with my giving her Narcan. So narcan as a diagnostic had actually led me to the wrong diagnosis.
Rogue Medic and Ambulance Driver have some excellent material on this whole issue of the inappropriate use of Narcan.
Narcan Solves the Riddle, Part I
More Rogue Medic Narcan Posts
Ambulance Driver Article "Naloxone: The Most Abused Drug in EMS"
I particularly like this quote from a Boston Medic that Ambulance Driver cites in his article:
"Addicts take opiates and other sedatives specifically to induce a pleasant stupor. If they’re lethargic and hard to arouse, but still breathing effectively, it’s not an overdose. It’s a dose.” – experienced Boston paramedic
Rogue Medic sites an excellent study done years ago in LA.
The empiric use of naloxone in patients with altered mental status: a reappraisal.
The study asked the following questions:
# 1 - Can clinical criteria (RR of 12 or less, pinpoint pupils, and circumstantial evidence of opiate abuse) predict response to naloxone (Narcan) in patients with acute alteration of mental status (AMS)?
# 2 - Can such criteria predict a final diagnosis of opiate overdose as accurately as response to naloxone?
-Hoffman JR, Schriger DL, Luo JS. The empiric use of naloxone in patients with altered mental status: a reappraisal. Ann Emerg Med. 1991 Mar;20(3):246-52
730 patients with Altered Mental Status received narcan prehospitally from paramedics brought to two LA hospitals over 1 year period
Only 25 patients (3.4%) demonstrated a complete response to narcan
32 (4.4%) manifested a partial or equivocal response.
673 (92%) had no response.
19 of 25 complete narcane responders (76%) were ultimately diagnosed as having overdosed
2 of 26 partial responders (8%) (with known final diagnosis)
4 of 195 non-responders (2%) (with known final diagnosis). Note: They only reviewed 195 of the 673 non responder charts.
Of the 25 complete responders to Narcan
19 had opiate overdose
6 had seizure or closed head injury.
Their conclusion was:
“The study indicates that there is no diagnostic benefit derived from the administration of naloxone to all AMS patients.”
“In addition, response to naloxone created a substantial amount of diagnostic confusion...”
-Ann Emerg Med. 1991 Mar;20(3):246-52
That study came out when I was still as EMT.
Good lessons, as I had learned the hard way.
The bottom line:
Just because they woke up after you gave them narcan doesn't mean they woke up because you gave them narcan.
So you ask, what do I do if I don't have Narcan in my kit (Narcan being the bubble drug that just didn't make the Essential Eight)? The answer is I bag the patient or pop in an LMA or even intubate until the patient rouses (sometimes a good stimulation like an OPA in the throat is all an apneic Heroin addict needs), the Heroin wears off ,or I can get the patient to the hospital. But let's say I have a third floor carry-down and my patient is 300 pounds, well then my Essential Eight List becomes an Essential Nine, and Narcan is in the club
***
Naloxone (Narcan)
Class: Narcotic antagonist
Action: Reverses the effects of narcotics by competing for opiate receptor
sites.
Will reverse respiratory depression cause by narcotics
Indications: Suspected overdose with depression of respiration and/or hypoxia
Contraindication: none for emergency field use
Side effect: Narcotic withdrawal
Dose: 0.4mg to 2.0mg - titrate to respiratory effort
Route: IV push; IM; IN; ET
Pedi dose: 0.1mg/kg (max 2 mg per dose)
I rank Aspirin (ASA) 10 out of the 33 drugs we carry.
We give ASA to patients with suspected acute coronary syndrome. The American Heart Association rates the early administration of Aspirin as a Class I intervention. The literature is overwhelming in support for ASA. It is inexpensive, safe and reduces mortality and morbidity.
I gave it 36 times last year.
Why don't I rate it higher? It is the same reason I didn't give it more.
I used to carry the bottle of Aspirin in my pocket and see how quick after I 'd walked in the door I could say open wide and pop those four little pills in. Now Aspirin use has become so prominent that many of my patients have already self-administered Aspirin before I get there -- either they took it themselves, were given it by a friend or coworker or a medical professional on the scene gave it to them. When I do bring them to the hospital, the first question I am asked is "Did they get Aspirin?" If not, the hospital staff are quick to dole out the dose. If I didn't carry it, they would still all get it in a quite timely fashion.
I do have a recurring issue with Aspirin that I have never gotten a definitive answer on. I don't think a definitive answer exists. The question is: should someone on Coumadin take Aspirin? Many doctors, most in fact, have told me yes, in an emergency setting in the presence of chest pain, it is fine. Others, and a fair number of others, including a local cardiologist who was handing a STEMI patient off to me, told me no. I think it probably is just a matter of preference. When, and this happens often, a patient tells me they can't take Aspirin because they are on Coumadin, I just say fine, we'll defer to the doctor at the hospital. I could bully them into taking the Aspirin, but why in such a stressful moment get them upset.
I know one medic who risked blinding a patient by forcing Aspirin on him after he had experienced chest pain while undergoing a delicate eye procedure at a local doctor's office. There was a big to-do about this. The I-can-do-no-wrong medic evidently got in a shouting match with the doctor, who ordered him not to give the aspirin because of the extreme danger of bleeding in the eye due to the surgery. You do need to be careful. When in doubt, defer to the hospital.
I gave Aspirin to a patient with a head bleed once thinking she was having an MI. The call was for chest pain, I got tunnel vision. A misread 12-lead (ventricular strain pattern), and habit(get the aspirin in quick), caused me to pop the ASA down the hatch before I did my full assessment and history taking. If there were strings attached to those little orange tablets I would have pulled on them to bring those babies up from her gullet.
Bottom line. Aspirin is a great drug that belongs on every ambulance. I try to cast a wide net when I give it (I don't have to be 100% certain the patient is having cardiac pain -- if it is pleuritic pain, well, the Aspirin will make them feel better anyway), but I never press it on a patient and try to do a full assessment first. If Aspirin wasn't so widely available to patients, I would give it far more than I do.
***
I recieved an interesting email from a respected reader on the ASA/coumadin issue:
I asked your question to an ED attending that I know well. He's also toxicologist so she's a great resource. The short answer is that you can give ASA to someone taking Coumadin. The slightly longer answer is that they do different things. ASA interferes with platelet aggregation, while Coumadin thins the blood. Since they do different things, the only contraindication to giving ASA is allergy to ASA. I also asked him about having 9-1-1 operators instruct patients to take ASA before EMS arrives and he feels that it is very beneficial. In fact, he said that of all the things we do for MI patients none is more important than giving ASA. So, go ahead and give that ASA to chest pain patients that you think are having ACS or an MI.
***
Aspirin (Acetylsalicylic acid)
Class: Antiplatelet
Action: Inhibitor of platelet aggregation
Effects: Decrease clotting time
Indication: Chest pain of cardiac origin
Contraindication: Allergy to aspirin
Dose: 325mg tab or 4-baby aspirin (81mg per tab)
Route: PO
Side Effects: None with field use
I rank Amiodarone 11 out of the 33 drugs we carry.
I know the literature for Amiodarone is almost as weak as the literature for Lidocaine. I will leave the recommendations up to the AHA (currently they recommend amio for VT with pulses while leaving you the option of lidocaine or amio for VFIB/VT without pulses -- that may all change in October with the new recommendations scheduled to come out). I have chosen Amio over Lidocaine as my antiarrythmic of choice based largely on personal, unscientific anecdote.
The years have given me a certain hard-won calmness on the job, but there are a few calls out there that get me a little uptight amomng them -- bad respiratory distress and symptomatic VT in a patient who is still talking to me.
I read a cardiology book once where a wise old doctor sighted his preference for medication over electricity by saying that electricity always (at least briefly) produces asystole. Asystole is death and death isn't a good thing, so you want to avoid asystole if you can. I like that man's thinking.
Our dose for VT with pulses is to draw up 150 mg of Amiodarone, mix it in a 100 ml bag of fluid and run it in over 10 minutes. If I am only carrying 250 bags, I will spike the bag, pull out the spike, squirt out 150, then put the spike back in. In the story below I posted back in 2006, we had just gotten Amiodarone, and instead of mixing the Amio, I gave it as a bolus like we do in cardiac arrest. I could argue that since I was uncertain how unstable the patient was I gave the VT with pulses dose at the VT without pulses rate. In truth, I just wanted to get the drug in her and did the simplest quickest thing I could. I have noticed as a clinical coordinator, that this is the most common medication error. Likely a combination of ignorance, panic and unwillingness to risk waiting 10 minutes to give the whole dose, medics slam it in. That can lead to hypotension. I know better now. I also have a little more confidence the Amiodarone will work. Here's the story:
What's Going on Back There?
"Woman not acting right according to her husband. History of lupus," the dispatcher tells us.
It is a nice house in a residential neighborhood in the north section of town. We back in the drive, and then wheel the stretcher in through the open garage door.
"You don't need that. She can walk out," an officer says, as he comes out of the door leading into the house.
So we leave the stretcher in the garage and walk into the sparely furnished spacious house. Inside we find a woman in her thirties sitting in a chair with a faraway look in her eyes. "She's not acting right," her husband, a large muscular man in a orange shirt that is the color of a prison jumpsuit, says. "It is not her at all. This been going on all day."
I approach her and have her squeeze my hands. She has equal grips. I raise my arms and she keeps holding my hands. "Let's go and keep your hands up." She lets go and keeps her arms up. While they appear a little unsteady, there is no drift. Her pupils are equal but not reactive at all to my penlight. "Are you in any pain?"
She shakes her head.
I ask the husband what hospital he wants us to take her too. He tells us. I ask if he knows her meds.
"I have them right here," he says. He is holding her pocket book.
"Any drugs or alcohol?" I ask.
"No," he says, sounding close to being offended.
It is genneraly my style to do as much as I can while transporting. If the patient doesn't appear critical or to need an immediate intervention, I tend to always do my workup in the back of the ambulance on the way to the hospital. We are about twenty minutes from the hospital. I expect to have a complete assement, history, and basic ALS done along with my runform written by the time we hit the hospital. I help her up and we walk out to the garage where my partner has set up the stretcher. The woman appears slightly unsteady, so I hold her left arm as we walk.
The husband steps up into the back of the ambulance with us. "No, you have to sit in the front," I say. For a moment I think why not let him sit there. I can the history I need from him without having to schooch up to the front to talk to him, but I have another partner in the back with me and I am going to do an ALS workup, so I guess I'd rather not have him back there.
My partners are fairly new to EMS. Driving for the first time is the young man I wrote about in the story Compressions. In the back with me is another new EMT, who is very eager, but still needs more seasoning. My partner takes her blood pressure while I strap a tourniquet on her arm. He gets 160/100. That's certainly noteworthy.
She is watching me as I look for a vein. She seems almost like someone who is high. I'm wondering if she is seeing tracks when I move my hand in front of her eyes. It is very strange.
I get a flash on the IV, and withdraw the needle, and start drawing blood. I have about half a tube, but it is drawing so slowly, I decide to just attach the saline lock. I detach the vacutainer, and while I am clamping down on the vein with my left hand, suddenly the patient starts to shake. She isn't just shaking, she is seizing violently.
"What's going on back there? What's going on?" the husband demands.
"She's having a seizure," I say. "It's okay; I have medicine to stop it."
"What's going on? What's going on! Is she all right?"
I am holding on to her arm, clamping the vein off for dear life. She is having a gran mal seizure. I can't reach my narcs, which are locked up in a cabinet behind the captain's chair. I'm not panicked because I'm thinking maybe she had a seizure earlier and was acting so weird because she was postictal. Besides, most seizures stop after a couple minutes anyway. I have to believe hers will stop, or hope so at least. I'm going to give her a minute or two to find out. While she is still flailing I manage to get the saline lock attacked to the catheter and taped down.
Then she stops seizing. She sits there now, looking off to the left. She is awfully still. I don't think she is breathing. I look at her closely, but I can't see any movement. I do a sternal rub. No response. I don't feel a pulse, but we are bumping down the road so I can't be certain.
The man in front is flipping out. "Shouldn't we be going faster? Shouldn't you have the lights on? Is she all right?"
"Get out my airway kit," I say to my partner, while I quickly put her on the monitor. I need to see what is going on. I'm hoping for a nice sinus tack.
Here's what I see:
I cut off her shirt and slap the pads on.
"Step it up to a three," I say to the driver.
I am tempted to shock her, but I flash back to calls I have had in the past where a patient suddenly went into v-tack and I shocked them -- few with a good outcome. I shock them, they die. First shock doesn't do anything, second shock kills them. Not everytime for sure, but several memmorable times. I had patients who were talking to me. I'd shock them, and they would say -- they both in fact said the same words. "You're killing me." I'd apologize, hit them again, and they would die. In ACLS they teach you to jump to electricity if the patient is unstable. I remember one teacher saying "Go ahead and jolt em!" But I don't think she has seen what I have. I don't like electricity on a live person. But on the other hand -- not only is she not talking, she might not even be breathing. I can't readily tell. She is having a period of post-seizure apnea or she is breathing mightly lightly. I do have an IV. My med kit is on the bench next to me. There is that line in the ACLS books about giving a brief trail of meds if there is time. She is going to need me to breathe for her in a minute, but she should still have some good oxygenated blood in her. I unzip the med kit and pull out a vial of amiodarone. I draw up 150 mg and push it in into the lock. I look at the monitor.
EMS is all about the action, but sometimes it’s about waiting.
What happened? I'm thinking. Did she seize because she was in v-tach or did she go into v-tack because of the seizure? It was a true gran mal seizure, not a hypoxic seizure. People stop breathing after a seizure sometimes, but then start up again. But she's in v-tack. What the ? What do I do?
"What's going on?" the husband is shouting. The driver has one hand on the wheel and the other trying to hold the man into his seat.
Should I shock her? If I do, the next minute I know I'm going to be doing CPR. But soon I am going to have to do something more. I can't wait too long.
Should I have the driver pull over and grab a board out of the outside compartment so we can lay her down on it and verifying that she is pulseless start CPR? How is the husband going to act?
I look back at the monitor.
Whew! She is out of v-tack. Thank the Lord. The amio worked. I'm not certain if it’s a sinus tack or a rapid afib. The rate runs from 140 to 170.
I have the ambu-bag in my hand, but now I tell my partner to get a nonrebreather out of the cabinet.
I have a pulse. There's some small chest rise. I get a blood pressure 170/120. She still doesn't respond to a sternal rub. We check her blood sugar. HI, which means it’s over 600.
I try to patch to the hospital, but all I can hear on the radio is a high-pitched whine.
"What's going on? What's going on back there?" the husband demands.
The whining stops on the radio and when I ask if the hospital is on, the operator tells me they are off now, but he will try to get them back on. They come back on, I give my patch, but get no acknowledgement.
I put in another IV and start running fluid in. She is still unresponsive. Her rhythm is looking better.
I think about tubing her, but she is satting at 98%, so I just watch her airway.
We park at the hospital, and the husband, comes around to the back and when we open the doors, he sees her laying there, her breasts hanging out in the open. I quickly grab a sheet and cover her up.
The husband wants to know what's going on. I tell him I'm not really certain. She had a lethal heart rhythm, but she's out of it now. Her sugar is high. He confirms she is not a diabetic and has never had seizures before.
We wheel her in. They never got our patch so they are not expecting us. They quickly get us a room. She is responding to the sternal rub now, and mutters a few words. I give my report while they get the rest of her clothes off.
When her lab results come back, her sugar is 1200, and most of her electrolytes are way out of whack.
The nurse tells me her husband kept saying how slow we drove to the hospital.
Here’s what her final rhythm looked like when we turned her over.
I'm been doing nothing but nursing home, doctor's offices, visiting nurse, and minor MVA calls. I knew I was due.
Maybe if I shocked her, she would have converted and been okay. Maybe not. I'm glad it worked out the way it did. I wish I had her on the monitor before she seized, curious what her original rythmn was. If she had seized a few minutes later I would have had her on there. I'm glad I already had the IV in.
"Woman not acting right according to her husband. History of lupus," the dispatcher tells us.
You never know in this job.
***
Amiodarone (Cordorone)
Class: Antiarrythmic
Action: Reduces myocardial cell membrane excitability by increasing the
effective refractory period
Inhibits alpha and beta adrenergic stimulation, causing peripheral
vasodilation and decreased heart rate
Indication: Cardiac arrest -- ventricular fibrillation
Wide Complex Tachycardia w/pulse>150 bpm
Contraindication: none for cardiac arrest, contraindicated for wide complex tachycardia
with hypotension (synchronized shock indicated). Bradycardia.
Dose: Cardiac arrest – 300 mg IV; May repeat at 150 mg
Wide Complex Tachycardia w/pulse>150 bpm – 150mg IV over 10
minutes
Drip – 1mg/min
Route: IV
Side Effects: Hypotension, bradycardia, headache, dizziness, nausea, vomiting
I rank Atropine 12 out of the 33 drugs we carry.
Aside from routine use in cardiac arrest, I use Atropine two or three times a year for patients with symptomatic bradycardia. I have no reason to believe it does any good at all in cardiac arrest, but as far as symptomatic bradycardia, as long as the patient is not in a third-degree block, I have had good success with Atropine.
Earlier in my career, I used Atropine a bit more, but that was before I knew that many people thanks to beta blockers had every day pulses in the high 40's, low 50's. I also used to more readily give it to a patient having an MI (heart attack), which can increase their oxygen demand and cause more damage. Now I only give it to patients having an MI if they are hypoperfusing. Ah, the learning curve.
The best bradycardia calls are for the patient passed out in the bathroom. You find them on the floor, cold and clammy, no pressure, pulse in the 20's. Straining to go to the bathroom, their vagus nerve overpowered them, knocking their heart rate down and they lacked the ability to rebound on their own. We used to give a full amp of Atropine, now we give 0.5, and if that doesn't work another 0.5 mg, etc. A couple times I have given the full 1 mg by mistake. Old dogs. Still the drug works well, the pulse picks up, the patient wakes up, the skin colors up and drys out and all is well in paramedic land. "You fixed them," the doctor says to me in the ED. Music to my ears.
If I don't have atropine in my kit, I can always pace the patient. Other options are Dopamine and an epi drip.
***
We can also give Atropine to organophosphate poisionings, but I have never had one.
***
Atropine (Atropine Sulfate)
Class: Antimuscarinic
Parasympathetic blocker
Anticholinergic
Action: Blocks acetylcholine (ACh) at muscarinic sites
Indication: Symptomatic bradyarrhythmias
Cholinergic poisonings
Asystole
Refractory bronchospasm
Contraindication: Relative contraindication wide complex bradycardia in the setting of acute ischemic chest pain
Side effects: Tachyarrhythmias
Exacerbation of Glaucoma
Precipitation of myocardial ischemia
Dose: Bradyarrhythmias - 0.5mg , may repeat every 3-5 minutes
Asystole - 1mg IV MR (May repeat) IV q 3-5 minutes (total max. dose 3mg)
Organophosphate poisonings - 1mg - 2mg; may repeat as needed
Route: IV push
Pedi dose: 0.02mg/kg IV
I rank Dopamine 13 out of the 33 drugs I carry.
We use Dopamine for cardiogenic shock or septic shock refractory to fluids.
I have never used a lot of Dopamine over the years. When I started we carried Dopamine in vials and had to mix up our own drips. Working as a single medic, if I had a patient who needed Dopamine, they usually needed too much attention from me for me to break away and mix up a drip (and we had fairly short transports to the hospital). Over the years I have grown more comfortable with mixing drips, while at the same time we now carry a premixed Dopamine. Lately I have started to use Dopamine more with return of spontaneous circulation (ROSC) from cardiac arrest. I have had success to the extent that where before I often lost pulses after regaining them as the epinephrine wore off, I have had many more patients gain and hold a decent pressure once I have the Dopamine hung. Still, most of these patients end up dying in the ICU.
If I am giving someone Dopamine, as I said before, they are pretty bad off. I have only ever given it twice for septic shock after having dumped a liter of fluid into a patient with no change in hypotension, but I don't know the patients' final outcomes.
I rate Dopamine where I do because it at least has the potential to be a lifesaver.
We don't carry med pumps so the drip is pretty much of an eyeball, and then titrate to blood pressure. When you have no pressure, you bump it up. You get a pressure above 90, you ease it down.
Several times at the hospital I have had to warn nurses about shutting the Dopamine off completely. Recently I brought in a cardiac arrest ROSC with a BP of 120-something systolic, the nurse shut off (unhooked) the Dopamine because the pressure was good. I said, you might not want to do that, but she never hooked it back up, and when I came back from writing my run form,they were doing CPR. They eventually got pulses back and ended up putting the patient back on Dopamine. Like so many others, she made it to the ICU only to die within a few days.
I only used Dopamine once last year, but have used it twice so far this year. All three cases were post-rescucitation care.
***
Dopamine (Intropin)
Class: Naturally occurring catecholamine, adrenergic agents
Action: Stimulates α, β1 and dopaminergic receptors
Effects: 0.5 to 2 μg/kg/min - Renal and mesenteric vasodilation.
2 to 10 μg/kg/min - Renal and mesenteric vasodilation persists and
increased force of contraction (FOC).
10 to 20 μg/kg/min - Peripheral vasoconstriction and increased FOC (HR may
increase).
20 μg/kg/min or greater - marked peripheral vasoconstriction (HR may
increase).
Indication: Shock - Cardiogenic
- Septic
- Anaphylactic
Contraindication: Pre-existing tachydysrhythmias or ventricular dysrhythmias.
Precaution: Infuse in large vein only
Use lowest possible dose to achieve desired hemodynamic effects,
because of potential for side effects.
Do not D/C abruptly; effects of dopamine may last up to 10 minutes after drip
is stopped.
Do not mix with NaHCO3 as alkaline solutions will inactivate dopamine.
Side effect: Tachydysrhythmias
Ventricular ectopic complexes
Undesirable degree of vasoconstriction
Hypertension relate to high doses
Nausea and vomiting
Anginal pain
Dose: 2.0 - 20. μg/kg/min titrated to desired effect
Route: IV drip
Pedi dose: same as adult dose - titrate to effect
I rank Zofran 14 out of the 33 drugs I carry.
Zofran is an anti-emetic. When I started as a medic, we had Dramaine for motion-sickness, nausea. Then we got Reglan, then we got Phenergan, and now (once it went generic) finally we have Zofran. All I can say is Horray for Zofran!
I gave Zofran to more patients (41) last year than any other drug, more than aspirin, more than nitro, more than breathing treatments. It is a excellent drug. I give it to anyone who is vomiting or nauseaous. While it hasn't worked on every patient, since we got Zofran, it is an extremely rare event that I got vomitted on. And while a few patients may continue to feel nauseous, most say they feel better.
In putting together this list, it is hard to weigh all the variables: does the drug safe lives? does it do something that needs to be done right away? does it make the patient feel better? does it truly work? and often do I use it?
I can't say that Zofran is a life-saving drug, but it is an excellent comfort drug. It is rare that I am ever nauseous, but the few times I have been, it is a truly awful experience. It makes you feel subhuman, pathetic, and puny. Zofran gives patients their dignity back, in addition to keeping the floor of my ambulance clean.
I keep a stash of Zofran in my bench seat IV tray, next to the Aspirin and Nitro, so it is right there at the handy.
"This should help with your nausea," I say.
Horray for Zofran!
***
Ondansetron (Zofran)
Class: Antiemetic; Serotonin Receptor Antagonist, 5-HT3
Action: Selectively antagonizes serotonin 5-HT3 receptors
Indication: Nausea; Vomiting
Contraindication: Hypersensitivity to Ondansetron
Precautions: Hypersensitivity to other selective 5-HT3 antagonists
Adverse effects: Headache (40% incidence)
QTc Prolongation
Tachycardia; Anginal chest pain (rare)
Constipation; diarrhea; dry mouth
Dizziness (5% incidence)
Transient Blindness (rare)
Pregnancy Class: B
Adult Dose: 4 mg or Slow IV over 2 – 5 minutes
Pediatric Dose: 0.1 mg/kg (max. single dose of 4 mg) IM or slow IV over 2 –
5 minutes
Routes: Slow IV over 2 – 5 minutes
Notes: Ondansetron causes less sedation and incurs minimal risk of
dystonia as compared to other antiemetics such as
Promethazine (Phenergan ®), prochlorperazine
(Compazine®), or Metoclopramide (Reglan®).
I rank Cardizem 15 out of the 33 drugs I carry.
We didn't have Cardizem when I started as a medic. If we had someone in rapid afib and they were unstable enough we could shock them. I never had such a patient, and a good thing. As I have said before, I am not a fan of electricity unless my patient is in vfib or VT without a pulse. Shocking talking people -- not for me. I remember many years ago when I was a brand new EMT in Massachusetts, we had taken a patient into a small hospital and there in the ED they had a young man in a rapid tachycardia that they hadn't been able to break with medicine. They had given him a sedative, and after waiting for it to take hold, applied the shock. The kid, who was probably fifteen or so, but with the build of a football player, came off the table in pain, and then he lay there on his side whimpering. They still hadn't broken the rhythm. They gave him some more sedative, and waited. I couldn't stand to watch it. I heard his scream from the entryway.
Once we got Cardizem, it took me a little while to get the hang of it. You have to push it slowly, and you need to be patient. It is not the sudden fix that Adenosine is. Initially I was frustrated because while I would get a response (the rapid afib might decline from the 160-170's to the 110-120's, by the time I was in triage it would be back up in the 150-160 range). I started giving a small rebolus that seemed to help. Eventually, we had drips added to our guidelines and now I always hang a drip. I put 25 mg in a 250 ml bag. I set it at 5mg/hr and if I notice the rate inching up, I up the drip. It works great. I usually always do two lines, one to give the Cardizem through and one in case their pressure drops and I need to give them a bolus.
I do rapid afibs fairly often in the town I work in because of the large elderly population. The call usually comes in as an elderly person feeling weak and dizzy. I may find them sitting in a recliner, pale, and just looking sick. I did one just last week. I remember saying to my partner it sounded like the prototypical call in our town, old sick person wants to go the hospital, likely they have the flu. In the house, I introduce myself and my partner, ask a few quick questions (how to you feel? any trouble breathing? any pain?) and inquire what hospital they want to go to. I help them to the stretcher and then we take them out to the ambulance. Unless someone is really sick or having chest pain, I rarely do much in the house. Out in the ambulance, if I haven't already done so, I get them in a Johnny, listen to their lungs, and while my partner gets a blood pressure, I put them on the heart monitor. Sometimes, I just tell my partner to head to the hospital nonpriority while I do the BP.
So I put the guy on the monitor, and son of a gun... "Well, there's your problem," I say.
Our Cardizem used to come in a syringe with powder in one chamber and a dilutant in the other that we would mix together, now it comes in a vial that we have to keep chilled or else we have to change it out every month. Since we got the cooler for the hypothermia protocol, we keep our Cardizem in there. Well, I put in a line and then draw up the Cardizem; I go into my rapid afib talk. "It's pretty common in people as they age -- it is not a heart attack. Remember when the elder George Bush passed out and threw up on the Japanese ambassador (they all remember) -- his problem was he was in rapid afib. It can be controlled with medicine.” I explain the anatomy of the heart, the atria and the ventricles, and how his atria are not pumping properly, not flushing all the blood out and how longterm if not corrected this can lead to a stroke. I tell them the medicine I am about to give them should slow their heart down to a more normal rate and they should start feeling better. And they usually do.
The American Heart Association 2005 Guidelines include a line in their rapid afib algorithm that we do not include in ours. That line is "expert consultation." It comes before cardizem. More specifically, they write "We recommend a 12-lead ECG and expert consultation if the patient is stable." I was at an EMS conference shortly after the guidelines came out and was able to ask a doctor who had participated in writing this section of the guidelines what the AHA meant by the "expert consultation" line, and he basically said, it meant if the patient was stable, medics should leave them alone until a doctor can examine the patient.
It is hard to disagree with that, but at the same time, while the patient is stable, they are feeling pretty miserable and at least in our area, if we don't give them Cardizem, the ED will, so the doctors at our medical advisory committee felt the paramedics could be trusted to go ahead and make the patient more comfortable and take care of the problem. They basically left the choice up to us. If the patient is feeling crappy, and there are no contraindications, I usually give them the Cardizem. If they say they feel great and are only going to the hospital because they were at the doctors for a routine physical and the doctor while doing a routine ECG, discovered they were in a rapid afib in the 160s, then I leave it alone.
***
Diltiazem (Cardizem)
Class: Calcium channel blocker
Action: Partial blockade of AV node conduction
Indication: Atrial fibrillation, Atrial flutter, narrow complex tachycardia
Contraindication: Hypotension
Hypersensivity to drug
Wide complex tachycardia
Known history of Wolf Parkinson White (WPW)
2° or 3° AV block
Relative contraindication: Already on Digoxin and Beta Blocker
Side effect: May induce VF if given to patient with wide complex tachycardia that is due to WPW.
May cause hypotension
Dose: Initial dose: 0.25mg/kg slow IV (average dose 20mg in adult male)
May repeat with 0.35 mg/kg (25 mg average) in 10-15 minutes if no or
diminishing effect. Decrease by 5 mg per bolus for elderly (>70 yr/old).
Route: IV push (bolus) given over 2 minutes; reconstitute according to
manufacturer’s recommendation.
Pedi dose: 0.25mg/kg
Important points: If patient is hypotensive secondary to drug administration:
- If not in failure give IV fluids
- If bradycardic administer CaCl2
- If still bradycardia give Atropine
- Transcutaneous pacing may be necessary for markedly symptomatic
bradycardia.
- If CHF is present or worsens administer Dopamine infusion
- If all of above fail (persistent hypotension >2-5 minutes) administer glucagon
1 mg IV
My choices are getting harder and harder as my drug box shrinks.
Alas, today I rank Adenosine 16 out of the 33 drugs I carry.
I wrote quite a bit about Adenosine a few months ago in a post Adenosine/PSVT that first got me thinking about doing a series on the drugs I carry in my med bag.
While I only give Adenosine a few times a year, it has always been one of my favorite drugs. It is a great paramedic drug because you can fix the problem on the spot and the results are dramatic. Someone calls 911 because they are weak and clammy and they feel this rapid palpitating in their heart. You try to feel a pulse and you can’t. You put them on the monitor and behold they are cranking away at 220. You turn the monitor toward your partner and away from the patient’s view. My hands always used to shake when I’d do the IV for this type of patient (prestage performance anxiety). Fortunately this patient has a nice big fat AC and the catheter easily sinks in.
You carefully explain what you are about to do, how you will inject some medicine in the IV line that will soon fix their problem, while it may make them feel a little strange, but that strange feeling will pass quickly, you add. You slam the drug in, followed by a flush. The person gets a weird expression on their face, while your audience – partner, bystanders gasp as the monitor goes asystole, and then weird funky beat, weird funky beat and then a few more weird beats and the person is back in a regular rhythm at 80, and they feel so much better and you feel so much better and you print out the strips and show the printout to the patient and say this was your heart going 220 and then here’s what happened when I gave you the medicine and you felt all weird, see that flat line -- that was you -- and then here’s you now, good as new, and you -- the paramedic -- are everybody’s hero.
So why only 16 out of 32? Well, there are many great drugs still to come, and while great, if I didn’t have Adenosine, I could try Cardizem or Amiodarone, or if I have to, I could shock the person back to a regular rhythm (I’m not a big fan of this).
I have had a few patients who found Adenosine so uncomfortable, that they have asked to be cardioverted (shocked) instead. Once I offered a trial of Cardizem and it worked great. There was no dramatic asystole, just an easy slowing. The other patient I convinced to let me give them Adenosine with success.
Farewell, Adenosine, old friend. (I am glad it is only a mock farewell.)
***
Adenosine (Adenocard)
Class: Endogenous nucleoside
Action: Stimulates adenosine receptors; decreases conduction through the AV node
Indication: PSVT
Contraindication: Patients taking Persantine or Tegretol.
Precaution: Short half-life must administer rapid normal saline bolus immediately after
administration of drug. Use IV port closest to IV site.
Side effect: Arrhythmias, chest pain, dyspnea, bronchospasm (rare)
Dose: Adult - 6mg IV over 1-2 seconds; may repeat 12mg twice at 2 minute
intervals. Pedi - 0.1mg/kg, may repeat twice at 0.2mg/kg
Route: Rapid IV push, followed by a flush
I rank Glucagon 17 out of the 33 drugs we carry.
We primarily use Glucagon for hypoglycemia when we cannot get an IV and the patient isn't alert enough to drink juice. I did not use Glucagon at all last year. I gave D50 19 times. My secret EMS pride has always been my IV skills. I like to think of myself as a Zen master of IVs. And so I know I am hexing myself when I write this -- I know somewhere out there right now a diabetic with no veins is slipping into unconciousness, and I will be summoned to perform, and then empty catheter wrappers all around me, I will despair to the heavens that I have lost my IV karma and at last reach into my kit for the Glucagon. For all the IVs I have gotten, I have been humbled as well.
Sure Glucagon is great to have when you have an unresponsive diabetic and you can't get a vein, but you do have options. You can choose between the tube of glucose in the rectum or the EZ-IO. One is painful for me when the 350 pound diabetic wakes up and wonders why his butt is sticky, the other is painful for me watching the patiient writhe in pain while I push the D50 into his leg bone. I have never availed myself of either option and hope never to have to. Fortunately I don't have to really take Glucagon off my truck and should have it always available.
There are some drawbacks to Glucagon. It doesn't always work. Glucagon converts the liver glycogen to glucose, but if the person doesn't have any glycogen stores, then there is nothing to convert and so no revival. If a diabetic has a hypoglycemic episode on Monday and is given Glucagon, and they have another hypoglycemic episode on Tuesday, it is quite likely that the Glucagon won't work on Tuesday like it did on Monday because the Monday dose used up the stores and they haven't had time to rebuild back sufficiently.
Also, Glucagon doesn't work right away like D50. It is much slower acting. I have had people rouse anywhere between 3 and 20 minutes after I gave them the drug.
***
There are other uses for Glucagon. We can give it in beta blocker overdose. In cases of "persistent hypotension or symptomatic bradycardia refractory to atropine and fluids," we can consider Glucagon at 0.1 mg/kg (max 5mg) IV. Repeat every 5 minutes as needed. There's the problem. The dose is way more than any ambulance carries. Glucagon is very expensive and comes in 1 mg vials (actually 1 mg of powder and 1 vial of dilutant that are combined and mixed to become active.) We carry two mgs in our kit and maybe another 3 mgs in our spare box. Glucagon has a very short half-life (3-6 minutes) while a beta blocker like Propranolol has a half life of 12 hours. An old medic I know told me about a beta blocker overdose he did many years ago where the hospital sent ambulances out to other hospitals and ambulance companies to bring back more Glucagon because the hospital had exhausted its stores treating one patient.
***
Glucagon can also be used to help dislodge food caught in the esophagus. I used it this way once for a lady with a fish bone caught in her throat, but I had no immediate suuccess with it. It is not a magic bullet instant results drug like adenosine, narcan or D50. I know a Doctor who treats food caught in the throat by giving the patient glucagon, having them take a nitro, and then drink a soda. We carry nitro, but have no sodas, not even in the cooler where we keep the chilled saline we use for our induced hypothermia protocol.
***
Glucagon
Class: Pancreatic hormone
Action: Increases blood glucose by converting liver glycogen to glucose
Indication: Hypoglycemic patient who does not have IV access
Beta-blocker or calcium channel blocker overdose
Food bolus impaction in the esophagus
Contraindication: Known hypersensivity
Pheochromocytoma / insulinoma
Precaution: Mix with own diluent - do not mix with saline
Side effect: Nausea / vomiting
Hyperglycemia
Dose: 1mg (1unit)
Route: IM
Pedi dose: 0.5 - 1mg
I rank Magnesium 18 out of the 33 drugs we carry.
I use magnesium very rarely. I used it once years ago for a patient in Torsades de Pointes with success. The call was an emergency transfer from the VA hospital to an acute care hospital. We arrived on the floor to find a breathless nurse telling us her patient had gone into cardiac arrest and she had performed two minutes of CPR before the patient opened her eyes and came back to life.
Yeah, right, I thought.
The patient was sitting up in bed reading a romance novel when we were introduced to her. A nice lady in her sixties who didn’t understand what the fuss was about. We chatted with her as we put her on our stretcher, and then just as we started wheeling her out the door, she passed out. I looked at the monitor – V-fib. I reached for the monitor and was gelling up the paddles when she opened her eyes and sat up. She was back in a sinus rhythm. I looked at the strip I'd recorded and saw the episode wasn’t v-fib, but the classic low amplitude/high amplitude/low amplitude of Torsades. In the ambulance, she went out again. I had just drawn up the magnesium when she revived. She wasn’t out but thirty seconds. I injected the magnesium into a small bag of saline and hooked her up to the drip, and she had no more episodes as long as she was with me, which admittedly wasn't but another ten minutes.
A couple times I have used magnesium on cardiac arrests where the v-fib looked like it might be Torsades, but was likely just v-fib.
We can also use magnesium for eclamptic seizures. I have never had one of these calls, but I did fictionalize one in my novel:
Overbrook was in the Charter Oak public housing complex just a few blocks away from our location. Two story brick buildings built during World War II were laid out around several oval roads. The buildings looked in disrepair, the grass was burned. Shirtless children shouted and waved at us as we approached. Ahead we saw a parked police car and 463, its lights on and back door open.
The stretcher was outside the building in low position with the straps undone and the sheet spread out.
“They upstairs,” a young boy said. “Davey’s sister sick. She got the shakes.”
I followed Troy up the narrow staircase to the second floor. He took the steps three at a time, easy as walking.
We entered the apartment that smelled of rancid hamburger.
“Let them do their jobs!” I heard someone bark.
A man and woman were yelling at a police officer in the room at the end of the hall.
“Just take her to the hospital!” the man shouted.
“Calm down or I’m going to have to arrest you,” the officer said.
“That’s my daughter!” the man said.
“She’s sick! Lord, she’s sick!” the woman cried.
We pushed into the room. “Coming through,” Troy said.
A young woman lay on the bed convulsing, arms and legs jerking together. She had an oxygen mask on her face. She had to be two hundred twenty pounds. On the wall was a shelf of teddy bears and a poster from Disney’s Beauty and the Beast.
Andrew Melnick, a short, skinny paramedic, just twenty years old, was trying to tape an IV down on the woman’s jerking arm. Blood backed up in the IV line. Melnick’s hands shook.
“What do you have?” Troy asked.
“Lord, help my baby!” The woman cried.
“Take her to the hospital!” the man shouted. His breath reeked of alcohol. The police officer pushed him back. “Calm down or you’re out of the room.”
“Everyone quiet!” Troy said.
“She said she had belly pain,” Andrew said. “Then all of a sudden she started seizing. I just got a line and gave her five of Valium, but it’s not working.”
“Did you get a pressure before she started?”
“230/130.”
“Is she pregnant?”
“Pregnant? My daughter not pregnant,” the man said.
“She’s a good girl!” the mother shouted. “A church girl!”
“Take her to the hospital before she dies!”
“That’s it, you’re out of here.” The officer grabbed the man by the arm.
The IV line was knocked loose. Blood squirted in the air.
“Lee hold her shoulder,” Troy said. “Get some tape on that. Andrew get me an 18.” He knelt on the woman’s forearm to hold it steady and took the IV catheter Andrew handed him. “She’s got to be eclamptic.”
“But she said there was no chance.”
“Look at her pants. That’s not pee, she broke her water.”
Her sweat pants were soaked at the crotch. The smell wasn’t urine.
Troy had the IV in. “Give me some mag.”
Andrew fumbled with the one cc syringe as he tried to stick the needle into the small vial of magnesium I had handed him from the med kit. He pulled the plunger back. The drug drained into the chamber.
“Easy, my friend,” Troy said. “Get it in there and push it slow.”
Andrew again had trouble as he tried to stick the needle through the rubber port on the IV line.
“Easy,” Troy said. “That’s it. Now push slow.”
I felt a tension easing in the girl’s arms. The seizure stopped.
“Get your airway kit out,” Troy said.
The woman lay still. Her chest wasn’t moving. She wasn’t breathing.
“Bag her,” Troy said. He tossed me the ambu-bag as Andrew unzipped his airway kit and fumbled to get out the laryngoscope.
I applied the mask over her face, holding a tight seal around her mouth and bending her head back to keep her airway open as I squeezed the bag.
“How my daughter doing in there?” the man shouted.
The cop barred the doorway.
“Just fine,” Troy said to the man. “I’m shutting the door.” To us, “She still has a good pulse. Tube her.”
Andrew nudged me to the side and stuck the scope in her mouth and swept her tongue to the side, peering in looking for her vocal chords.
“She’s bradying down,” Troy said, “Get that tube in.”
“I can’t see the chords.”
Troy reached up and pressed on the front of the woman’s neck.
“I think I’m in,” Andrew said.
“You’re not,” Troy said. “I didn’t feel it pass.”
“Heart rate’s thirty,” I said.
“No, I’m in.”
“Pull it out,” Troy said.
Andrew attached the ambu bag to the end of the tube. Gave one squeeze. The bag didn’t reopen. I saw the belly rise. He pulled the bag off. Vomit surged out of the tube.
“Listen to me next time,” Troy said. “No, leave the tube there. Go in above it. Don’t go in so deep this time. She’s anterior.”
Troy handed him another tube. He went back in. More puke came out of the other tube.
Andrew’s partner turned his head. I could hear him vomit.
“Rate’s fifteen.”
Troy pressed his fingers against the neck again, just below the Adam’s apple. “That’s it. I felt it pass.”
Andrew attached the bag. This time you could see vapor in the tube. Good chest rise. Troy listened with his stethoscope while Andrew bagged. “Nothing in the belly. Good on the left. Nothing on the right. Pull back a little. That’s good. Solid placement. Tie it off. Yank the other tube.”
“Rate’s coming up,” I said.
But Troy wasn’t looking at the monitor. “We’ve got company.”
“What?”
Troy had pulled the woman’s sweat pants down. There between her legs was a bloody motionless baby.
“Throw me a blanket.”
I handed him a towel that was by the bedside.
Troy lifted the child and rubbed it with the towel. He brought the baby up to his mouth and gave it two breaths. He moved his fingers up and down on its chest. In between breaths, he told Andrew how to set up a magnesium drip, while Andrew’s partner bagged the woman through the tube.
“Drip set,” Troy said, “Hang it from the wall hanger. Lee get her on the board and strapped tight.” He gave the baby two more breaths. “Andrew get the infant ambu out, then get the OB kit and let’s get the chord cut.”
It was hot in that room, and I was sweating too, lifting and turning the woman to get the board under her and the straps around her fat. I was so busy I didn’t have time to stop and admire Troy, the calm he displayed. He kept us focused. At his direction I unhooked the woman from the monitor, and applied patches to the baby, who they laid on the short board on the dresser. Its color wasn’t quite as mottled. Troy had a tube in the baby’s mouth, and coached Andrew inserting a small catheter into the umbilical vein.
“Nice job,” he said to Andrew. “A little epi, a little atropine, and maybe things will be all right. You know the dose?”
“I have a field guide.” He reached for his side pocket.
“.01 per kilogram for the epi. .02 for the atropine,” Troy said. “Let’s make it .35 ccs for the epi and 1 cc for the atropine.”
The baby’s rate came up to 140. Troy stopped the compressions. Its color was close to pink now. “Attention all,” Troy announced. “In case you haven’t noticed. It’s a boy.”
***
The newest use for magnesium is as an IV drip in severe asthma. I have never used it (partialy because my old dog brain can never remember that we can do this now), but the few medics I know who have used it swear by it. I think if I had had this experience, I would likely list Magnesium higher.
***
Magnesium Sulfate
Class: Electrolyte
Action: Facilitates the proper function of many enzyme systems in the body
Facilitates the Na-K magnesium dependent ATPase pump
Blocks calcium non-selectively
Indication: Polymorphic ventricular tachycardia (Torsades de pointes)
Refractory or recurrent VF or pulseless VT if has documented
hypomagnesemia
Eclampsia
Severe Asthma
Contraindication: None for field emergency use
Precaution: Use with caution or not at all in the presence of renal insufficiency
or high degree AV block.
Side effect: Hypotension - mild but common
Heart block - uncommon
Muscular paralysis, CNS and respiratory depression - toxic effects
Dose: Torsades (pulseless)
- 2 grams over 1-2 minutes
Eclampsia
- 4 grams over IV drip over ½ hour if actively seizing
VF/VT (suspected hypomagnesemia)
- 2 grams IV bolus
Severe Asthma
- 2 grams in 100cc over 10 minutes IV infusion
VT/Torsades with a pulse
- 1- 2g slow IVP over 5 - 60 min
Route: IV drip or IV push
I rate Benadryl 19 out of the 33 drugs we carry.
We use Benadryl as an antihistamine in allergic reactions and anaphalaxis. We can give it IV, IM, and since we just got the pediatric syrup, we can give it PO.
An ED doctor told me once, Epi stops the reaction and Benadryl cleans it up. So while Benadryl is a great drug for allergic reactions, it is not the ultimate life-saver epi is. Also, I have found that quite a number of the allergic reactions I do, the patient has already gotten Benadryl either from a family member or a medical person like a doctor or school nurse. Still I would hate to not have Benadryl in my kit. Like Zofran and Morphine, it is a great comfort drug, making the patient feel so much better.
***
We also use Benadryl for dystonic reactions. Dystonic reactions are something to see. The person's neck and face and arms get all contorted and jerked up -- its a reaction to certain drugs.
I have probably only done five of these calls in all my years.
Here’s one I did a few years ago called Escaped Mental Patient.
A guy escapes from a mental health floor of a local hospital, hitchhikes to his friend's house, then sits on the porch waiting for the friend to get home. Suddenly, he starts to feel his neck tighten up, and his face and arms. He can't move them. Panicking, he staggers out into the road, lurching in and out of traffic, trying to get someone to help him. He thinks he is dying.
Finally someone calls 911 and reports a crazy man wandering in and out of traffic who appears sick or deranged.
When we get there he is very scared and anxious. I ask him what meds he is on, and he says he has been on Haldol for the last four days.
That's the answer right there. Haldol can cause dystonic reactions, which produce symptoms just like the man is having.
I give him 50 mg of Benedryl IV and within minutes he can move his neck and face and arms.
"I thought I was dying," he says. "I can't believe no one stopped to help me. Aren't people supposed to help others in distress."
"They probably thought you were an escaped mental patient," I say.
"I thought I was going to die," he says.
**
Another indication we used to use Benadryl for (before we carried Haldol), was adding it to Ativan to calm violent psychs. It didn't work as well as Haldol.
***
Diphenhydramine (Benadryl)
Class: Antihistamine
H1 blocker
Action: Blocks histamine receptor sites
Indication: Systemic anaphylaxis
Drug induced extrapyramidal reactions
Contraindication: None with emergency use
Precaution: Asthma
Side effect: Sedation
Hypotension
Dose: 25 -50mg
Route: IV push, may also be given IM
Pedi Dose: 1mg/kg
I rank Versed 20 out of the 33 drugs we carry. If we did not also carry Ativan, I would have ranked it much higher.
We use Versed for a number of purposes.
1. We give it IM (intramuscular) or IN (intranasal) to seizing patients if we are unable to get an IV. If we get an IV we give Ativan.
2. As post intubation sedation for patients who start to buck the tube.
3. As sedation for patients who we pace or cardiovert.
4. To reduce shivering in patients with return of spontaneous circulation (ROSC) who we have initiated the hypothermia protocol on.
I have given Versed IM several times to seizing patients, but have yet to have it work well. In each case however, I was able to get an IV and give Ativan, which ended the seizures. Whether or not the Versed would have eventually done the trick, I don’t know. We just got the intranasal indication for Versed, but haven’t yet gotten our drug changed to the proper concentration to give it IN so I haven’t obviously used it this way yet.
I have used versed postintubation and found it worked great. We recently allowed Ativan to be used this way as well. I still use Versed.
I have never used it for pacing or cardioversion (I haven’t paced or cardioverted anyone since we got the indication), but I have used it many times for patients whose internal defibrillators were going off.
This seems to be an increasingly common call. Perhaps because more and more people are getting the devices. I have had some patients tell me that their doctors have told them only to call 911 if the defib goes off more than once. While I have had some people call after one firing – these are usually patients who are experiencing it for the first time – most patients who call are having to go off with some frequency. Once I had a patient have his go off while he was testifying before the state legislature. I can only imagine how that looked. Maybe it appeared like the chairman of the committee was zapping him because he didn’t like his answers. It is quite painful to observe. I usually give Vered and Amiodarone (if I see VT on the monitor), and have had very good results (although sometimes I think their defibs stop firing because they have stopped walking around and are now resting). A couple times I have had patients who reported 20 plus firings and who fired actively in front of me, but then never fired again once they laid down on the stretcher. Sure I gave them amiodarone, but it took awhile for the IV and then 10 minutes to drip the amio in.
I have also used Versed as part of the induced hypothermia protocol.
***
Midazolam (Versed)
Class: Benzodiazepine (short acting)
Action: CNS depressant
Effect: Sedation
Indications: Pre-cardioversion; TCP; seizure control; sedation post-intubation
Dose: 2-5 mg (0.1 mg/kg); Administer 50% dose to patients >70 years old: IN dose:
Adults over 50kg, 10mg (2ml) of Midazolam; Pediatrics 0.2mg/kg not to
exceed 10mg.
Route: Slow IV push; IM; IN
Side Effects: Decreased level of consciousness
Hypotension
Respiratory depression
Special Information: Any patient receiving Versed must be closely monitored. This
must include (if physically possible) pulse oximetry, ECG, capnography (if
available), all vital signs and respiratory effort.
For IN doses, load syringe with appropriate milliliter volume of midazolam
(use only 5mg/ml concentration) and attach MAD nasal atomizer . Administer
half volume as atomized spray to each nostril.
I rank Solu-Medrol 21 of the 33 drugs we carry.
Solu-Medrol is a systemic steroid that works as an anti-inflamatory.
We used to carry 1 gram vials of Solu-Medrol to give to head injured patients until studies showed that it wasn't the best thing for them to be getting. Now we give 125 mg Solu-Medrol slow IV to patients having asthma and COPD exacerbations, and those having allergic reactions.
The drug has a funny little mechanism on the vial, where we push down on the top and it releases the rubber chamber divider enabling you to shake the bottle and mix the powered drug with the solution so you can draw it up. I always enjoy watching my preceptees try to figure out how it works the first time they have to give it. "Like this," I always end up saying as I demonstrate.
It is my understanding that Solu-Medrol doesn't reach its peak effect for 6-12 hours after we give it, but that studies have shown the earlier it is given, the less likely the patient will have to be admitted to the hospital.
I had a hard time remembering to give the drug when we first got it for these indications, but now I am getting better and am fairly used to giving it and do it routinely now, perhaps not on all calls I should, but certainly on the more serious ones.
You could say we go without carrying the drug without much harm to the patients, but the question is how quickly does the hospital jump to give the drug if EMS has failed to. I would say our giving the drug right away may save the patient an hour (from when we can give the drug to when he would otherwise get it in the hospital), which may make a difference.
***
Methylprednisolone (Solu-Medrol)
Class: Steroid
Glucocorticoid
Anti-inflammatory
Action: Thought to stabilize cellular and intracellular membranes
Indication: Asthma attack of greater than 2 hour’s duration,
Anaphylactic reaction
Contraindication: none for emergency field use
Dose: Reactive airway disease - 40 to 125mg
Pedi dose: Reactive airway disease - 2 mg/kg (max 125 mg)
Route: IV push – slow
I rank Sodium Bicarbonate 22 on my list of 33 drugs. I rate it above calcium partly because it links me more closely with Johnny and Roy, and more importantly because it can be used for tricycliate overdose, and for crush injuries (I have never used it for these indications).
I use it only sporadically in cardiac arrest -- when I have gone through everything, but am not quite ready to quit, and only then if the patient has renal failure issues.
* crush injuries are not in our protocol, but if we encountered one, we could call medical control for permission to use sodium bicarbonate. It is my understanding that it should only be given for crush injuries of major extremities after lengthy entrapment, and that it should be given just prior to release of the limb from whatever has been crushing it.
***
Sodium Bicarbonate (NaHCO 3 )
Class: Alkalotic agent
Action: Increases protein binding of tricyclic antidepressant and shunts potassium intracellularly as well as increasing renal elimination. Neutralizes acid in the blood. May help pH return to normal limits.
Indication: Tricyclic antidepressant overdose, hyperkalemia (consider strongly if cardiac arrest in renal dialysis patient).
Contraindication: Digitalis, Respiratory acidosis
Not to be used routinely in cardiac arrest (exceptions noted above).
Side effect: Metabolic alkalosis
Lowers K+ which may increase cardiac irritability
Worsens respiratory acidosis if ventilation is inadequate
I rank Calcium 23 out of 33 drugs I carry.
I don't use calcium very much, but there is one situation I always reach for it in -- cardiac arrest in a diaylsis patient. While we don't have labs in the field, a dialysis patient is a possible bet to be hypocalcemic and/or hyperkalemic, and calcium can save lives if they are. We can also consider calcium in the setting of calcium channel blocker overdose.
I can't claim any arrest saves using it, but I have had quite a number of return of spontaneous circulation and hospital admissions after I have used it.
We can also use calcium for symptomatic bradycardia due to suspected calcium channel blocker overdose with medical control orders. I have never used it for this.
***
Calcium Chloride
Class: Electrolyte
Action: Facilitates the actin/myosin interaction in the heart muscle.
Indication: Hypocalcemia
Hyperkalemia with arrhythmia
Calcium channel blocker intoxication with hypotension or symptomatic bradycardia
Contraindication: Not to be mixed with any other medication - precipitates easily.
Precaution: Patients receiving calcium need cardiac monitoring
Side effect: Cardiac arrhythmias
Precipitation of digitalis toxicity
Dose: Usual dose is 5-10ml of 10% Calcium Chloride in 10ml.
Route: IV
Pedi Dose: 0.2ml/kg of 10% concentration
***
Here's an excerpt from my novel, Mortal Men, that includes a call where Calcium is used:
“The real rivalry between Troy and Ben started the day Sidney coded,” Joel said. “Sidney Seuss -- he’s the guy in the portrait in the front office. He founded the place. A real old time ambulance man. He was just getting ready to start his dialysis treatment – he had his own machine in his office - when he crumpled to the ground. His secretary screams. When Ben gets there, he sees Sidney lying on the carpet. He’s blue. No breathing, no pulse. Ben rips Sidney’s shirt open, puts the paddles on his chest. He’s in v-fib. He shocks him. 200 Joules. No change. Shocks him again. 300 Joules. Nothing. 360. Nothing.
“The secretary starts CPR while Ben goes for the airway. Sidney’s a big broad guy with no neck. A difficult tube. Ben’s looking down into his throat, trying to move his tongue out of the way. He sees the chords for a moment, passes the tube. Puke comes up. He’s in the esophagus.
“That’s when Troy and I come in,” Victor said. “We’d been in the office resupplying. Troy sidesteps the puke, and while Ben tries again, Troy slams an IV in Sidney’s arm. Ben’s still struggling with the tube, Troy says, ‘Let me try.’ He takes the scope from him. Then like that -- ‘I’m in,’ he says. Ben pushes epi and lidocaine into the IV line. They shock him again 360 joules. No change.
“’Calcium,’ Troy says.
“‘Calcium?’ Ben says. We carry it, but it’s not in the routine protocol.
“‘Calcium. His kidneys suck.’
“Ben goes ahead and gives it to him. They shock him again.
“Ben looks at the monitor -- sees a rhythm. You don’t have to feel a pulse. You can just look at his neck and see it pounding.
“Then Sidney opens his eyes and he’s looking right up at Troy. He looks a little confused like maybe he was expecting to see Satan or St. Peter. Instead Troy Johnson is the one grinning at him.
“‘Afternoon, boss,’ Troy says. ‘I see I’m not the only slacker around this place likes to get in a good snooze.’
“Troy was the golden boy after that. Sidney gave Troy his own dedicated ambulance, his own shift whatever hours he wanted to work, and let him pick whatever partner he wanted. Told the dispatchers no transfers for Troy. They have to leave him free for the big bad ones. The Deputy mayor coded. Troy saved him. One of the high-ranking police brass coded. Troy brought him back to life. Head of the chamber of commerce choked on a piece of meat the size of his fist; Troy yanked it out with a pair of McGill’s. The guy was well enough to give the after dinner speech.
“Every save Troy got, Sidney made a show of visiting the patient in the hospital, and bringing a photographer along. Ben wasn’t happy about it -- that and the fact every time Sidney saw Ben and Troy together he ribbed Ben about it. ‘Good, I got my bodyguard here to keep my chief paramedic from killing me.’ The truth is we got some good publicity in those days. We were miracle workers. The pride of the city. Paramedics. We were all like Johnny and Roy on that old Emergency show. You could walk tall.”
“Not any more?”
“No, that’s the past. Sidney’s dead. Things are changing for the worse. They don’t get better, we could be out of business. We could all be looking for jobs. So you can understand why no one’s happy.”
I rank Haldol 24 out of 33 drugs I carry. I would rank it much higher except:
A. I use it only in combination with Ativan, and Ativan may do more of the work than Haldol.
B. One of my prides is my ability to talk to psychs and get them to come peacefully, so it is rare I have to restrain somone.
C. In the town where I work, dispatch commonly calls the commercial service to transport psychiatric patients so I don't deal with the same volume of agitated patients I used to when I worked more in the city.
Last year I did not use Haldol at all.
But when you need it, it is a great drug. We combine it with Ativan in the same syringe now (we used to have to use two syringes) and can use it after attempts to talk down a patient have failed and physcial restraint will likely result in injury or the patient continuing to fight despite the restraints. (See full guideline below).
***
This is my favorite Haldol story - Sleepy Boy or Fetch My Dart Gun:
We get called for a violent psych at the juvenile school. Wait for PD, our dispatcher tells us.
A violent psych at the juvenile school. The last violent psych I had at a juvenile school was a fifty pound ten-year-old who was standing up on top of the cabinents in the principal's office jumping up and down screaming at the top of his lungs after already having thrown all the books that were on top of the cabinent down on the floor. I reached up, plucked him off the cabinents, tucked him under my arm, laid him on the stretcher and wrapped him in a blanket, then told him to knock it off, which surprisingly he did.
When we arrive, a staff member meets us in the hall and asks us if we are familiar with Andy.
I am not.
Big kid, thirteen years old, autistic, out of control today. They have six people holding him down, he says.
Six people, I think, right. Talk about overkill.
I enter the room, nod to the cop, who is standing by the door. I look about the room, then look down on the ground, where there are indeed six people holding Andy down. Andy is two hundred fifty pounds minimum, maybe two-seventy. He has the muscled shape of a big bear. There is a grown man on each limb, a large grown man leaning over his torso, and another man holding his head down. He looks up, despite the hold the man has on him, and roars. I swear the room shakes.
"You're just one crew?" the cop asks. "You have restraints?"
***
Now when I first took my EMT class many years ago, I wasn't too keen on the section of the course where we practiced restraining patients. I mean I wasn't certain I wasn't going to vomit at the first sight of gore, and I wasn't certain how good I was going to be at wrestling patients. I was as tall as I am now, but not nearly in the shape I am in now. I was sort of skinny and flabby at the same time.
I was lucky that one of my partners when I first stared working was a black belt karate instructor, but other times I worked with tiny women. In the same way I hoped that I never had to deal with the massive chemical hazmat train wreck mutlicasulaty plane crash call, I hoped I wouln't get called for the big guy who wanted to kick my ass.
I cultivated a calm approach, and learned to rely on my voice and on the trait of patience, which I have in fair abundance, and when faced with being patient or getting pummeled, I am always happy to be patient. But there are always some patients who patience doesn't work on. That's why we have cops, but cops don't like to get worked up any more than paramedics.
In recent years, restraining patients has also gone somewhat out of favor due to some tragedies -- patient's dyig of asphxia. A couple years ago, our protocols were rewriten to address issues of restraint. In the case of Andy, in my mind, I flip through the first two pages of the protocol to half way down the third page, under the title "Chemical Restraint."
***
"We're going to sedate him," I say. (If this was movie, I would have said to my partner, "Fetch my dart gun.")
2 mg Ativan and 5 mg Haldol IM.
He screams when I stick him in the thigh. He presses against his restrainers, tries to spit, but they quickly put a face shield over him. He calls me nasty names.
Then we sit and wait. He settles down for a moment, but any time anyone moves or tries to talk to him, he starts fighting again.
Ten minutes go by. He is still angry and yelling.
I excuse myself and go out to the ambulance and call medical control. The doctor approves my request for a second dose. "By all means," he says.
Andy nearly throws everyone off him when I hit him in the other thigh.
I sit back down in a chair and wait.
A staffer asks what the plan is now.
"I'm going to sit here until he's asleep," I say.
Five minutes later, he starts to snore.
One by one I have each of the restrainers get up. We nudge Andy, and he opens his eyes, and sleepily gets up and lays down on the stretcher like a little boy who has stayed up past his bedtime.
He snores all the way to the ER.
***
Haloperidol (Haldol)
Class: Tranquilizer, antipsychotic
Action: Inhibits CNS catecholamine receptors, strong anti-dopaminergic and weak anticholinergic.
Acts on CNS to depress subcortical areas, mid-brain and ascending Reticular Activating System
Indication: Chemical restraint for violent, agitated, and aggressive patients who present a danger to themselves or to others and who cannot be safely managed otherwise.
Contraindications: Agitation secondary to shock or hypoxia
Hypersensitivity
Parkinson’s Disease
CNS Depression
Relative contraindication if has seizure history
Side effects: Extrapyramidal symptoms (dystonic reaction), restlessness, spasms
Lowers seizure threshold
Hypotension
Tachycardia
Vomiting
Blurred vision
Dose: 5 mg IM
Route: IM
***
Here is our restraint guideline:
North Central EMS Behavioral Emergency Guidelines
EMS providers may use physical and/or chemical restraints on patients who pose a danger to themselves or others.
Providers should make every effort to ensure that law enforcement and adequate assistance are present when attempting to restrain a violent or combative patient.
Only the minimum amount of restraint necessary to protect providers and the patient should be used.
Providers should first attempt to verbally calm the patient down. If the patient does not comply, physical restraint may be attempted.
Providers should assess the patient for medical conditions that could be contributing to the patient’s behavior. If an assessment cannot be performed prior to physical restraint, it should occur as soon as possible after restraint is applied when it is safe and feasible.
Physical restraints must be soft in nature and pose no threat to the patient’s safety.
Only the extremities shall be restrained and these restraints must be assessed every five minutes.
Patients must never be hog-tied, restrained in a prone position with hands tied behind their backs or placed between backboards or mattresses. No restraint shall ever be tied around the head, neck or chest. A surgical mask, spit shield, or an oxygen mask may be placed loosely on the patient to prevent spitting.
Handcuffs may only be used by law enforcement or correction officials on patients in their custody. If the law enforcement officer insists that the patient remain handcuffed during transport, they must either accompany the patient or provide a key to EMS personnel.
Chemical restraint may be used per guideline following unsuccessful attempts at verbal and/or physical restraint or when a patient continues to forcibly struggle against physical restraints.
All restrained patients must have continual reassessment of vital signs and neurovascular status of distal extremities. In chemically restrained patients (safety permitting) this should include ECG, pulse oximetry, and capnography if the patient is no longer alert.
Documentation must include justification for restraint, type of restraint used, restraint procedure, results of continual reassessment, medications administered, the indications for the administration, and any other care rendered.
Do not hesitate to involve medical direction in any call involving restraint.
I rank Metoprolol 25 out of the 33 drugs I carry.
Our indication for Metoprolol is for rapid atrial fibrillation and PSVTs in patients already on oral beta blockers. We do not use Metoprolol for Acute Coronary Syndrome care. A few years back Metoprolol was considered life-saving in ACS care, but then more research came out and while it is life-saving for some patients, it is detrimental to others and the experts felt it would be too difficult for us (and I agree0 to distinguish the best candidates lacking our ability to know the patient's ejection fractions and other considerations.
Despite not being used for ACS, I was very excited to get Metoprolol and anxious for the first time I could use it.
The patient, an elderly gentleman on Atenolol (another beta blocker), was in a rapid afib in the 160-170 range. I drew up the 5 mg of Metoprolol, pushed it slowly and waited. Nothing happened. I waited and waited. Nothing. Our next step is to call medical control, but since we were already arriving at the hospital, I just brought him on in. I gave my report, got him in the room, went and wrote my run form, came back, looked up at the monitor and saw he had slowed considerably and was in a controlled afib in the 70's.
"So, the Metoprolol finally worked," I said to the nurse.
"No," she said, "We gave him Cardizem."
After that episode I would be tempted to put Metoprolol at the bottom of my list. Here was a drug that prevented me from giving a drug that would have done the trick. But, subsequently I have talked to medics who have given the 5 mg and had it work. I have also learned that the 5 mg is often followed with another 5 mg after five minutes or so and then another 5 mg to a total of 15 mg. That usually does the trick, and if it doesn't, well then you can go to Cardizem if the blood pressure is still decent.
And I have to ask myself, if I am on beta blockers, and I go into a rapid afib, would I rather have more beta blocker or Cardizem, which can really drop my pressure? A little more beta blocker seems the most reasonable. I just need to be prepared to call medical control and ask for additional doses if needed and indicated.
***
Metoprolol (Lopressor)
Class: Beta Blocker
Action: Partial blockade of Beta Receptors
Indication: Atrial fibrillation, Atrial flutter, narrow complex tachycardia
Contraindication: Hypotension (SBP < 110mmHg)
Bradycardia (HR < 70bpm)
Hypersensivity to drug
1st, 2nd or 3rd Degree Heart Block
Asthma
Acute Pulmonary Edema
Recent Cocaine Use
Side effect: Pulmonary Edema
Hypotension
Weakness
Dose: 5mg SIVP
Route: IV push (bolus) given over 5 minutes
Pedi dose: None
Important points: Utilize Metoprolol for patients experiencing narrow complex tachycardias that
are taking oral Beta Blockers.
I rank Lidocaine 26 out of 33 drugs.
We can use Lidocaine for ventricular fibrillation and for ventricular tachycardia without pulses.
We no longer use Lidocaine for ventricular tachycardia with pulses (Amiodarone is preferred by the American Heart Association). Until recently we used to use Lidocaine for VT with pulses, and much longer ago, used it for ventricular ectopy. Nowdays, ventricular ectopy is pretty much left alone.
If we did not also carry Amiodarone, I would rank Lidocaine higher. When forced to choose between the two, I take Amiodarone. The research is sketchy, but I have had better luck with Amiodarone. When I have given Lidocaine to people in VT, it hasn't always turned out too well.
Here's a 2004 story (with a few new edits) called The Man Who Wouldn't Die where Lidocaine didn't help (not that Amiodarone would have).
***
We’re called for a person not feeling well in an elderly housing hi-rise not far from the hospital. The man is an emaciated AIDS patient, who is laying naked on the couch in his dark apartment. He has a colostomy bag. His girlfriend says they were at the emergency department for seven hours today, then left.
“What did the doctors say was wrong?”
“Nothing. We were in the waiting room.”
The fire fighter first responder says he can’t feel a pulse, but the man is talking and alert. Its not unusual to have a difficulty feeling a pulse on some AIDS patients who are often baseline hypotensive. Since it is so dark in the apartment, I just say put him on the stretcher, give him some 02 and we’ll work him in the ambulance.
Downstairs in the ambulance, I try for a blood pressure and can’t hear anything. His nail beds are white. I put in an IV while my partner Arthur puts him on the monitor.
“Why are you grimacing?” Arthur asks.
The man is suddenly writhing.
“My chest hurts,” he says.
I look at the monitor. Crap. He’s in V-tack.
I slam some lidocaine in the IV line and tell Arthur to get in front and drive to the hospital. We are only a couple blocks away.
I put the pads on the man’s chest. I could give the Lidocaine longer to work (but I don't think it will) or I could shock him. With no pressure, I probably should have shocked him right away anyway. “This is going to hurt,” I say.
Before I hit the shock button, I pull out my intubation kit and have it ready. (I have had bad experiences with shocking live people in the past.)
I shock him.
He screams.
Still v-tack.
“Sorry, I have to do it again.”
I shock him. He’s out. Flat line.
I grab a tube and using a device called a bougie, slide the bougie between the vocal chords, then slide the tube over it. I’m in in like twenty seconds. I do some compressions, ventilate through the tube, grab some epi and slam it in the line, and just like that we are out at the hospital.
Another EMT comes around and helps us unload the patient. When we wheel him into the cardiac room, the doctor takes one look at his emaciated body and says, “He’s asystole, he’s dead.”
“But he just coded like two minutes ago,” I say.
“Look at him, he’s terminal.”
The doctor is right. He looks like a Biafrian.
“He was v-tack. I shocked him twice. He was here for seven hours today in the waiting room.”
The doctor ponders a moment, looks at the ECG, says, “11:34,” and leaves the room.
The nurse takes the rest of my report, then writes in the time, then goes over to prepare the body.
The man takes a breath, a deep gasp.
She jumps. “Oh, my god.”
He gasps again, and with each gasp, his breathing becomes more regular. She hooks him up to the monitor. He has a rythmn.
“I guess I better get the doctor.”
She comes back with the doctor just in time to see the man take his last gasp. The monitor goes back to straight line.
The doctor shakes his head. “He’s dead,” he says.
“You don’t want to give him some epi?”
“No.”
He turns to leave the room. The man takes another deep gasp.
The doctor turns and glares at him as if to command him to cut it out. He’s still breathing.
The doctor approaches, lays his hand on the man. He stops breathing.
“I’m giving him epi,” the nurse says.
“Fine,” the doctor says. He glares at me. “Thanks again,” he says.
I have been bringing him a number of codes lately. “My pleasure,” I say.
I leave to write my run form. When I come back fifteen minutes later there is a sheet over the man. The nurse stands across the room watching him.
“He’s really dead now?” I ask.
She gives me a sarcastic smile as she accepts my run form, then returns her gaze to the body on the ER table.
***
The only reason I don't have Lidocaine lower on my list is because we also use it as premedication for Intraosseous insertion in conscious patients prior to administration of fluid or other drugs. I have not used it this way yet, but I intend to. As I wrote in the following excerpt fromIO on Living Person even though a person may be unconcious, they can still apparently feel the pain of fluids being pushed through an IO.
***
My preceptee asks if he should give the lidocaine dose before hand. The lidocaine dose is a pain-control measure for conscious patients. While the drill itself causes only minor pain, they say it is the fluids being pushed that really hurts. This guy reacted to the drill with only the faintest of groans. “Not necessary,” I say. “He’s unconscious.”
I prepare a saline flush while my partner spikes a bag. I push the 10 ccs of fluid and from out of the depths of unconsciousness, the patient screams and nearly comes off the stretcher. I keep pushing and he keeps screaming. It is a good thing it only takes four or five seconds to push the saline. As soon as I am done pushing, he drops back to unconsciousness.
I think maybe we should have given him the lidocaine (Although that likely would have hurt just as much pushing the saline in). Maybe next time.
***
From our Regional Guidelines:
Lidocaine (Xylocaine)
Class: Antiarrhythmic
Action: Decreases ventricular irritability
Elevates fibrillation threshold
Indication: Refractory Ventricular Tachycardia or ventricular fibrillation
Recurrent runs of Ventricular tachycardia and after successful defibrillation to prevent the reoccurrence of VF or VT
Contraindication: AV blocks
Sensitivity to medication
Idioventricular rhythms
Sinus bradycardias, SA arrest or block
Ventricular conduction defects
Not used to treat occasional PVCs
Precaution: Reduce dose in patients with CHF, renal or hepatic diseases
Side effect: Anxiety, apprehension,
Toxicity: Early: decreased LOC, tinnitus, visual
disturbances, euphoria, combativeness, nausea, twitching,
numbness, difficulty breathing or swallowing, decreased heart rate.
Late: Seizure, hypotension, coma, widening QRS complex, prolongation of the
P-R interval, hearing loss, and hallucinations.
Dose: 1.0 -1.5 mg/kg, may repeat 3-5 minutes
IV - Drip usual dosage rate 2-4 mg/min
Route: IV, IO, ET - double usual IV dose.
Pedi dose: 1.0mg/kg total pedi dose-3mg/kg
I rank Toradol 27 out of the 33 drugs I carry.
First, let me say, I am a huge proponent of pain management. As a member of the committee that writes our regional guidelines, I fought for an alternative to morphine for those patients in pain who were allergic to mophine. The first result was Toradol. Later, we secured Fentanyl. The Fentanyl, however, hasn't yet shown up in our controlled substances kits, although I am told it is coming. As with any change to controlled substances, each change requires DEA approval and must work its way administratively through both hospital, pharmacy, and DEA heirarchies and back and forth until the policy is set in stone. I know this because it took a year to get Fentanyl in the kits of one of the paramedic services I oversee. When Fentanyl arrives in my kit, it will likely be ranked quite high on my list and push Toradol down even further, possibly to the point where we will have no need to carry it.
Toradol requires on-line medical orders for us to use. And there are some doctors who will never let us use it. Their vieww is there are just too many possible side effects, particuarly in elderly patients to give the drug without having an ED doctor first examine the patient and do a set of labs. The patient may have some degree of renal failure or, if they are a candidate for surgery, Toradol can interfere with their clotting.
The ideal patient for Torodal is probably a thirty-five-and under-year-old otherwise healthy adult who is presenting with kidney stones. Yet on a number of times I have called for permission to use it for patients with apparent kidney stone flank pain, I have been denied and told to just use morphine. All told I think I have only gotten permission to use the drug 3 times. Only once did I use it for someone who was allergic to morphine -- an older woman who had broken her shoulder. I called and got orders, gave the drug and it worked quite well. The other two times were for kidney stones and I gave the Toradol along with morphine, again with positive results. If I think a patient has kidney stones I will always call for Toradol even if I think there is a good chance they will turn me down. I don't take it personnally.
***
Ketoraloc Tromethamine (Toradol)
Class: Non-steroidal Anti-inflamatory (NSAID)
Action: Analgesic, anti-inflammatory, and anti-pyretic via inhibition of prostaglandin synthesis
Indication: Moderate to severe pain, especially renal colic (kidney stones)
Contraindications:
Hypersensitivity to ketorolac, aspirin or other NSAIDS
Age <1 year old
History of peptic ulcer disease, gastrointestinal bleeding or perforation
Advanced renal impairment
Hypovolemia
Cerebrovascular bleeding
Any patient at high risk of bleeding
Late pregnancy, active labor or nursing mothers
Patients currently receiving aspirin or NSAIDs
Precautions: Patients ≥ 65 years of age or less than 50 kg
History of renal disease
Dehydration
Pregnancy class C
Side Effects:
Can cause peptic ulcers, gastrointestinal bleeding and/or perforation
May precipitate renal failure in patients w/ dehydration or renal impairment
Nausea (12%)
Dyspepsia (12%)
Headache (17%)
Drowsiness (6%)
Adult Dose:
Patients <65 years of age:
One dose of 30 mg Slow IV or Deep IM
Patients ≥ 65 years of age, renally impaired and/or less than 50 kg (110 lb)
of body weight:
One dose of 15 mg Slow IV or Deep IM
Pediatric Dose:
One dose of 0.5 mg/kg up to a maximum of 30 mg Slow IV or Deep IM
I rank Tylenol 28 out of 33 in my drug kit.
First, let me say, I am speaking only of the Tylenol in my kit and not my own personal stash. If I were rating my own personal stash of Tylenol, then I would have to add Tylenol and Ibuprofen to my as yet unrevealed list of Eight Essential Drugs, making it The Essential Ten.
The Tylenol I carry in my kit is restricted to pediatrics with fevers. We can give it to pediatrics greater than 6 months old if they have a temperature 101.5°F (38.5°C) or greater or if the patient is believed to be febrile (with no thermometer available) and they have not had Tylenol within the last four hours.
These are some of our PEARLS:
· This Guideline is NOT to be used for patients suffering from environmental hyperthermia
· If the patient is vomiting, suppositories are more appropriate and oral acetaminophen should be
withheld.
· Administer once the patient is in the ambulance to avoid patient/parent refusal after treatment.
· Concentrated infant drops (80 mg per 0.8 mL) are recommended and may be dispensed using a
needless syringe.
· Do not administer acetaminophen if the patient has received greater than 15 mg/kg dose in
the last 6 hours.
Tylenol is an awesome drug for kids with fevers, but in the short time we have had it in our guidelines, I rarely have occasion to use it. My town is more old people than young families and the young families tend to have Tylenol on hand.
While as a parent I gave Tylenol quite a bit this last year, as a Paramedic, I did not give it at all.
***
Acetaminophen (Tylenol)
Class: Antipyretic; Analgesic
Action: Antipyretic effect via direct action on the hypothalamus heat-regulation center; Unknown mechanism of analgesia
Indications: Pediatric fever; Minor pain
Contraindication: Hypersensitivity to acetaminophen
Adverse effects: Hepatotoxicity in overdose
Nausea
Pedi Dose: 15 mg/kg every 4 – 6 hours as needed
Route: PO; PR
Note: Concentrated infant drops (80 mg per 0.8 mL) are recommended and may be dispensed using a needless syrin
I rank Activated Charcoal 29 on my list of 33 Drugs.
I must confess that in my 22 years riding ambulances, 18 as a paramedic, I have never given Activated Charcoal to a patient. Certainly there had to have been a few in the crowd who could have benefited, and certainly quite a number eventually got the charcoal in the hospital.
Our indication is for toxic ingestions in concious patients.
There are any number of reasons I haven't given it.
1. We cannot give it on standing orders, but must call for on-line control.
2. The patient is likely to resist drinking it.
3. We don't do NG tubes.
4. There is the making a mess in your ambulance factor.
5. Our transport times are usually not extended.
6. There is some medical controversy about giving activated charcoal to pediatrics.
7. Just not thinking about it.
I am not using the excuses that a) I couln't find it or b) it was expired.
I just ran a little stopwatch test and was able to find the Activated Charcoal in less than 15 seconds in my ambulance right where I thought it was (okay, I wasn't certain). It doesn't expire for a couple months so good that I am writing this now and not in April.
***
I did some literature searches on the activated charcoal and found no convincing evidence either way. One one hand, prehospital administration makes the treatment available to more patients who would otherwise not meet the 1 hour time constraint, but on the other there is also the risk of aspiration and no clear cut complelling evidence that it makes a huge difference in outcome.
Here is a summary from one review (Activated charcoal for pediatric poisonings: the universal antidote?):
SUMMARY: If used appropriately, activated charcoal has relatively low morbidity. Due to the lack of definitive studies showing a benefit in clinical outcome, it should not be used routinely in ingestions. AC could be considered for patients with an intact airway who present soon after ingestion of a toxic or life-threatening dose of an adsorbable toxin. The appropriate use of activated charcoal should be determined by the analysis of the relative risks and benefits of its use in each specific clinical scenario.
Here are few more articles to check:
The potential role of prehospital administration of activated charcoal.
Prehospital activated charcoal: the way forward.
***
I also came across this bit of Activated Charcoal EMS humour on the internet:
Top Ten Things to Do With Activate Charcoal
***
While for now I am listing Activated Charcoal low on my list, I do promise to discuss its possible use with some doctor friends and look more critically at whether or not I am missing opportunities to help some of my patients.
***
Activated Charcoal
Class: Adsorbent
Action: Adsorbs many drugs and poisons in the GI tract
Indication: Toxic ingestions - not caustics or pure petroleums
Contraindication: None for emergency use
Dose: 30-50-100 grams
Route: PO - usually in liquid form to drink
Pedi dose: 1-2 grams/kg
I rank Tetracaine 30 on my list of 33 drugs.
We use Tetracaine prior to insertion of Morgan lenses in patients age 6 years and older who have sustained an exposure injury to the eye(s), (i.e. dry or liquid chemical).
The drops numb the eye and make it easier for the patient to tolerate the Morgan Lens.
Here is our Morgan Lens procedure:
· Explain procedure to patient and give rationale.
· Unless contraindicated*, instill one or two drops of Tetracaine.
· Instruct patient not to touch/rub eye(s).
· Spike IV bag and attach/flush tubing, connect Morgan Lens, maintain sterile environment of Morgan Lens.
· Have the patient look down, insert the Morgan Lens under the upper lid, then have the patient look up, retract lower lid and allow lens to drop into place.
· Begin flow rate at wide open and maintain this rate per patient tolerance. Have plenty of towels or chux to absorb flow.
Tetracaine is a nice little drug, but it has been years since I have used a Morgan Lens. When I worked more regularly in the city and dealt with more patients who had been maced or pepper-sprayed, I had more occasion to use the Morgan Lens, although many times we just irrigated the eyes with the IV tubing, as ift takes a high-level of cooperation for a patient to accept a Morgan Lens in their eye.
Nice to have Tetracaine in the kit, but I can do without it if I have to.
***
Tetracaine Ophthalmic Solution
Class: Topical anesthetic for the eye only
Action: Produces anesthesia in the eye approximately 30 seconds after application
Indication: For pain control in burns to the eye
Contraindication: Known allergic reaction to Tetracaine or Novocain type medications.
Dose: 1 or 2 drops to the affected eye
Route: Topically to the eye
Pedi dose: 1 or 2 drops to the affected eye
I rate Phenergan as 31 on my list of 33 Drugs. Once it had a much higher rating, but with the arrival of Zofran, I have used it in the way the Baltimore Orioles used their backup shortstop when Cal Ripken was playing.
Phenergan is great, but Zofran is so much safer and works so much better. An arguement can be used that Phenergan's sedative properties are useful in some patients. Me, I would prefer to give them the drug that is most likely to stop their nausea and vomiting with the fewest side effects.
Here's a story, Hyperexcitability and Abnormal Movement I first posted in September 2007 that taught me something about the side effects of Phenergan, particuarly if pushed a little too fast in the elderly:
***
The 84 year old woman, who lives at home, says she is light-headed, feels shaky and is seeing white spots, but she really doesn’t want to go to the hospital.
“Well, if you are light-headed, feeling shaky and seeing white spots, you need to go to the hospital,” I say.
“Okay,” she says.
That was easy.
We get her in a Johnny top and on the stretcher. Out in the ambulance, I do a 12 lead and a full assessment. She has a sinus rhythm with occasional PACs and a right bundle branch block. No ST elevations. Her lungs are slightly decreased, but it could just be that my hearing is slightly decreased. Her skin is warm now, although she says she felt sweaty earlier. Her abdomen is soft, her grip strengths are equal.
Her blood pressure is 180/100. Her heart rate is in the 90’s. She is Satting at 95% so I put her on a cannula at 2 lpm.
I try to get a history, but she is 84, partially deaf and a poor historian.
On the way to the hospital, I notice that she seems uncomfortable.
I ask her is she is in pain and she says her back hurts. Is this new pain or old pain?
I have arthritis, she says.
So you have had this pain before?
What?
The pain.
She is holding her belly and looks like she is trying to sit up more, so I undo the belt and slide her up, but it doesn’t seem to help. She seems very anxious.
I am starting to get concerned, but no matter what I ask, I can’t get a good answer.
I’m going to throw up, she says.
I quickly grab an emesis basin, and while she belches, I take out the med kit and pull out an ampule of Phenergan. I draw up 12.5 mg and dilute it in 10 cc of NS. I tell her I am giving her something for her nausea as I push it slowly through the saline lock I put in her arm.
We are just a few minutes from the hospital now so I tell her I am going to call the hospital and tell them we are coming.
My patch starts out routine. “I’m four minutes out with an 84 year old female complaining of light-headedness, shakiness and seeing white spots...” But as I am talking she is changing in front of my eyes. She gets a crazy unfocused look. She seems like she is trying to come off the stretcher, but doesn’t seem to have control of her left side. She arches her back and is grasping at her chest with her right arm.
I don’t remember what I say on the rest of the patch, something about the patient is going nuts and I’m not certain what is going on.
When we get to triage the patient cannot follow commands, her left side is weak, she is moving strangely, almost spastically, and she is still nauseous. If I ask her a question, I get a nonsensical answer. She is completely altered. Her skin is also diaphoretic and she looks quite pale.
We get her into a room and the nurse gets a doctor and as I relate the history, he assesses her. He runs through the same diagnostic possibilities I had thought of – everything from throwing a clot to MI to AAA.
I did give her some Phenergan – 12.5 for her nausea, I say.
Phenergan? He says.
Yeah. Phenergan 12.5
Was she like this before you gave her the Phenergan?
No, she was a little crazy, something was going on, but she wasn't like this. She could talk to me at least.
It could be the Phenergan, he says – it’ll make them do this.
Really? I've seen it makes them very lethargic, and I know it can produce a produce a dystonic reaction, but nothing like this.
***
I see the nurse the next day. I ask her about the patient. The CAT scan was clean. As soon as the Phenergan wore off, she was alert and oriented with equal neuros. Still, they admitted her for observation. She did after all have that problem about being light-headed, feeling shaky and seeing white spots.
***
I check the drug appendix for Phenergan at the back of my protocol book.
Under side effects, it says: “May impair mental and physical ability.”
Under contraindications, it reads “Hx of prior idiosyncratic/hypersensitivity reactions to Phenergan.”
I hope they tell her to remind any future paramedics who offer her Phenergan that she now apparently is one of those people who have had an idiosyncratic/hypersensitivity reaction to Phenergan.
I talk to some other medical people who have witnessed the same phenomenon in patients, particularly elderly. Phenergan can make them go crazy, they say.
The link below on Phenergan side effects mentions "Hyperexcitability and abnormal movements."
***
Next time, I give Zofran.
(Or if I am out of Zofran, for the elderly at least start with 6.25 mg of Phenergan instead of the full 12.5 mg.)
***
Promethazine (Phenergan)
Class: Antihistamine (H1 antagonist)
Action: Antiemetic, some sedative effect.
Indications: Nausea and vomiting; motion sickness.
Contraindications: Comatose states
Patients who have received a large amount of Depressants
Subcutaneous Injection (causes tissue inflammation and necrosis)
Hx of prior idiosyncratic / hypersensitivity reactions to Promethazine
Allergy to sulfites (contains sulfite preservative)
Children under 2 y.o. (High risk of respiratory arrest / SIDS)
Precautions: For intravenous use, Promethazine MUST be diluted in at least 10mL NS or D5W.
A large, proximal vein should be used and the paramedic must ensure the IV is
patent prior to administration. Administer slowly through a flowing IV line
and stop administration if the patient reports burning.
Side effects: Drowsiness
May impair mental and physical ability
Dystonia, extrapyramidal symptoms
Phlebitis and pain on injection from undiluted solution
Tissue irritation and necrosis from infiltration.
Dosage: 12.5 maximum single IV dose; 25 mg maximum total dose (depending on size and
weight of patient).
Route: Slow IV; Deep IM
I rank Vasopressin 32 on the list of 33 drugs I carry.
We started carrying Vasopressin a few years back thanks to some initial research that showed it worked better than epinephrine in cardiac arrest. I remember reading about the study, and then trying to figure out who made vasopressin so I could buy stock in the company, thinking about all the vasopressin that would be bought. And while we eventually started carrying vasopressin, that research, of course, was not replicated in larger studies.
Here is the conclusion of a International Liaison Committee on Resuscitation (ILCOR) 2010 worksheet that looked into the question of of epinephrine versus vasopressin in cardiac arrest.
"In summary, the use of vasopressin alone or in combination with epinephrine as the first line vasopressors during resuscitation from cardiac arrest offers no benefit related to short- and long-term survival compared to the use of epinephrine alone."
When we first got vasopressin, we were told that we could us it as a first-line vasopressor, then we wouldn't need to give another vasopressor for twenty minutes. That sounded good. Hit them with one dose of vasopressin, and then you don't have to worry about another epi for twenty minutes instead of giving epi every three to five minutes. Then when the 2005 AHA guidelines came out, we were told vasopressin could only be used in place of the first or second epi, which made it far less handy.
In most cardiac arrests, I go right with epi. I go with epi because that is how I have done it for years. I hardly ever think about vasopressin. I always have a hard time changing my routine to accomadate new drugs. But then once I have used them once, they become easier to remember. But with vasopressin, it is not just remembering I can give it. If I do remember I can give it, the next thought is why bother? Epi is quick and easy to give. We have premixed bristojets. To give vasopressin I have to get a syringe and draw up two 20 mg vials to get my 40 mg dose. Not practical when there is no documented benefit.
So, in summary, you can take vasopressin from my kit. I will not miss it.
I did not use it at all last year.
***
From our regional guidelines:
Vasopressin (Pitressin)
Class: Vasopressor, antidiuretic
Action: Potent alpha agonist in cardiac arrest, causes vasoconstriction
Indication: Cardiac arrest to replace first or second dose of epinephrine
Contraindication: History of hypersensitivity to vasopressin
Dose: One-time dose of 40 units IV push
Route: IV
Lasix - Number 33 out of 33 on my Essential Drug List. (Note: Only 8 of the 33 will be ultimately deemed essential.)
***
Dear EMS Medical Control-
I am an 87-year -old man with pneumonia and sepsis laying in a hospital bed, feeling rather miserable. Two days ago one of your paramedics gave me Lasix believeing the junky sounds in my lungs were a sign of pulmonary edema. He was wrong. As a consequence my blood pressure dropped from 170/90 at my house to 90/40 in the ED where they gave me two liters of fluid in addition to several very strong antibiotics, and I am told my kidneys are not functioning so well. I know I am old and approaching the end of my life, but I was once a vibrant man who taught school for many years and often demonstrated for various causes such as civil rights and against the slaughter of baby seals. If I were able, I would make a sign and demonstrate in front of your house. I would lean against my walker and hold my sign up for passing cars and the news cameras to see. "Stop the Horror! Ban Lasix!" I know I am not the first victim. I wish to be the last. Those of us with pneumonia and sepsis are sick enough without Lasix making us worse.
Respectively
Patient X.
***
As you know for the last year I have been a clinical coordinator at a local hospital. Our EMS Medical Director and I have had lengthy discussions about taking Lasix off our sponsored services's trucks. The problem is we are part of a larger region and we try to do all our protocols regionally. The region just finished up its 2009 protocols, and won’t be addressing changes until later this year with an implementation target date of sometime next year. We both agree we should take Lasix away. We don’t want to act unilaterally. But I am thinking (with each imaginary letter we recieve) that maybe we ought to act now.
In 2006, a study appeared in Prehospital Emergency Care that revealed that Lasix was given inappropriately to 42% of prehospital patients.
Evaluation of prehospital use of furosemide in patients with respiratory distress.
For the last two years I have been keeping track of all prehospital use of Lasix from our various sponsored services using similar criteria to the mentioned study. I have found a 37% inappropriate rate, a rate that has improved only marginally with education.
Looking closely at the patient data, it is clear just how difficult the diagnosis can be (lacking a chest X-ray and a BNP blood test). The indicators that many of us were taught in paramedic school don’t always hold up. Some patients with fevers had CHF, while some patients who were not febrile had pneumonia. Some patients on Lasix had pneumonia and some patients not on Lasix had CHF. Some pneumonia patients had significant edema and some CHF patients didn’t have any edema. The only sign that at all was suggestive of CHF was blood pressure. In general if a patient had a BP over 170 systolic they were more likely to have CHF (Except for patient X here). Speaking of blood pressures when I tracked BPs in the ED, nearly every patient, CHF or not, who received Lasix prehospitally experienced a huge (although sometimes transient) BP drop in the ED.
I know about misdiagnosing CHF myself. In 2006, the very day after reviewing the before mentioned article at a journal club meeting, I had a patient in severe respiratory distress who sounded like a washing machine. I gave Lasix. She turned out to have pneumonia. D’oh!
When I was a newer medic in the last 1990’s, one year I gave Lasix 21 times. If I thought I heard rales, I gave Lasix. I was told by another paramedic (be careful of your infomation sources) that Lasix was basically harmless. How many of those patients had pneumonia or sepsis? At least 40% is probably a close starting guess. This past year I didn’t give Lasix at all.
Several years back, we added the following caution to our regional protocols:
CHF vs. Pneumonia: If the clinical impression is unclear and transport time is not prolonged, consider using Nitroglycerin and withholding Lasix or Bumex or contact medical control.
Yet people continue to give Lasix to patients who are not in CHF. I think it stems from our natural incliniation to want to do something to help, particuarly if the patient's respiratory distress is severe.
With CPAP and Nitro now the hallmarks of CHF treatment, I think it is clearly better to deny Lasix to someone who might have CHF than give it to someone with pneumonia or sepsis.
That seems to be the clear direction EMS is headed in. Check out this article from JEMS.
Meds Under Scrutiny
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From our June 2009Regional Guidelines:
Furosemide (Lasix)
Class: Loop diuretic
Action: Blocks active reabsorption of chloride in the kidney, results in diuresis.
Mild venodilation results in decreased preload
Indication: Pulmonary edema
Contraindication:
Children under 12 yrs
Pregnancy, caution with allergy to sulfa drugs but rarely cross reacts
Precaution: Lasix bolus should be given over 1 minute
Lung sounds should be noted before and after administration of Lasix
Patients already taking diuretics may require a high dosage
Side effect: Dehydration
Decreased circulating plasma volume
Decreased cardiac output
Loss of electrolytes K+ and Mg++
Transient hypotension
Dose: 0.5 - 1.0 mg/kg (usual dose 40 mg), or double patients usual daily dose up to 200 mg IV
Route: IV push - slow
