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Mass sociogenic illness initially reported as carbon monoxide poisoning

Wed, 22 Feb 2012 08:00:14 +0000 By Rogue Medic 3 Comments

Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the excellent material at these sites.

This is adding to what I wrote yesterday about the continuing failure of Masimo’s RAD-57.^[1] The RAD-57 does not demonstrate any kind of acceptable sensitivity or specificity to be marketed as a mass screening device – and especially not to screen firefighters to go back to fighting fire. This is just more evidence that the RAD-57 does not accurately measure carboxyhemoglobin (COHb).

Here is a report of a mass delusion that seems to have been compounded by the use of the Masimo RAD-57 non-invasive CO monitor. CO (Carbon monOxide) is a significant cause of poisoning in the US, but not relevant in this case. The RAD-57 incorrectly identified CO poisoning in half a dozen people who do not appear to have had any exposure to CO.

Sociogenic illness is a rare but well-described phenomenon. It involves a constellation of physical signs and symptoms without an organic cause in a group of individuals with a common ‘‘exposure’’ (1–8). It often occurs in the setting of large gatherings such as schools or when large numbers of people are living or working in close proximity.^[2]

I wrote about a different example of mass delision a couple of weeks ago.^[3] We underestimate our ability to delude ourselves, but we are great at self-delusion and we are most delusional in groups. No need for any objectivity. Just go with the feeling of a group.

Approximately 15 min into the mass, one child fainted, followed by another child. The children did not have any seizure activity and immediately awoke with normal mental status and were removed from the church. Within minutes, several more children reported a variety of complaints, including nausea, hand paresthesia, and dyspnea.^[2]

A poison strong enough to cause people to pass out, is not going to result in a return to normal mental status right away.

The ﬁre department initially evaluated the patients with complaints, including obtaining carboxyhemoglobin (COHb) oximetry and oxygen saturation readings from a hand-held portable Masimo^® device (Masimo Corporation, Irvine, CA). At the scene, 6 patients were reported to have elevated COHb levels. As such, the church was closed and paramedics, as well as the city’s hazardous materials (HAZMAT) team, were called to the scene.^[2]

If only someone had told them that the RAD-57 doesn’t work, much of the chaos could have been avoided.

Image credit.

Blood COHb levels, obtained in all patients soon after arrival in the ED, ranged from 0.2% to 1.2% (mean 0.65%). The hospital laboratory reference range for COHb is < 1.5% for non-smokers and as high as 5% for smokers. However, this upper value can be much higher in heavy smokers (9). None of our patients had elevated blood COHb levels.^[2]

A magic diesel cure?

It’s a miracle!

In the ED, all patients had normal physical examinations, including neurologic and respiratory examinations.^[2]

Were their physical exams much different on scene?

Subsequent evaluation of the church, classrooms, and surrounding premises by ﬁre department and HAZMAT personnel found no evidence of carbon monoxide or any other toxicants.^[2]

The interesting part that is not well described is the initial response of the fire department. Almost always, they have atmospheric CO alarms on their gear. When a firefighter walks into a room with elevated CO, the alarm goes off. When there is a report of a possible CO exposure, a couple of fully geared up firefighters will investigate everywhere they can in a building, looking for areas where CO might be leaking and for areas where CO might have accumulated.

There is no mention of any finding of CO at any time on scene.

No – the RAD-57 is not an indication of the presence of CO.

The affected persons were sitting in various areas of the church and many of the unaffected individuals were sitting near affected persons. This variability is not consistent with a simple asphyxiant. Furthermore, several patients became symptomatic after leaving the church, which would not be seen with a simple asphyxiant.^[2]

Exposures to gasses should present with a predictable pattern. The people in the most heavily concentrated area should be the most affected, with the smallest people (generally children) and the most active people (also generally children) being more affected than the larger and less active people. That was not the case. This suggests MSI (Mass Sociogenic Illness, or mass delusion).

the escalation of symptoms and increased number of persons affected along with increasing ﬁre and ambulance presence is a common phenomenon in MSI, referred to as ‘‘line of sight transmission.’’^[2]

Even if it appears obvious that this is a mass delusion, we should provide treatment as appropriate for the symptoms presented. In this case, some oxygen is the only treatment indicated and the only treatment provided.

I wonder if this will lead to others reporting similar cases of mass delusions compounded by ~~Magic 8 Ball~~ RAD-57 readiongs.

Accuracy of Noninvasive Multiwave Pulse Oximetry Compared With Carboxyhemoglobin From Blood Gas Analysis in Unselected Emergency Department Patients

Tue, 21 Feb 2012 18:10:39 +0000 By Rogue Medic 2 Comments

Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the excellent material at these sites.

The Masimo RAD-57 non-invasive CO monitor is promoted as an accurate way to identify patients at risk of life-threatening complications of CO poisoning. CO (Carbon monOxide) is a significant cause of poisoning in the US, with hundreds of fatalities each year.

Masimo claims that their RAD-57 is able to accurately measure blood levels of CO without any complicated lab equipment. If it works, the RAD-57 might save some lives. Unfortunately, the research that has not been funded by Masimo does not support a decision to buy a RAD-57 until after they improve the device.

Suspicion of CO poisoning is very important in identifying CO poisoning. One study was conducted at a burn center among patients already suspected of having CO exposure.

The RAD device correctly identified 11 of 23 patients with laboratory values greater than or equal to 15% carboxyhemoglobin (sensitivity 48%; 95% CI 27% to 69%).^[1]

A coin flip is going to be just as accurate as a test that identifies only 48% of the affected patients.

The RAD-57 was shooting at fish in a barrel and still missed most of the time.

Dr. Michael O’Reilly (Executive Vice President of Masimo Corporation) has claimed that those researchers, who are not on the Masimo payroll, are biased against his device.^[2]

What does he understand about science, objectivity, or controlling for biases?

Nothing comes to mind.

Even some people who are not on the Masimo payroll have suggested that the RAD-57 might be useful and that the next study (quoted below) would confirm the usefulness of the RAD-57.

Compared with the large population used for the calculation of bias and precision, the number of patients actually found to be poisoned was small, especially in the group of poisoned smokers. Therefore, the opportunity for false-negative results was limited. Because a false-negative reading could have serious medical consequences, this device should be tested in a much larger number of poisoned patients to confirm the generalizability of our stated cutoff values.^[3]

This does not contradict the first study.

What is the problem?

Symptoms of CO poisoning are nonspecific, ranging from mild headache, nausea, confusion, and dizziness to end-organ injury such as myocardial infarction,⁶ stroke,⁷ and death. ^{[8] and [9]} Diagnosis is therefore difficult and relies on clinical suspicion and confirmation by measurement of carboxyhemoglobin (COHb), using either venous or arterial10 blood gas analysis. However, COHb analyzers are not ubiquitously available.¹¹ As a result, many victims of CO poisoning might be overlooked and misdiagnosed. ^{[12] and [13]} ^[3]

Suspicion of illness/exposure is the most important part of identification.

If we examine patients without considering suspicion, does the RAD-57 improve identification?

Maybe, but this study is not capable of testing that hypothesis.

These are only patients who are going to have ABGs (Arterial Blood Gas measurements) regardless of what the RAD-57 shows. We don’t know how many of the patients who did not have ABGs, or did not have ABGs within one hour of RAD-57 measurement, actually had CO poisoning.

Blood gas analysis (arterial or venous) (Table 1) was performed later as a standard procedure in our ED on discretion of the treating physician for a variety of clinical reasons.^[3]

If the patient had a low reading on the RAD-57 and did not have an ABG, should we conclude that the unmeasured carboxyhemoglobin level was also low?

Of course not.

31% of patients who had ABGs were excluded because there was more than one hour between RAD-57 measurement and ABG measurement. How many of these patients were presenting as unstable and had the RAD-57 measurement omitted? How many of these patients were presenting as very stable and had the RAD-57 measurement over an hour before the ABG?

We do not know.

How many of the 17 patients in the documented sample had life-threatening symptoms?

We do not know.

Maybe all 17.

Maybe zero.

How many of the 17 patients in the documented sample had only minor symptoms?

We do not know.

Maybe all 17.

Maybe zero.

This kind of information is not included in the study.

What was the basis of diagnosis of CO poisoning?

The diagnosis of CO poisoning was based on increased COHb levels and clinical symptoms consistent with poisoning, including headache, vomiting, abdominal pain, and loss of consciousness.^[3]

Identifying 16 out of the 17 patients in the 1,578 patient sample is impressive, but when we limit the patients to those with symptoms suggesting CO poisoning, we lose any possible value of the non-invasive screening.

These are the patients who are going to have blood drawn to assess for CO poisoning regardless whether anyone uses a RAD-57.

There is no benefit to RAD-57 screening in this setting.

What about using the RAD-57 in 1,017 EMS patients, regardless of the reason for the 911 call?

Of the 11 patients with a SpCO >15%, 10 were transported to a hospital for which the investigators had institutional review board (IRB) approval to review the patient’ s medical record. Of those 10, none had confirmatory venous carboxyhemoglobin levels. The two patients with an SpCO level of 21% did have a repeat SpCO documented at triage upon arrival to the emergency department. Their repeat levels were 8% and 2%. None of the 10 patients with levels >15% ultimately were diagnosed with and treated for carbon monoxide exposure or toxicity.^[4]

The same idea, just not limited to patients chosen by having ABGs measured within one hour of RAD-57 measurement.

The result is very different.

None of the patients with elevated RAD-57 measurements had carboxyhemoglobin measured by drawing blood.

None of the patients with CO poisoning (according to the RAD-57) were treated for CO poisoning.

Is the RAD-57 reliable for determining if a patient should not go to the hospital?

Absolutely not.

What is the target audience of RAD-57 marketing?

Firefighters.

What is the patient population studied?

Patients already being treated in the hospital. They may include firefighters, but there is nothing in the study to indicate if there are any firefighters in the sample.

Quick and easy-to-use—requires no user calibration and does not require patient cooperation or consciousness.^[5]

Dr. Michael O’Reilly (Executive Vice President of Masimo Corporation) had a bunch of excuses for the study that did not agree with the research paid for by Masimo. One excuse was that incorrect use of the RAD-57 interfered with results, even though Masimo trained the people using the RAD-57. Would Dr. O’Reilly have mentioned this if the study had produced the results he wanted?

Image credit.
Trust me. I am here to serve you.

Keep Firefighters Safe From CO Poisoning

> Have CO levels tested on the scene with the Masimo Rad-57.

• Just because firefighters don’t feel like they have CO poisoning doesn’t mean that they don’t have unsafe levels of carboxyhemoglobin (SpCO) in their bloodstream.

• That’s why rehab guidelines support the use of on-scene CO testing.⁶ To be safe, have SpCO levels tested with a Masimo Rad-57 before going back into the fire and during overhaul, even if firefighters think they’re okay.

> Get prompt on-scene treatment.

• Recognition is the key to immediate on-scene treatment. With early recognition, treatment for CO poisoning can begin immediately, which significantly reduces both immediate and long-term health risks.^[6]

To be safe, have SpCO levels tested with a Masimo Rad-57 before going back into the fire and during overhaul, even if firefighters think they’re okay.

Masimo is providing very bad advice. Is Masimo trying to kill firefighters?

And if the RAD-57 does not detect CO poisoning, is that any reason to allow a firefighter to go back into a fire?

Absolutely not.

The RAD-57 should NEVER be used to screen asymptomatic people for CO poisoning.

The RAD-57 should NEVER be used to rule out CO poisoning.

Footnotes:

^[1] Performance of the RAD-57 pulse CO-oximeter compared with standard laboratory carboxyhemoglobin measurement.
Touger M, Birnbaum A, Wang J, Chou K, Pearson D, Bijur P.
Ann Emerg Med. 2010 Oct;56(4):382-8. Epub 2010 Jun 3.
PMID: 20605259 [PubMed - indexed for MEDLINE]

Free Full Text Article from Ann Emerg Med with links to Free Full Text PDF Download

^[2] Performance of the Rad-57 pulse co-oximeter compared with standard laboratory carboxyhemoglobin measurement.
O’Reilly M.
Ann Emerg Med. 2010 Oct;56(4):442-4; author reply 444-5. No abstract available.
PMID: 20868919 [PubMed - indexed for MEDLINE]

Free Full Text of letter and author reply from Ann Emerg Med with links to Free Full Text PDF Download

^[3] Accuracy of noninvasive multiwave pulse oximetry compared with carboxyhemoglobin from blood gas analysis in unselected emergency department patients.
Annals of Emergency Medicine podcast
Podcast Download in MP3 Format

^[4] Non-invasive carboxyhemoglobin monitoring: screening emergency medical services patients for carbon monoxide exposure.
Nilson D, Partridge R, Suner S, Jay G.
Prehosp Disaster Med. 2010 May-Jun;25(3):253-6.
PMID: 20586019 [PubMed - indexed for MEDLINE]

Free Full Text PDF Download from Prehosp Disaster Med.

^[5] RAD-57
Masimo
Product information page

^[6] RAD-57 for Fire/EMS
Masimo
Product information page

Touger, M., Birnbaum, A., Wang, J., Chou, K., Pearson, D., & Bijur, P. (2010). Performance of the RAD-57 Pulse Co-Oximeter Compared With Standard Laboratory Carboxyhemoglobin Measurement Annals of Emergency Medicine, 56 (4), 382-388 DOI: 10.1016/j.annemergmed.2010.03.041

O’Reilly, M. (2010). Performance of the Rad-57 Pulse Co-Oximeter Compared With Standard Laboratory Carboxyhemoglobin Measurement Annals of Emergency Medicine, 56 (4), 442-444 DOI: 10.1016/j.annemergmed.2010.08.016

Nilson D, Partridge R, Suner S, & Jay G (2010). Non-invasive carboxyhemoglobin monitoring: screening emergency medical services patients for carbon monoxide exposure. Prehospital and disaster medicine, 25 (3), 253-6 PMID: 20586019

Roth, D., Herkner, H., Schreiber, W., Hubmann, N., Gamper, G., Laggner, A., & Havel, C. (2011). Accuracy of Noninvasive Multiwave Pulse Oximetry Compared With Carboxyhemoglobin From Blood Gas Analysis in Unselected Emergency Department Patients Annals of Emergency Medicine, 58 (1), 74-79 DOI: 10.1016/j.annemergmed.2010.12.024

Filed Under: Alarms, Critical Judgment, Heresy, Paramedicine 101, Research Blogging, Risk Management

Intramuscular Midazolam for Seizures – Part III

Mon, 20 Feb 2012 08:50:58 +0000 By Rogue Medic 1 Comment

Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the excellent material at these sites.

I have already pointed out my disappointment with the references of this large double-blind, randomized, noninferiority trial comparing IM (IntraMuscular) midazolam (Versed) with IV (IntraVenous) lorazepam (Ativan). One of those criticisms appears to be just due to a typographical error. The footnote in the text was ¹¹, but the footnote should have been ¹.

The relationships among benzodiazepine dose, respiratory depression, and subsequent need for endotracheal intubation are poorly characterized, but higher doses of benzodiazepines may actually reduce the number of airway interventions. Our data are consistent with the finding that endotracheal intubation is more commonly a sequela of continued seizures than it is an adverse effect of sedation from benzodiazepines.¹¹ ^[1]

Here is some of the information from footnote ¹. One interesting aspect of this double-blind study is that there is a placebo group. Patients received 2 mg IV lorazepam, 5 mg IV diazepam (Valium), or IV placebo. Treatment could be repeated one time if seizures continued for more than 4 minutes or if seizures recurred.

Cardiorespiratory complications before arrival at the hospital and at the time of transfer were important secondary outcomes that relate to the safety of out-of-hospital therapy with intravenous benzodiazepines. Despite concern regarding the adverse effects of these agents, we found a trend toward lower rates of out-of-hospital complications (primarily respiratory compromise) in the active-treatment groups than in the placebo group. This suggests that respiratory complications associated with prolonged seizures may be more pronounced than those caused by intravenous lorazepam and diazepam given at relatively low doses.^[2]

The doses are low. The lorazepam dose is only half of the 4 mg used in the IV lorazepam vs. IM midazolam study.

The doses of midazolam and lorazepam used in this trial are consistent with the most effective doses for the treatment of status epilepticus that are reported in the literature.^9,10 Although these initial doses are higher than the ones used by many EMS systems and emergency physicians, they are the same as those approved for this indication and are in line with those used by epileptologists.^[1]

Is there added safety from the lower doses?

The epilepsy specialists and the FDA (Food and Drug Administration) do not recommend lower doses.

Were the low doses effective?

2 mg midazolam?

Does anyone really expect such a small dose to make a difference?

Despite the beneficial outcomes associated with intravenous lorazepam and diazepam, 41 to 57 percent of patients who received active treatment were still in status epilepticus at the time of arrival at the emergency department. These patients were more than twice as likely to require intensive medical care as those whose seizures ended outside the hospital. Differences in the causes of the episodes of status epilepticus are unlikely to account for this difference. These observations, coupled with the favorable risk–benefit profile associated with lorazepam and diazepam in this trial, suggest that higher doses should be studied to define the optimal therapy for patients with out-of-hospital status epilepticus.^[2]

An editorial refers to the study just published^[1] and to the benzodiazepine vs. placebo study.^[2] Describing the complications in the placebo study, the author wrote –

Successful termination was much more common in the two groups that received benzodiazepines (59% with lorazepam, 43% with diazepam, and 21% with placebo). Since respiratory distress was twice as common in the group given placebo as in either of the groups given a benzodiazepine, the best way to avoid the need for intubation is to stop seizure activity.^[3]

This presents an interesting conundrum. Doses of benzodiazepines (midazolam, lorazepam, diazepam, . . .) are often limited, due to a fear of causing respiratory complications.

When treating seizures, higher doses of benzodiazepines may actually protect patients from respiratory complications.

With a fatality rate around 10%, seizures are certainly not benign.

Maybe early treatment with high dose benzodiazepines can significantly decrease that fatality rate.

Finally, relatively few out-of-hospital interventions have been evaluated in randomized controlled trials,¹⁶ and when they have been evaluated carefully, therapies with intuitive appeal have often been found either to lack benefit or to cause harm to patients.^17-20 ^[2]

The irony is that we may be doing the opposite by limiting doses of benzodiazepines to less than what is recommended by the FDA.

What do you think?

See also Part I and Part II. To be continued in Part IV.

Footnotes:

^[1] Intramuscular versus intravenous therapy for prehospital status epilepticus.
Silbergleit R, Durkalski V, Lowenstein D, Conwit R, Pancioli A, Palesch Y, Barsan W; NETT Investigators.
N Engl J Med. 2012 Feb 16;366(7):591-600.
PMID: 22335736 [PubMed - in process]

^[2] A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus.
Alldredge BK, Gelb AM, Isaacs SM, Corry MD, Allen F, Ulrich S, Gottwald MD, O’Neil N, Neuhaus JM, Segal MR, Lowenstein DH.
N Engl J Med. 2001 Aug 30;345(9):631-7. Erratum in: N Engl J Med 2001 Dec 20;345(25):1860.
PMID: 11547716 [PubMed - indexed for MEDLINE]

Free Full Text from N Engl J Med. with link to PDF Download

^[3] Intramuscular versus intravenous benzodiazepines for prehospital treatment of status epilepticus.
Hirsch LJ.
N Engl J Med. 2012 Feb 16;366(7):659-60. No abstract available.
PMID: 22335744 [PubMed - in process]

Silbergleit, R., Durkalski, V., Lowenstein, D., Conwit, R., Pancioli, A., Palesch, Y., & Barsan, W. (2012). Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus New England Journal of Medicine, 366 (7), 591-600 DOI: 10.1056/NEJMoa1107494

Alldredge BK, Gelb AM, Isaacs SM, Corry MD, Allen F, Ulrich S, Gottwald MD, O’Neil N, Neuhaus JM, Segal MR, & Lowenstein DH (2001). A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus. The New England journal of medicine, 345 (9), 631-7 PMID: 11547716

Hirsch LJ (2012). Intramuscular versus intravenous benzodiazepines for prehospital treatment of status epilepticus. The New England journal of medicine, 366 (7), 659-60 PMID: 22335744

Filed Under: Heresy, Midazolam, Paramedicine 101, Pharmacology, Research Blogging, Sedation

Intramuscular Midazolam for Seizures – Part II

Sun, 19 Feb 2012 06:30:47 +0000 By Rogue Medic 1 Comment

Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the excellent material at these sites.

While there have been studies comparing IM (IntraMuscular) midazolam (Versed) with IV (IntraVenous) anti-epileptic medications, this is a large study that compares IM midazolam with the best IV anti-epileptic medication in a double-blind, randomized, noninferiority trial.

All adults and those children with an estimated body weight of more than 40 kg received either 10 mg of intramuscular midazolam followed by intravenous placebo or intramuscular placebo followed by 4 mg of intravenous lorazepam.^[1]

For the study, there were two different doses for the auto-injector (similar to an EpiPen auto-injector). The doses were not small.

Midazolam for seizures is an off-label use both when given IM and when given IV.^[2]

The lorazepam IV doses in the study are according to the FDA label –

For the treatment of status epilepticus, the usual recommended dose of Lorazepam Injection is 4 mg given slowly (2 mg/min) for patients 18 years and older. If seizures cease, no additional Lorazepam Injection is required. If seizures continue or recur after a 10- to 15- minute observation period, an additional 4 mg intravenous dose may be slowly administered.^[3]

Unfortunately, my protocols only permit 1/4 or 1/2 the dose of lorazepam for seizures, which may be repeated every 5 minutes up to a maximum of one full dose recommended as the initial dose by the FDA.^[4] There is no adult IM use of midazolam.

There is often a concern about carefully adjusting pediatric doses. How did they handle that in this study?

In children with an estimated weight of 13 to 40 kg, the active treatment was 5 mg of intramuscular midazolam or 2 mg of intravenous lorazepam.^[1]

But such high doses will lead to deadly outcomes

Except that this excuse to give low doses is not supported by the authors of this study.

The relationships among benzodiazepine dose, respiratory depression, and subsequent need for endotracheal intubation are poorly characterized, but higher doses of benzodiazepines may actually reduce the number of airway interventions. Our data are consistent with the finding that endotracheal intubation is more commonly a sequela of continued seizures than it is an adverse effect of sedation from benzodiazepines.¹¹ ^[1]

That is a very interesting comment. The authors believe that intubations are increased by not controlling the seizure, rather than by giving large doses of a benzodiazepine. Unfortunately. I did not see anything to support that statement in the paper they cited as footnote 11.^[5]

See also Part I. To be continued in Part III, and Part IV.

Footnotes:

^[2] MIDAZOLAM HYDROCHLORIDE injection, solution
[Hospira, Inc.]
DailyMed
NLM
FDA label

I checked all of the injectable formulations of midazolam. They are the same. None include recommended dosing for seizures, but all include warnings about midazolam possibly causing seizures.

^[3] Lorazepam (lorazepam) Injection, Solution
[Baxter Healthcare Corporation]
DailyMed
NLM
FDA label

^[4] Seizure
Pennsylvania Statewide Advanced Life Support Protocols
7007 – ALS – Adult/Peds
Page 100/128
Free Full Text PDF of All ALS Protocols

Titrate until seizure stops.

Split the dose in half. Repeat the dose in 5 minutes.

There is no option for adult IM dosing.

^[5] A prospective, randomized study comparing intramuscular midazolam with intravenous diazepam for the treatment of seizures in children.
Chamberlain JM, Altieri MA, Futterman C, Young GM, Ochsenschlager DW, Waisman Y.
Pediatr Emerg Care. 1997 Apr;13(2):92-4.
PMID: 9127414 [PubMed - indexed for MEDLINE]

Chamberlain JM, Altieri MA, Futterman C, Young GM, Ochsenschlager DW, & Waisman Y (1997). A prospective, randomized study comparing intramuscular midazolam with intravenous diazepam for the treatment of seizures in children. Pediatric emergency care, 13 (2), 92-4 PMID: 9127414

Filed Under: Heresy, Midazolam, Pharmacology, Research Blogging, Sedation

Too Old To Work Gets Cantankerous

Sat, 18 Feb 2012 15:05:34 +0000 By Rogue Medic 10 Comments

Too Old To Work, Too Young To Retire does not appear to like what I wrote about EMS being armed and dangerous.^[1]

This post is well below your usual standards regarding data and analysis. You certainly wouldn’t use statements such as,

The police have psychological screening, but for EMS the only screening seems to be to have failed the police psych exam.

in any other context regarding EMS, but you feel free to use such gratuitous insults regarding EMS providers when it comes to something that you don’t favor.

When did TOTWTYTR become a stranger to sarcasm?

If TOTWTYTR wishes to contradict me, he can provide his own sarcasm.

Another job that EMS often considers as an alternative to EMS is nursing. If I made a comment about intubation not making EMS better than nurses, would that also be offensive?

It certainly undermines your credibility when it comes to your other declarative statements about EMS, providers, physicians, and medical control.

Certainly?

Please explain how sarcasm undermines credibility. After all, TOTWTYTR never uses sarcasm to make a point./

Statistically civilian gun owners are safer at handling their firearms than are police officers. Most police officers are not “gun people” and many that I know view having a firearm as a liability. On the other hand, civilian gun owners spend a lot of time practicing and especially practicing safe handling of their firearms.

People in EMS are not civilians any more than police are civilians.

We are uniformed emergency personnel. The uniform is a bit of a clue.

Why do we think we won’t be donating our weapons to the people we want to protect ourselves from?

There is no data to support the long spoken lie that civilians will always have guns taken away from them by criminals. Another myth you are perpetuating with this post.

I did not mistakenly call EMS civilians, TOTWTYTR did.

I did not state that this would always, or even frequently, happen.

The fear of being shot/stabbed appears to be due to a lack of understanding.

Better to be judged by 12 than carried by 6.

Where are the shot/stabbed LODDs (Line Of Duty Deaths)?

This is just another example of the thinking that comes up with –

If it saves just one life . . . .

We ignore unintended consequences in our focus on potential murders.

Image credit.

I do not know of any evidence that EMS is any more likely to use a weapon on an attacker than have their own weapons used on them.

Please provide some of the facts you claim contradict the question I asked.

Of course, TOTWTYTR‘s partner will be able to conceal a firearm and still have ready access to it in a confined environment.

Of course, TOTWTYTR‘s partner will be able to shoot only the bad people and would never fire a round through a wall, or a door, or a window.

All of the sharpshooters in EMS are above average shots.

If nothing else, we always choose the best places to draw our weapons.

I guess facts are only important when it’s something you believe in. Noted for future reference.

Show me some research on EMS being shot at.

I made a sarcastic comment and I asked a question. I did not present them as facts.

In TOTWTYTR‘s eyes, that reflects on the research I cite and the commentary I provide on that research?

Please provide some evidence of EMS (not tactical EMS) preventing murders by carrying weapons.

Please provide some evidence of EMS firing shots safely when attacked by people presenting a genuine threat. Tactical EMS does not count, because I have not suggested that they not carry weapons.

Complaining that I do not provide citations for sarcasm is just plain silly. However, I did not notice TOTWTYTR providing any facts.

Go listen to the discussion on the EMS Office Hours podcast – Arming EMS – Defensive or Simply Offensive.

Footnotes:

^[1] Arming EMS – Defensive or Simply Offensive
Rogue Medic
Thu, 16 Feb 2012
Article

Filed Under: EMS Office Hours, Heresy, Mythology

Intramuscular Midazolam for Seizures – Part I

Fri, 17 Feb 2012 12:10:30 +0000 By Rogue Medic 4 Comments

A study of IM (IntraMuscular) midazolam for EMS to treat seizures. The study looks at status epilepticus, but any seizure still present when EMS arrives should be treated. The terminology does not help. The only time I use the term status epilepticus is when teaching/writing about seizures; not when describing what I treated; not when thinking about what to do.

Many emergency medical services (EMS) systems, however, have begun to use intramuscular midazolam rather than an intravenous agent, largely because intramuscular administration is faster and is consistently achievable. ² This practice has become increasingly common despite the lack of clinical-trial data regarding the efficacy and safety of intramuscular midazolam.^[1]

Really?

In about an hour, using PubMed and Google, I found these. All of them examine the use of IM midazolam. Only one is not on humans.

1988

IM midazolam for status epilepticus in the emergency department.
Mayhue FE.
Ann Emerg Med. 1988 Jun;17(6):643-5.
PMID: 3377295 [PubMed - indexed for MEDLINE]

A 71-year-old man presented with a continuous generalized tonic-clonic seizure of 80 minutes duration. Multiple attempts to establish an IV line failed. Ten milligrams of midazolam hydrochloride was administered IM and was followed by prompt termination of seizure activity. This report discusses the pharmacokinetic and anticonvulsant properties of midazolam as an alternative to diazepam for the initial treatment of status epilepticus.

1991

A comparative pharmacokinetic study of intravenous and intramuscular midazolam in patients with epilepsy.
Bell DM, Richards G, Dhillon S, Oxley JR, Cromarty J, Sander JW, Patsalos PN.
Epilepsy Res. 1991 Nov-Dec;10(2-3):183-90.
PMID: 1817958 [PubMed - indexed for MEDLINE]

Since intravenous administration of AEDs including diazepam is not always feasible in status epilepticus there are obvious advantages in having an effective intramuscular formulation. Our data suggest that midazolam may be such a drug.

1992

Midazolam in treatment of epileptic seizures.
Lahat E, Aladjem M, Eshel G, Bistritzer T, Katz Y.
Pediatr Neurol. 1992 May-Jun;8(3):215-6.
PMID: 1622519 [PubMed - indexed for MEDLINE]

Midazolam (Versed), the first water-soluble benzodiazepine, has had widespread acceptance as a parenteral anxiolitic agent. Its antiepileptic properties were studied in adult patients with good results. Midazolam was administered intramuscularly to 48 children, ages 4 months to 14 years, with 69 epileptic episodes of various types. In all but 5 epileptic episodes, seizures stopped 1-10 min after injection. These results suggest that midazolam administered intramuscularly may be useful in a variety of epileptic seizures during childhood, specifically when attempts to introduce an intravenous line in convulsing children are unsuccessful.

1994

Intravenous versus intramuscular midazolam in treatment of chemically induced generalized seizures in swine.
Orebaugh SL, Bradford SM.
Am J Emerg Med. 1994 May;12(3):284-7.
PMID: 8179731 [PubMed - indexed for MEDLINE]

It is concluded that midazolam is effective in the control of tonic-clonic manifestations of generalized seizures when administered by the IV or the IM route

1997

Midazolam in treatment of various types of seizures in children.
Yakinci C, Müngen B, Sahin S, Karabiber H, Durmaz Y.
Brain Dev. 1997 Dec;19(8):571-2.
PMID: 9440805 [PubMed - indexed for MEDLINE]

No side effects were observed. These results suggest that i.m. administration of midazolam may be useful in a variety of seizures during childhood, especially in case of intravenous (i.v.) line problem.

A prospective, randomized study comparing intramuscular midazolam with intravenous diazepam for the treatment of seizures in children.
Chamberlain JM, Altieri MA, Futterman C, Young GM, Ochsenschlager DW, Waisman Y.
Pediatr Emerg Care. 1997 Apr;13(2):92-4.
PMID: 9127414 [PubMed - indexed for MEDLINE]

CONCLUSIONS:
IM midazolam is an effective anticonvulsant for children with motor seizures. Compared to IV diazepam, IM midazolam results in more rapid cessation of seizures because of more rapid administration. The IM route of administration may be particularly useful in physicians’ offices, in the prehospital setting, and for children with difficult IV access.

1999

Use of intramuscular midazolam for status epilepticus.
Towne AR, DeLorenzo RJ.
J Emerg Med. 1999 Mar-Apr;17(2):323-8. Review.
PMID: 10195494 [PubMed - indexed for MEDLINE]

The pharmacodynamic effects of midazolam can be seen within seconds of its administration, and seizure arrest is usually attained within 5 to 10 min. Case reports and a recent randomized trial that demonstrate the successful use of i.m. midazolam in the termination of epileptic seizures are reviewed.

2002

Midazolam for the treatment of out-of-hospital pediatric seizures.
Vilke GM, Sharieff GQ, Marino A, Gerhart AE, Chan TC.
Prehosp Emerg Care. 2002 Apr-Jun;6(2):215-7.
PMID: 11962570 [PubMed - indexed for MEDLINE]

CONCLUSION:
Prehospital IV midazolam is an effective intervention for pediatric seizures, while IM midazolam was associated with a 20% failure rate, with both having minimal risk of respiratory compromise.

This was the only study of midazolam cited as a midazolam study by the authors.

Controlling seizures in the prehospital setting: diazepam or midazolam?
Rainbow J, Browne GJ, Lam LT.
J Paediatr Child Health. 2002 Dec;38(6):582-6.
PMID: 12410871 [PubMed - indexed for MEDLINE]

CONCLUSION:
Midazolam controls seizures as effectively as diazepam in the prehospital setting. Furthermore, midazolam potentially reduces respiratory depression and time to treatment.

2005

Status epilepticus: an evidence based guide.
Walker M.
BMJ. 2005 Sep 24;331(7518):673-7. Review. No abstract available.
PMID: 16179702 [PubMed - indexed for MEDLINE]

Free Full Text from PubMed Central.

Intramuscular midazolam vs intravenous diazepam for acute seizures.
Shah I, Deshmukh CT.
Indian J Pediatr. 2005 Aug;72(8):667-70.
PMID: 16131771 [PubMed - indexed for MEDLINE]

CONCLUSION:
i.m. midazolam is an effective agent for controlling acute convulsions in children especially in children with febrile convulsions. It has relatively no side effects as compared to Intravenous diazepam and can be used as a first line agent for treatment of acute convulsions in patients with difficult intravenous access.

2010

Human safety and pharmacokinetic study of intramuscular midazolam administered by autoinjector.
Reichard DW, Atkinson AJ, Hong SP, Burback BL, Corwin MJ, Johnson JD.
J Clin Pharmacol. 2010 Oct;50(10):1128-35. Epub 2010 May 13.
PMID: 20466872 [PubMed - indexed for MEDLINE]

Midazolam in an autoinjector was evaluated in an open-label dose escalation study involving 39 healthy participants. Safety and pharmacokinetic parameters were determined for doses ranging from 5 to 30 mg. No serious adverse events were noted during the study.

2011

RAMPART (Rapid Anticonvulsant Medication Prior to Arrival Trial): a double-blind randomized clinical trial of the efficacy of intramuscular midazolam versus intravenous lorazepam in the prehospital treatment of status epilepticus by paramedics.
Silbergleit R, Lowenstein D, Durkalski V, Conwit R; Neurological Emergency Treatment Trials (NETT) Investigators.
Epilepsia. 2011 Oct;52 Suppl 8:45-7. doi: 10.1111/j.1528-1167.2011.03235.x.
PMID: 21967361 [PubMed - indexed for MEDLINE]

That is a preliminary release of information from the study that was just published in NEJM.

This practice has become increasingly common despite the lack of clinical-trial data regarding the efficacy and safety of intramuscular midazolam.^[1]

I haven’t looked at the rest of the study, but I hope that more thought went into the study design than went into the search for other research.

To be continued in Part II, Part III, and Part IV.

Footnotes:

^[1] Intramuscular versus Intravenous Therapy for Prehospital Status Epilepticus
Robert Silbergleit, M.D., Valerie Durkalski, Ph.D., Daniel Lowenstein, M.D., Robin Conwit, M.D., Arthur Pancioli, M.D., Yuko Palesch, Ph.D., and William Barsan, M.D. for the NETT Investigators
N Engl J Med 2012; 366:591-600February 16, 2012
Preview from NEJM

Apparently, there is no PubMed abstract, yet.

Late entry 02/18/2012 22:27 – Correction, there is a PubMed abstract for this study –

Intramuscular versus intravenous therapy for prehospital status epilepticus.
Silbergleit R, Durkalski V, Lowenstein D, Conwit R, Pancioli A, Palesch Y, Barsan W; NETT Investigators.
N Engl J Med. 2012 Feb 16;366(7):591-600.
PMID: 22335736 [PubMed - in process]

Filed Under: Heresy, Midazolam, Pharmacology, Research, Sedation

Arming EMS – Defensive or Simply Offensive

Thu, 16 Feb 2012 20:00:05 +0000 By Rogue Medic 3 Comments

On EMS Office Hours most recent show, Jim Hoffman, Josh Knapp, and I discussed a topic I have written about several times – particularly my recent post Why are We So Afraid of Our Patients.

Arming EMS – Defensive or Simply Offensive

Original cartoon credit.

How well prepared are we to use lethal force on the job? Not medications, endotracheal tubes, and other potentially lethal interventions, but guns, knives, clubs, and other weapons.

Randy called in and made some good points.

Why do we think we won’t be donating our weapons to the people we want to protect ourselves from?

If we carry weapons that are concealed well enough that nobody notices, how long will it take to draw the weapon in a confined space while being attacked?

The police have psychological screening, but for EMS the only screening seems to be to have failed the police psych exam.

Is is better to fight back or to run away?

We are not there to fight. We should not stay to fight.

How many EMS providers are murdered in any year?

How many of them are murdered on a call?

Will any of this be improved by putting a weapon in your partners’ hands?

This is not about whether you are safe with a weapon.

This is about whether your partner is safe with a weapon.

I have worked with a few people who would be safe with a weapon, but most of the partners I have had would only be dangerous with weapons.

We are not there to win arguments.

We are there to treat patients.

Go listen to the podcast.

Also listen to –

EMS Situational Awareness at EMS Office Hours.

Surviving the Next Shift the Standing Orders podcast.

Other sites mentioned on the podcast –

DT4EMS.com

EMS Museum post at Rescuing Providence

Copy & Paste post on Federal EMS agency at EMS Patient Perspective

Filed Under: EMS Office Hours, Ethics, Heresy, Mythology

How Bad are the Drug Shortages

Wed, 15 Feb 2012 17:00:36 +0000 By Rogue Medic 1 Comment

I rant a bit about the misuse of many of these drugs, but there are a lot of drugs used in EMS on the current drug shortage list.

There is a lot written about the drug shortages, but what drugs are affected right now? I copied a list of what drugs are currently experiencing shortages as of today from the FDA (Food and Drug Administration).^[1], ^[2]

What about EMS drugs?

Alfentanil Injection (Alfenta, Rapifen) – An opioid that may be used in some EMS systems as a substitute for fentanyl. Or another reason for EMS to use ketamine.^[7]

Atracurium besylate (Tracrium) – A paralytic used in RSI (Rapid Sequence Induction/Intubation).

Atropine Sulfate Injection – Amphastar lists no delays, but other manufacturers list manufacturing delays and an increase in product demand. One manufacturer temporarily suspended production in April 2011.

The FDA search shows that there were drug shortages updates for atropine on 12/11/2008, 4/07/2009, and 9/30/2011 (the current shortage?), but all of the cached pages are the most recent, so the original information is not there.^[3]

Following concerns about possible terrorist attacks using poisons that may be treated with atropine, the long term stability of atropine, and the continuing lack of evidence of benefit of atropine in treating cardiac arrest.^[4]

How much did each of those contribute to another magic treatment biting the dust?

Caffeine, anhydrous (125 mg/mL) and Sodium benzoate (125 mg/mL) (Starbucks, Dunkin’ Donuts) – OK, that is not the kind of caffeine they are referring to. There might be true rebellion among EMS and hospital personnel if caffeine were not available.

What does that tell us about sleep deprivation, medicine, and the need for naps on the job?

Calcium Chloride Injection – If we are treating emergency hyperkalemia (which I recently saw written as hyperpotassiumemia ) with anything other than calcium chloride as the first line drug, we are not providing good patient care.^[5]

But calcium is dangerous!!

The danger of calcium is just another EMS myth.

What is dangerous is using much less effective treatments, such as sodium bicarbonate.

What is even more dangerous is using harmful, but ineffective treatments, such as sodium polystyrene sulfonate (Kayexalate)

Calcium Gluconate – A less concentrated form of calcium, that is safer in IV (IntraVenous) lines of questionable patency, not that this is the biggest concern in treating peri-arrest patients. IO (IntraOsseous) works for calcium chloride.^[6]

Desmopressin Injection (DDAVP, Stimate, Minirin) – Similar to vasopressin.

Dexamethasone Injection (Decadron) – Methylprednisolone (Medrol, Solu-Medrol) is a good alternative that is not listed as a current drug shortage.

Diazepam Injection (Valium, Diastat) – The common alternative benzodiazepine sedatives (lorazepam [Ativan] and midazolam [Versed]) are also listed as current drug shortages.

Maybe this is a good reason to start carrying ketamine.^[7]

Digoxin Injection – An inotrope alternative to catecholamines. The only inotrope not supposed to raise heart rate or myocardial oxygen demand at therapeutic levels. On the other hand, there is debate about whether digoxin improves outcomes.^[8], ^[9]

Diltiazem Injection (Cardizem) – Verapamil (Calan, Isoptin, and Verelan) is the common alternative calcium channel blocker that should be used in the place of diltiazem for A Fib (Atrial Fibrillation) or SVT (SupraVentricular Tachycardia).

Diphenhydramine Hydrochloride Injection (Benadryl) – A medication to treat dystonic reactions. For dystonia, it can be replaced by benztropine (Cogentin). The more common use of diphenhydramine is as an antihistamine, such as after IM (IntraMuscular) epinephrine for anaphylaxis. It may sedate and decrease itching, but do not expect diphenhydramine to reverse anaphylaxis.

An example of dystonia. Image credit.

Etomidate Injection (New!!) (Amidate) – Etomidate is commonly used for pseudo-RSI or DFI (Drug Facilitated Intubation). In Pennsylvania, we have a dose of 0.3 mg/kg, that is often restricted even more by some medical command doctors out of an apparent fear of giving a dose that might be effective. Should they want to give orders for more, the maximum dose listed in the protocol is 30 mg. The medical command doctor can order more, but few seem to realize that this is not a restriction on what they can order. Etomidate is only supposed to be used with a paralytic for RSI, but is expected to be both sedative and paralytic, when EMS uses it in Pennsylvania.

Why use a not-very-effective drug at a dose that is not expected to be effective?

Fentanyl Citrate Injection (Sublimaze) – The shortage of both benzodiazepines and opioids are just more reasons for EMS to use ketamine.^[7]

Furosemide Injection (Lasix) – A drug that EMS should not use. Furosemide is so far down on the list of treatments for CHF (Congestive Heart Failure), that it suggests we have been digging a grave for the patient, if we stay on scene long enough to give furosemide. A worthless EMS treatment.^[10], ^[11] Pennsylvania is ahead of most states in moving furosemide to medical command order only, but the better move is to remove it from EMS use completely.

Ketorolac Injection (Toradol) – A pain medicine related to aspirin, so not a good idea for trauma, but some people are less worried about interfering with the ability of trauma patients to stop bleeding than they are about the possibility that the 10/10 severe pain patient might stop screaming and, without anyone noticing, stop breathing.

One possible superiority is for calculi (kidney stones and gall stones). Of course, this is just another reason for EMS to use ketamine.^[7]

Labetalol Hydrochloride Injection (Normodyne, Trandate) – A beta blocker. Beta blockers have been de-emphasized since the CRUSADE trial, but there are still EMS indications in heart attack. Patients with signs of dramatic catcholamine release (they look as if someone gave them epinephrine) except for patients with tachycardia (greater than 110 beats per minute).

Lorazepam Injection (Ativan) – Not the best, or even the second best, EMS sedative, but one that is preferred by a lot of people. A much better idea is midazolam, because aggressive doses can be given and they should be wearing off at about the time the patient is being transferred to the ED (Emergency Department), so that one-on-one observation of a heavily sedated patient is not required and flumazenil (Romazicon) is not given. Another reason for EMS to use ketamine.^[7]

Magnesium Sulfate Injection – A safer antiarrhythmic than amiodarone and a treatment for some of the arrhythmias caused by amiodarone, such as torsades des pointes.-

Mannitol Injection – An osmotic diuretic used in some EMS systems.

Methylphenidate HCl (Ritalin) – Possibly the second most common EMS drug – after caffeine.

Metoclopramide injection (Reglan) – Anti-nausea medication.

Midazolam Injection (Versed) – This used to be my favorite EMS sedative, but this is one more reason for EMS to use ketamine.^[7]

Morphine Sulfate Injection – For pain management and another reason for EMS to use ketamine.^[7]

Nalbuphine Injection (Nubain) – A poor substitute for morphine and a pathetic excuse for risk management. Just another reason for EMS to use ketamine.^[7]

Naltrexone Oral Tablets (New!!) (Depade, ReVia) – With the use of nebulized naloxone, who knows what might be next? As long as we are treating something other than respiratory depression (patients unlikely to be able to use a nebulizer), maybe oral tablets will be next and the longer acting opioid antagonist may appeal to those terrified of any potential for respiratory depression.

NeoProfen (ibuprofen lysine) Injection – For treatment of PDA (Patent Ductus Arteriosus) in premature babies. Some EMS may use this, but it is more likely to be found in the ED or neonatal ICU.

Ondansetron Injection 2 mg/mL (Zofran) – One effective antiemetic.

Ondansetron Injection 32 mg/50 mL premixed bags (Zofran) – Same thing, different preparation.

Oxytocin Injection, USP (synthetic) (Pitocin) – For post-partum hemorrhage that is not otherwise controlled. Massage the fundus and consider direct pressure. Direct pressure is not in EMS protocols, but when the alternative is the death of the patient, do we want to stop the bleeding, or do we want to follow protocols?

Pancuronium Bromide Injection (Pavulon) – A paralytic used in RSI.

Phentolamine Mesylate for Injection (Regitine) – For treatment of extravasation of catecholamines (epinephrine, dopamine, dobutamine). Not usually carried by EMS (after all, it only happens in other EMS systems), but used in the ED (even to treat the extravasation of catecholamines from EMS IVs – but only from those other EMS systems).

Procainamide HCL Injection (Pronestyl) – An antiarrhythmic that is very effective, but it has a lot of side effects – just like the much less effective drugs that are used in its place.

Prochlorperazine Injection (Compazine) – Another anti-nause medication. This is also one of the drugs that may cause dystonic reactions.

Promethazine Injection (Phenergan) – Still another anti-nause medication. Another drug that may cause dystonic reactions.

Vasopressin Injection (Pitressin) – An alternative to epinephrine as a pressor to treat cardiac arrest, even though there is no evidence of improved survival. Also goes by the name “pit,” so that it can be easily confused with Pitocin (“pit”) used in OB/GYN.

Vecuronium Injection (Norcuron) – A paralytic used in RSI.

That is it for the drugs that are used in some EMS systems. Fortunately, a lot can be replaced by ketamine, or their use can be reduced by the use of ketamine. Pain management, sedation, RSI, excited delirium, DSI (Delayed Sequence Intubation), et cetera. One long list of reasons for EMS to use ketamine.^[7]

Also see Stressful Drug Shortage Update.

Footnotes:

^[1] Current Drug Shortages
Drug Shortages
FDA
02/15/2012
Drug shortage Update

^[2] List of medications from FDA drug shortages update on 02/15/2012

Acetylcysteine Inhalation Solution

Alcohol Dehydrated (Ethanol > 98%)

Alfentanil Injection

Amikacin Injection

Amino Acid Products (New!!)

Aminocaproic Acid

Ammonium Chloride Injection

Ammonium Molybdate Injection

Ammonul (sodium phenylacetate and sodium benzoate) Injection 10%/10%

Amphetamine Mixed Salts, ER Capsules

Amphetamine Mixed Salts Immediate-Release Tablets

Anadrol-50 tablets (Oxymetholone Tablets)

Aquasol A

Atracurium besylate

Atropine Sulfate Injection

Avalide (irbesartan and hydrochlorothiazide)Tablets

Bleomycin Injection

Bupivacaine Hydrochloride Injection

Buprenorphine Injection

Butorphanol Injection

Caffeine, anhydrous (125 mg/mL) and Sodium benzoate (125 mg/mL)

Calcitriol 1 mcg/mL Injection

Calcium Chloride Injection

Calcium Gluconate

Cerezyme (imiglucerase for injection)

Chromic Chloride Injection

Cisplatin injection 1 mg/mL solution

Corticorelin Ovine Triflutate (New!!)

Cosyntropin Injection

Cyanocobalamin injection

Daunorubicin hydrochloride solution for injection

Desmopressin Injection

Dexamethasone Injection

Dexrazoxane Injection

Dextroamphetamine Tablets

Diazepam Injection

Digoxin Injection

Diltiazem Injection

Diphenhydramine Hydrochloride Injection

Doxorubicin (adriamycin) lyophilized powder

Doxorubicin Liposomal (Doxil) Injection

Doxorubicin Solution for Injection

Ethiodol (ETHIODIZED OIL) ampules

Etomidate Injection (New!!)

Etoposide solution for injection

Fabrazyme (agalsidase beta)

Fentanyl Citrate Injection

Fluorouracil Injection

Foscarnet Sodium Injection

Fosphenytoin Sodium Injection

Furosemide Injection

Haloperidol Decanoate Injection

Indigo Carmine Injection

Insulin glulisine [rDNA origin] injection) solution for injection (Apidra SoloStar)

Intravenous Fat Emulsion

Isoniazid Tablets

Ketorolac Injection

Labetalol Hydrochloride Injection

L-cysteine hydrochloride

Leucovorin Calcium Lyophilized Powder for Injection

Leuprolide Injection

Levaquin Injection

Levofloxacin Injection

Levoleucovorin (Fusilev) 50 mg single use vials

Lorazepam Injection

Magnesium Sulfate Injection

Mannitol Injection

Mesna 100 mg/mL Injection

Methotrexate Injection

Methylphenidate HCl

Methyldopate Injection

Metoclopramide injection

Mexiletine Capsules (150mg, 200mg, and 250mg)

Midazolam Injection

Mitomycin Powder for Injection

Morphine Sulfate Injection

Multi-Vitamin Infusion (Adult and pediatric)

Mustargen (mechlorethamine HCl) injection

Nalbuphine Injection

Naltrexone Oral Tablets (New!!)

NeoProfen (ibuprofen lysine) Injection

Neupro (rotigotine transdermal system)

Ondansetron Injection 2 mg/mL

Ondansetron Injection 32 mg/50 mL premixed bags

Ontak injection

Opana ER (oxymorphone hydrochloride) Extended-Release Tablets CII (New!!)

Orphenadrine Citrate Injection

Oxsoralen (methoxsalen) 1% topical lotion

Oxytocin Injection, USP (synthetic)

Paclitaxel Injection

Pancuronium Bromide Injection

Phentolamine Mesylate for Injection

Phytonadione Injectable Emulsion (Vitamin K)

Potassium Phosphate

Primaquine Phosphate Tablets

Procainamide HCL Injection

Prochlorperazine Injection

Promethazine Injection

Selenium injection

Sodium Acetate Injection

Sodium Chloride 23.4%

Sodium Phosphate Injection

Sulfamethoxazole 80mg/trimethoprim 16mg/ml injection (SMX/TMP)

Telavancin (Vibativ) Injection

Tetracycline Capsules

Thiotepa for Injection

Thyrogen (thyrotropin alfa) injection 1.1mg/vial

Thyrolar Tablets

Ticlopidine Tablets

Tobramycin Solution for Injection

Vasopressin Injection

Vecuronium Injection

Vinblastine Sulfate Injection

Voltaren gel 1% (Diclofenac Sodium Topical Gel) (New!!)

^[3] Atropine Sulfate Injection
FDA
FDA Search

^[4] What Will We Do With All of That Atropine
Rogue Medic
Fri, 22 Oct 2010
Article

^[5] Management of severe hyperkalemia.
Weisberg LS.
Crit Care Med. 2008 Dec;36(12):3246-51. Review.
PMID: 18936701 [PubMed - indexed for MEDLINE]

Free Full Text PDF

^[6] Comparison study of intraosseous, central intravenous, and peripheral intravenous infusions of emergency drugs.
Orlowski JP, Porembka DT, Gallagher JM, Lockrem JD, VanLente F.
Am J Dis Child. 1990 Jan;144(1):112-7.
PMID: 1688484 [PubMed - indexed for MEDLINE]

^[7] Is Ketamine an EMS Wonder Drug
Rogue Medic
Sun, 01 Jan 2012
Article

^[8] Update on digoxin therapy in congestive heart failure.
Haji SA, Movahed A.
Am Fam Physician. 2000 Jul 15;62(2):409-16. Review.
PMID: 10929703 [PubMed - indexed for MEDLINE]

Free Full Text from Am Fam Physician.

For many more years, digitalis continued to be an important part of heart failure management. The detrimental aspects of digoxin therapy were not considered important until excess mortality was reported in survivors of myocardial infarction who received digitalis.^13,14 Uncontrolled observations that the withdrawal of digoxin produced no ill effects also raised concerns about the efficacy of the drug.^15,16

^[9] The effect of digoxin on mortality and morbidity in patients with heart failure. The Digitalis Investigation Group.
[No authors listed]
N Engl J Med. 1997 Feb 20;336(8):525-33.
PMID: 9036306 [PubMed - indexed for MEDLINE]

Free Full Text from N Engl J Med.

In conclusion, digoxin had no effect on overall mortality in patients receiving diuretics and angiotensin-converting–enzyme inhibitors, but it did reduce the overall number of hospitalizations and the combined outcome of death or hospitalization attributable to worsening heart failure. In clinical practice, digoxin therapy is likely to affect the frequency of hospitalization, but not survival.

On the other hand, that is not a study of digoxin for emergency use.

^[10] Prehospital therapy for acute congestive heart failure: state of the art.
Mosesso VN Jr, Dunford J, Blackwell T, Griswell JK.
Prehosp Emerg Care. 2003 Jan-Mar;7(1):13-23. Review.
PMID: 12540139 [PubMed - indexed for MEDLINE]

Free Full Text PDF

^[11] Modern management of cardiogenic pulmonary edema.
Mattu A, Martinez JP, Kelly BS.
Emerg Med Clin North Am. 2005 Nov;23(4):1105-25. Review.
PMID: 16199340 [PubMed - indexed for MEDLINE]

Free Full Text PDF

Filed Under: FDA, Heresy, Pharmacology