Furosemide is good for filling the patient’s bladder, but the patient probably did not call for help filling his/her bladder.

- Rogue Medic

Valsalva the SVT or Shock the Monkey?


 

The Skeptics’ Guide to Emergency Medicine should be on your podcast list. The podcasts are short, so there is not much reason to avoid them. This one is 13 minutes.

Valsalva for SVT (SupraVentricular Tachycardia) is supposed to come before medication. At least that is the order of treatments of every EMS SVT protocol I have seen. Since medicine is expected to have more, and more serious, side effects, this is reasonable.

What medicines?

Adenosine has the side effects of -
 

Cardiovascular

Prolonged asystole, ventricular tachycardia, ventricular fibrillation, transient increase in blood pressure, bradycardia, atrial fibrillation, and Torsade de Pointes

Respiratory

Bronchospasm

Central Nervous System

Seizure activity, including tonic clonic (grand mal) seizures, and loss of consciousness.[1]

 

It appears to be reasonable to try to avoid those side effects.

Too much of this could become more of a problem than an SVT.
 


Click on images to make them larger. Image credit.[2] This is not the actual strip, but a strip of an adenosine pause edited to produce more asystole, which I have seen.
 

The side effect becomes much more of a problem when someone decides to treat the side effect, rather than wait for it to wear off.

We SLAM adenosine in because it wears off quickly. A minute, or two, of asystole is not a problem.

Giving a dose of epinephrine to a patient who had an SVT a minute ago and now has adenosine quickly wearing off – that may be a fatal problem.

But how effective is the Valsalva maneuver (VM)?
 

The VM is a non-invasive way to convert patients from SVT to sinus.It increases myocardial refractory period by increasing intrathoracic pressure thus stimulating baroreceptors in the aortic arch and carotid bodies Increases vagal tone (parasympathetic).[3]

 

Here is a big problem with the use of the Valsalva maneuver. It is just one method of attempting to stimulate the vagus nerve.

There are many other methods and they may be more successful. Carotid sinus massage (after auscultation for bruits), facial immersion in ice water (assuring that the airway does not become a problem), bearing down, blowing through a straw (even better may be a swizzle stick), digital circumferential sweep of the anus, coughing, . . . .

There are many ways of activating the vagal nerve, but my favorite is to act as if I have not started an IV before, go very s l o w l y with the insertion of the largest IV catheter I think I can get in the vein, and this has almost always broken the rhythm.

Yes, that is anecdotal, but I have only rarely needed to follow that with medication.

Yes, pain is not a nice thing, but it is much nicer than the side effects listed above.
 

Bottom Line: There is no standardized methods to perform a VM to terminate uncomplicated SVT that are evidence based.

Clinical Application: VM is a viable technique that is poorly researched for the conversion of SVT and should not be considered essential to attempt prior to chemical cardioversion.[2]

 

We need better vagal maneuvers.

We need good evidence on what works.
 

Go read the article and listen to the podcast.
 

-

Footnotes:

-

[1] ADENOCARD (adenosine) solution
[Astellas Pharma US, Inc.]

DailyMed
FDA Label

-

[2] Atrioventricular Re-entrant Tachycardia
Thumbnail Guide to Congenital Heart Disease
edited version of their adenosine ECG strip
Article

-

[3] SGEM#67: Shock the Monkey Tonight (Valsalva Maneuver for SVT)
Podcast Link: SGEM67
Date: March 23, 2014
Skeptics’ Guide to Emergency Medicine
Article and link to podcast

.

Is It Wrong To Medicate To The Point Of Needing Ventilation – Question from mpatk


Image credit.
 

In the comments to Where is the Line Between Good Pain Management and Bad, mpatk write the following –
 

To clarify, would you consider it acceptable to sedate to the point of requiring assisted ventilation for a sufficiently painful injury (e.g. multiple long bone fx’s)?

 

I have not needed to ventilate any of these patients, but I have added oxygen to keep some patients’ oxygen saturation above 93%.

Would it be wrong to medicate to the point of needing to ventilate?

There was a time when I would have taken the position that this is an indication of bad pain management/bad sedation, but I no longer agree with that.

We are there to provide appropriate care for the patient, not appropriate care for the patient up to the point of needing to assist with ventilation.

Most medical directors will probably disagree with me, but medical directors are getting better at encouraging appropriate pain management and sedation.

You, and I, do not have access to ketamine, but ketamine would be the ideal drug for many painful injuries. Ketamine provides sedation, analgesia, and dissociation, but generally does not cause any respiratory depression. Ketamine can occasionally cause laryngospasm, but that is easy to manage. I need to follow up on some earlier posts on ketamine and laryngospasm.[1],[2],[3]

But we do not have ketamine. should our patients suffer because we do not have the best drug for these patients?

No.

What is going to happen in the hospital?

The patient is going to need surgery, which generally involves ventilation through an endotracheal tube, or an LMA (Laryngeal Mask Airway). We could anticipate that and place an airway for ventilation.

We could give tiny titrated doses of naloxone (for suspected opioid-induced hypoventilation) and/or tiny titrated doses of flumazenil (for suspected benzodiazepine-induced hypoventilation).

This problem is not a lack of oxygenation, because we could treat that with a higher concentration of oxygen. This is a problem of inadequate removal of CO2 (Carbon DiOxide), or it is a combined problem of hypoxia and hypercarbia.

There is a discussion of procedural sedation by Dr. Al Sacchetti that is essential listening for anyone who provides sedation and/or pain management.[4]

Why should paramedics listen to this? Because this is important material to understand to be good at sedation and pain management.

Pay attention to the whole presentation, because Dr. Sacchetti makes some excellent points.

Most relevant to what I am writing is what he says from 27:00 to 28:15.

Would an LMA have been more appropriate? Maybe. Maybe not.

At 29:30 Dr. Sacchetti says –
 

The medication with the lowest complication rate is . . .
 
Propofol (Diprivan)?

Midazolam (Versed)?

Ketamine (Ketalar)?

Morphine?

Hydromorphone (Dilaudid)?

Fentanyl (Sublimaze)?

What do you think was the safest drug (lowest complication rate)?
 

 

 

 

 

 

 

 

 

 

ketamine.
 

Zero major complications.
 

At 30:00 he puts the safety of fentanyl and etomidate (EMS medications) in perspective, when compared with ketamine and propofol, which are often considered too dangerous for EMS.
 

Fentanyl has the highest complication rate followed by etomidate.
 


This list is in alphabetical order, not in order of complications, or number of patients, or . . . .
 

Perspective is important.

Airway management skill is essential.

Limiting EMS to the least safe medications does not protect patients.

-

Footnotes:

-

[1] Laryngospasm, hypoxia, excited delirium, and ketamine – Part I
Thu, 21 Jun 2012
Rogue Medic
Article

-

[2] Laryngospasm, hypoxia, excited delirium, and ketamine – Part I
Mon, 25 Jun 2012
Rogue Medic
Article

-

[3] Serious adverse events during procedural sedation with ketamine – Part I
Thu, 27 Sep 2012
Rogue Medic
Article

-

[4] Al Sacchetti: Procedural Sedation in the Community ED
April 28, 2010
Free Emergency Medicine Talks
Al Sacchetti
Page with free download of presentation in mp3 format.

The reference is to the ProSCED registry, which is described in the papers below – both are free.

Procedural sedation in the community emergency department: initial results of the ProSCED registry.
Sacchetti A, Senula G, Strickland J, Dubin R.
Acad Emerg Med. 2007 Jan;14(1):41-6. Epub 2006 Aug 31.
PMID: 16946280 [PubMed - indexed for MEDLINE]

Page With Free Full Text in PDF Download format from Academic Emergency Medicine. Click on Get PDF (97K).
 

The safety of single-physician procedural sedation in the emergency department.
Hogan K, Sacchetti A, Aman L, Opiela D.
Emerg Med J. 2006 Dec;23(12):922-3.
PMID: 17130600 [PubMed - indexed for MEDLINE]

Free Full Text from PubMed Central.

.

Why Do We Have So Little Respect For Our Patients?


 

Informed consent should require that we provide our patients with honest information about the treatment we are pushing.

Even implied consent assumes that an informed patient would make the decision to take the treatment if the patient had the capacity to make an informed decision and had honest information about the treatment.

What medical treatment do we use during cardiac arrest?

We use chest compressions and defibrillation.

Nothing else qualifies as medicine.
 


Download YouTube Video | YouTube to MP3: Vixy
 

Ventilations, epinephrine, norepinephrine, vasopressin, amiodarone, lidocaine, and procainamide, are witchcraft.

There is no evidence that ventilations, epinephrine, norepinephrine, vasopressin, amiodarone, lidocaine, or procainamide improve survival from cardiac arrest.

None.
 

 
Why don’t we limit treatments to what actually works, rather than what makes us feel like we are helping?

We are only exposing our patients to adverse effects for no benefit to the patient.

Nature has demonstrated a strong bias in favor of reality.

Our bias in favor of superstition is unnatural and unhealthy.
 

All treatments should be limited to high-quality controlled trials until there is valid evidence of improved outcomes with the treatment.

Surrogate endpoints do not count.

If we wish to develop an understanding of what we are doing, we need to study what we use.

If a treatment does not work under controlled conditions, why believe that it works in uncontrolled conditions?

Research gives the best opportunity to see the difference in outcome that is due to the just the treatment being studied.

If we think the treatment works, we should be insisting on showing off.

We are all talk.

We run away when challenged.

If we accept excuses for not finding out what we are doing, we end up with epinephrine for cardiac arrest – 50+ years of use, but we still do not know if it is beneficial, if it is beneficial in some patient populations and harmful in other patient populations, or if the effect is neutral.

There is no outcomes research that has shown improved outcomes, but epinephrine is the standard of care and research has been discouraged because it would be unethical to deprive patients of this witchcraft.

Any treatment that is used outside of controlled trials, without evidence of improved outcomes, is witchcraft. Why can’t we be honest about that?

I was a baby, when we started using epinephrine for cardiac arrest. I am a cantankerous old coot, now. There has been only one placebo controlled trial of epinephrine for cardiac arrest,[1] but that was crippled by political pressure because it would be unethical to deprive patients of the eye of newt.

Someday, medicine will grow up and start treating patients with something that actually works.

-

Footnotes:

-

[1] Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial
Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL.
Resuscitation. 2011 Sep;82(9):1138-43. Epub 2011 Jul 2.
PMID: 21745533 [PubMed - in process]

Free Full Text PDF Download of In Press Uncorrected Proof from xa.yming.com

This study was designed as a multicentre trial involving five ambulance services in Australia and New Zealand and was accordingly powered to detect clinically important treatment effects. Despite having obtained approvals for the study from Institutional Ethics Committees, Crown Law and Guardianship Boards, the concerns of being involved in a trial in which the unproven “standard of care” was being withheld prevented four of the five ambulance services from participating.

In addition adverse press reports questioning the ethics of conducting this trial, which subsequently led to the involvement of politicians, further heightened these concerns. Despite the clearly demonstrated existence of clinical equipoise for adrenaline in cardiac arrest it remained impossible to change the decision not to participate.

.

What Can EMS Expect From 2014? #3 Real Doses of Seizure Meds – IM Midazolam

 

Why should EMS treat seizures aggressively.

All seizures stop eventually.

True, so does all bleeding, but that does not mean that the patient has a good outcomes.

If we are to provide competent medical care, we should be using the safest and most effective treatments that make a difference for the patient.

The evidence supports aggressive EMS treatment of seizures with large doses of IM (IntraMuscular) midazolam (Versed).
 


Image credit.
 

Third, outcome tends to correlate with seizure duration even after one controls for other factors. Mortality among patients who present in status epilepticus is 15 to 22%; among those who survive, functional ability will decline in 25% of cases.6 [1]

 

This study used 10 mg midazolam IM vs. 4 mg lorazepam (Ativan) IV (IntraVenous).

This is more than most EMS systems use.

The low dosing appears to be out of a misguided fear of respiratory depression from too much benzodiazepine (midazolam or lorazepam or diazepam).

Do EMS medical directors understand the real risks?

 

In the 1998 Veterans Affairs Cooperative Status Epilepticus Study, the intravenous lorazepam dose used was 0.1 mg/kg. This means that many patients enrolled in the current study could have been underdosed based on the 4 mg intravenous lorazepam dose.[2]

 

This comment on the study suggests that the doses were too low.
 

Considering that midazolam had a treatment failure rate of 26.6% in this study, we think that the doses of midazolam that were used (10 mg) were smaller than the doses required for termination of prehospital seizure. It is anticipated that a fixed dose of 20 mg (two autoinjectors) of midazolam is the effective dose in humans.2 [3]

 

This letter on the study suggests that the doses were much too low.
 

Is there any evidence that large doses of benzodiazepines are more of a problem than the seizure?
 

No.

This has been demonstrated by research comparing the use of lorazepam, diazepam (Valium), and placebo to treat seizures.
 

Status epilepticus was terminated by the time of arrival at the emergency department in 59.1 percent of patients given lorazepam, 42.6 percent of patients given diazepam, and 21.1 percent of patients given placebo (P=0.001)[4]

 

How did the benzodiazepines affect outcomes?

 

An out-of-hospital complication (hypotension, cardiac dysrhythmia, or respiratory intervention) occurred in 7 (10.6 percent) of the patients treated with lorazepam, 7 (10.3 percent) of the patients treated with diazepam, and 16 (22.5 percent) of the patients given placebo (P=0.08). The most common complication was a change in respiratory status requiring ventilation assistance by bag valve-mask or an attempt at intubation (7 patients given lorazepam, 6 given diazepam, and 11 given placebo).[4]

 

Respiratory compromise was almost twice as common without benzodiazepines.

 

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 [5]

 

High dose benzodiazepines appear to be more likely to prevent intubation, than to result in intubation.

Why is this so difficult for medical directors to understand?

This was published in February 2012.

The original evidence showing benzodiazepines reduce the rate of intubation of seizure patients was published in August of 2001.

Why are so many EMS protocols still in the Dark Ages?

Medical directors are responsible for the airway management skills of their medics and basic EMTs.

Medical directors should not be choosing brain damage for seizure patients.

This is a misguided fear of the lack of airway management skills in the people the medical directors authorize to treat patients.

This is not competent medical direction.

We do not need to lower the doses of benzodiazepines to protect the anxieties of medical directors.

We need to raise the doses of benzodiazepine to protect the brains of seizure patients.
 

See also Part I, Part II, Part III, Part IV, Part V, Part VI, and Images from Gathering of Eagles Presentation on RAMPART.

-

Footnotes:

-

[1] Intramuscular versus intravenous benzodiazepines for prehospital treatment of status epilepticus.
Hirsch LJ.
N Engl J Med. 2012 Feb 16;366(7):659-60. doi: 10.1056/NEJMe1114206. No abstract available.
PMID: 22335744 [PubMed - indexed for MEDLINE]

Free Full Text PDF Download from the RAMPART Group.

-

[2] Comment from Farid Sadaka, MD
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]

Free Full Text from N Engl J Med.

-

[3] Intramuscular versus intravenous benzodiazepines for status epilepticus.
Xue FS, Liao X, Cheng Y.
N Engl J Med. 2012 May 17;366(20):1943; author reply 1944. doi: 10.1056/NEJMc1203428#SA1. No abstract available.
PMID: 22591303 [PubMed - indexed for MEDLINE]

Free Full Text from N Engl J Med.

-

[4] 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.

-

[5] 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]

Free Full Text from N Engl J Med.

.

What Can EMS Expect From 2014? #1 Ketamine Again


 

What changes need to be made in 2014, if they have not already been made?

Ketamine – for those of you who already have ketamine, great work. Continue to improve patient care. Do not let the rest of us slow you down.

Excited delirium – ketamine is the fastest way to sedate a violent patient.

Pain management – ketamine dissociates without respiratory depression.

RSI (Rapid Sequence Induction/Intubation) – ketamine dissociates without respiratory depression.

Asthma – ketamine opens the airway.

Awake intubation – ketamine dissociates without respiratory depression.

Sedation for extrication – ketamine dissociates without respiratory depression.

Seizures- ketamine stops seizures.
 

Safety – ketamine is safe.
 

Ketamine has a wide margin of safety; several instances of unintentional administration of overdoses of ketamine (up to ten times that usually required) have been followed by prolonged but complete recovery.[1]

 

Is any other sedative that safe?
 

Here are some podcasts to explain in more detail.

Dr. Mel Herbert on ketamine.
Ketamine Update.
Free mp3 Download From Free Emergency Medicine Talks

-

Dr. Baruch Krauss on ketamine.
Ketamine in the Emergency Department.
Free mp3 Download From Free Emergency Medicine Talks

-

Dr. Sergey Motov on ketamine.
Ketamine for Everything.
Free mp3 Download From Free Emergency Medicine Talks

-

Dr. Scott Weingart on ketamine.
Podcast 104 – Laryngoscope as a Murder Weapon Series – Hemodynamic Kills
Page with a link to the free mp3 download, but watch the video first – it is excellent.

More from Dr. Weingart.
EMCrit Podcast 40 – Delayed Sequence Intubation (DSI)
Free mp3 DownloadFrom EMCrit.

-

Dr. Jim DuCanto on ketamine.
Podcast 73 – Airway Tips and Tricks with Jim DuCanto, MD
Page with a link to the free mp3 download, but watch the video first – it is excellent.

-

Dr. Minh LeCong on ketamine myths –

PHARM Podcast 75 Ketamine MythBusters
Part 1 – Blowing your mind

PHARM Podcast 76 Ketamine MythBusters
Part 2 – Take the pressure down

PHARM Podcast 77 Ketamine MythBusters
Part 3 – Are you mad enough?

PHARM Podcast 78 Ketamine MythBusters
Part 4 – A fitting end?

 

Would you prefer to have something to read about ketamine?
 

 

Dr. Reuben Strayer on ketamine.

The Ketamine Brain Continuum
December 25th, 2013
by reuben in PSA & analgesia
Article

Awake Intubation: A Very Brief Guide
July 7th, 2013
by reuben in airway
Article

Ketamine as a suicidality reversal agent
June 4th, 2011
by reuben in psychiatry
Article

Taming the Ketamine Tiger
January 27th, 2011
by reuben in PSA & analgesia
Article

Ketamine for RSI in Head Injury
April 3rd, 2010
by reuben in .trauma-general, .trauma-head & face, airway
Article

Another reason to use ketamine for RSI in sepsis
November 24th, 2009
by reuben in airway
Article
 

Is there any good reason to not be using ketamine in EMS?

-

Footnotes:

-

[1] Ketamine Hydrochloride (ketamine hydrochloride) Injection, Solution, Concentrate
[Bedford Laboratories]

FDA Label
DailyMed
Label

.

EMS EduCast – Dr. Ben Abella on Coursera and Therapeutic Hypothermia

 

On the EMS EduCast, Dr. Ben Abella was on the EMS EduCast discussing the Coursera resuscitation course he taught and the way recent research on therapeutic hypothermia [1]should affect prehospital resuscitation.

Go listen to the podcast.

During the podcast Dr. Abella states –
 

I fear, many of the patients that I deal with are much more injured from iscemia reperfusion than the patients in that study. I wonder if the patients in that study just didn’t need that much cooling. You know, if you’re not that sick, you don’t need that much of a dose of medicine, maybe, and if you’re dealing with sicker patients you need more. Now, what I have just said is an unsubstantiated hypothessis. OK. That’s important for people to know. I am not basing that on fact, rather on my experience and opinion.[2]

 

That is only relevant in some cases.

Sometimes sicker patients require more.

Sometimes sicker patients require less.
 

Shock Values - 2004 Anes
 

Even with adequate fluid resuscitation, propofol remains substantially more potent in patients with hemorrhage. In marked contrast, the potency of etomidate is nearly unchanged in shock.[3]

 

According to this, we should only give 10% to 20% of the normal dose of propofol (Diprivan) to the sickest trauma patients, but we should give more than 100% of the normal dose of etomidate (Amidate) to the same patients.

Do the sickest patients require more medicine?

Sometimes yes. Sometimes no.

Pathophysiologists can provide good arguments either way, but pathophysiologists are the philosophers of medicine trying to explain the limited evidence that is available – until more evidence becomes available.

Dr. Abella may be right about starting therapeutic hypothermia prior to transport, but the best available evidence does not support his hypothesis.

Dr. Abella is clear that this is just his hypothesis and he is encouraging more research, because that is the way we find out whether the hypothesis is correct.

Go listen to the podcast.

-

The EMS EduCast is ending. This is the second to last podcast, from Bill Toon, Greg Friese, and Rob Theriault, but they have nearly 200 podcasts archived to listen to.

-

Footnotes:

-

[1] Targeted temperature management at 33°C versus 36°C after cardiac arrest.
Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J, Hovdenes J, Kjaergaard J, Kuiper M, Pellis T, Stammet P, Wanscher M, Wise MP, Åneman A, Al-Subaie N, Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge JF, Hingston CD, Juffermans NP, Koopmans M, Køber L, Langørgen J, Lilja G, Møller JE, Rundgren M, Rylander C, Smid O, Werer C, Winkel P, Friberg H; TTM Trial Investigators.
N Engl J Med. 2013 Dec 5;369(23):2197-206. doi: 10.1056/NEJMoa1310519. Epub 2013 Nov 17.
PMID:24237006[PubMed - indexed for MEDLINE]

-

[2] Dr. Ben Abella and the Coursera Cardiac Arrest MOOC: Episode 194
EMS EduCast
December 16, 2013
Podcast page.

-

[3] Shock values.
Shafer SL.
Anesthesiology. 2004 Sep;101(3):567-8. No abstract available.
PMID:15329579[PubMed - indexed for MEDLINE]

Free Full Text from Anesthesiology.

.

Should Basic EMTs Give Naloxone (Narcan)?

 
Should basic EMTs be giving naloxone (Narcan) when paramedics do not really understand the drug?

If a patient wakes up after naloxone, does that mean the patient had a drug overdose?

No – but most paramedics do not understand that.[1]

As of January 1, 2014, there will be even more people giving Narcan with little understanding of what they are doing.
 


Peter Thomson.
 

La Crosse firefighters soon could start carrying a life-saving drug for heroin users. The department is applying to be one of the state’s first groups of emergency medical technicians to administer Narcan, the antidote to an opiate overdose.[2]

 

Does naloxone save lives or just make it less work for first responders?

If the basic EMTs are not good at basic ventilation, will they be any better at drug administration?

Are drugs the cure for ventilation problems?
 

The department has witnessed a 53 percent jump in the number of potential drug overdoses since 2009, Chief Gregg Cleveland said.

In 2012, firefighters responded to 98 potential overdoses and 86 so far this year.[1]

 

A 53% increase?

98 last year.

86 so far this year (as of October).

10 months in, so an average of 8.6 per month = 103.2 for the whole year.

Going from 98 to 103 is not a 53% increase.

It isn’t even a 5.3% increase, but only 5.1%
 

Only 5% – not 53%.
 

Bad math.

Correction (13:00 12/28/2013) – the math is not based on the numbers in the article and I did not read the article correctly. The bad math is mine, not Chief Gregg Cleveland’s. Thank you to Christopher Jennison, Jordan L, and Parastocles for pointing out my error.

I apologize to Chief Gregg Cleveland for misrepresenting his statement as bad math, when it was my mistake.
 

Bad decisions.

What kind of time would be saved by having the fire department give naloxone?

What kind of bad outcomes would be prevented?

What kind of better outcomes would be expected?

What is the added cost of implementing this program?

What other programs would be deprived of this money?

Those are just some of the questions that should be asked.

The main question is –

If your fire department is doing such a bad job of managing BLS skills (BVM, positioning, painful stimulus, . . . ), why should we allow you to harm patients with ALS skills?

If your department is not harming patients, then where is the need?

Naloxone does not appear to be the answer to either problem.

Will naloxone cure the math problems of these drug pushing managers?

-

Footnotes:

-

[1] Acute heroin overdose.
Sporer KA.
Ann Intern Med. 1999 Apr 6;130(7):584-90. Review.
PMID: 10189329 [PubMed - indexed for MEDLINE]
 

Six of the 25 complete responders to naloxone (24%) ultimately were proven to have had false-positive responses, as they were not ultimately given a diagnosis of opiate overdose. In four of these patients, the acute episode of AMS was related to a seizure, whereas in two, it was due to head trauma; in none of these cases did the ultimate diagnosis include opiates or any other class of drug overdose (which might have responded directly to naloxone). Thus, what was apparently misinterpreted as a response to naloxone in these cases appears in retrospect to have been due to the natural lightening that occurs with time during the postictal period or after head trauma.

-

[2] Firefighters could be getting medication to save drug users
October 31, 2013 12:00 am
By Anne Jungen
ajungen@lacrossetribune.com
LaCrosse Tribune
Article

.

What is the Role of the Renal System in Acute CHF

 

I was asked this question –

What is the role of the renal system in CHF?

Since the question came from a paramedic, the use of diuretics for chronic CHF (Congestive Heart Failure) is not relevant, except that the Acute CHF/ADHF (Acute Decompensated Heart Failure) may be brought on by poor management of chronic CHF.
 

volume changes during acute pulmonary edema differ from those which were observed during chronic congestive heart failure.[1]

 

I rewrote the question by just adding the word acute

What is the role of the renal system in Acute CHF?

That is the right place to start.
 


Original image source.

This Golden Hour of acute CHF/ADHF is just as much a myth as the Golden Hour of trauma.
 

In

    Acute

        CHF

            There

                Is

                    NO

                        Significant

                            Role

                                For

                                    The

                                        Renal

                                            System.

-

Acute CHF =

Stress -> Increased work for a weak heart -> Fluid backup in the lungs -> Shunting fluid away from the organs not essential in an emergency – the liver, spleen, intestines, stomach, kidneys . . . .
 

Recovery from acute CHF =

Improvement -> Decreased work for a weak heart -> Fluid removal from the lungs -> Resuming fluid flow to the organs not essential in an emergency – the liver, spleen, intestines, stomach, kidneys . . . .
 

In ADHF/acute CHF, the body shuts down circulation to the renal system.

After the patient improves, the renal system begins to work again.

In acute CHF, there is no significant role for the renal system.

Since the renal system has no significant role in acute CHF/ADHF, diuretics should not have any significant role in the treatment of acute CHF/ADHF.

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Footnotes:

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[1] Blood volume prior to and following treatment of acute cardiogenic pulmonary edema.
Figueras J, Weil MH.
Circulation. 1978 Feb;57(2):349-55.
PMID: 618625 [PubMed - indexed for MEDLINE]

Free Full Text Download from Circulation in PDF format.

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