The only reason we get away with giving such large doses of epinephrine to these patients is that they are already dead.

- Rogue Medic

Search Results for: intubation

How Bad are the Drug Shortages

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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?

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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]

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

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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?

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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?

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Calcium Chloride Injection – If we are treating emergency hyperkalemia (which I recently saw written as hyperpotassiumemia :oops:) 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)

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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]

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

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

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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]

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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]

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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).

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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.

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An example of dystonia. Image credit.

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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. :oops:

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

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

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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.

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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. :oops:

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

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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).

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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]

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

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

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

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Metoclopramide injection (Reglan) – Anti-nausea medication.

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

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

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

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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.

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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.

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

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

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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?

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

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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). :cool:

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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.

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

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

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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.

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

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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]

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Also see Stressful Drug Shortage Update.

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Footnotes:

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

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[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!!)

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[3] Atropine Sulfate Injection
FDA
FDA Search

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

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[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

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[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]

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

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[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

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[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.

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[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

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[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

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Why are We So Afraid of Our Patients

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WANTYNU asks –

We all know EMS can be dangerous, so if you could carry a weapon, would you and which would it be?[1]

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Better to be judged by 12 than carried by 6.

This is the kind of reasoning used by the people who think they need to have a weapon to provide patient care.

This is not a valid choice this is just paranoia.

-

How many EMS personnel are shot on calls each year?

How many EMS personnel are stabbed on calls each year?

How many EMS personnel are attacked with any other lethal force on calls each year?[2]

The armed and dangerous EMS people would have us believe that the number is large.

In how many years is the number not zero?

Are we more likely to be shot or stabbed by our paranoid coworkers, by our family members, by our patients, or never to be shot or stabbed?


In the Standing Orders podcast on armed EMS,[3] the only real defense of EMS carrying weapons was as tactical medics. That is appropriate. You do not go on a raid without a weapon, but what does that have to do with going into someone’s home to provide medical treatment and carrying a weapon?

Not a thing.

How bad do our communication skills have to be for us to make people want to shoot, or stab, us?

I annoy a lot of people, some of whom carry weapons, but I do not feel any imminent threat.

Why are so many people in EMS so afraid?

-

Better to be judged by 12 than carried by 6.

The reasoning behind this seems to parallel the reasoning behind a lot of other bad decisions in EMS.

I am afraid of responsibility. I need extreme protection.

Flying everyone who might be seriously injured. Learning to assess patients competently is too much to ask.

Immobilizing everyone because they might sue us.

We need our endotracheal tube to save lives. We need to be able to pretend that we know more than nurses, just because of this one little used part of our scope of practice – something that we do very poorly, but why bring reality into this?[4] [5]

-

Maybe, if we want to be viewed as a profession, we should start thinking, rather than panicking.

-

Footnotes:

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[1] We all know EMS can be dangerous, so if you could carry a weapon, would you and which would it be?
WANTYNU
02/09/2012
FaceBook page

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[2] Surviving the Next Shift – Part I
Rogue Medic
Fri, 16 Dec 2011
Article

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[3] Surviving the Next Shift
Standing Orders
Dec 13, 2011
Podcast page

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[4] Prehospital intubations and mortality: a level 1 trauma center perspective.
Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ.
Anesth Analg. 2009 Aug;109(2):489-93.
PMID: 19608824 [PubMed - indexed for MEDLINE]

Of the 88 patients who were transported by ground, 46 (52%) were successfully intubated in the prehospital setting and 42 (48%) had a failed PHI (PreHospital Intubation)

Of the 203 patients, 115 (57%) were transported by air, and within that group, 94 (82%) were properly intubated in the field, and 21(18%) were not. Of the 88 patients who were transported by ground, 46 (52%) were successfully intubated in the prehospital setting and 42 (48%) had a failed PHI (P < 0.001 compared with patients transported by air).

Even though the flight crew success rate was dramatically better than the ground EMS intubation success rate, it is still unacceptably low. What is the difference between the flight crews with 82% intubation success and the ground crews with 95+% intubation success or the flight crews with 95+% intubation success?

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[5] Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.
Katz SH, Falk JL.
Ann Emerg Med. 2001 Jan;37(1):32-7.
PMID: 11145768 [PubMed - indexed for MEDLINE]

Free Full Text PDF

Trauma patients were significantly more likely to have misplaced ETTs than medical patients (37% versus 14%, P<.01). With one exception, all the patients found to have esophageal tube placement exhibited the absence of ETCO2 on patient arrival. In the exception, the patient was found to be breathing spontaneously despite a nasotracheal tube placed in the esophagus.

In spite of these studies, and others, few medics will admit that they are poor at intubation. We are all above average. At least, more of us do seem to be above average in deceiving ourselves. It seems to be an EMS job requirement.

.

NIH launches trials to evaluate CPR and drugs after sudden cardiac arrest

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The NIH (National Institutes of Health) announced two new resuscitation studies. This is not the kind of research to find any private sponsorship, but it is important – well, one study is.

The CCC trial will compare survival-to-hospital-discharge rates for two CPR approaches delivered by paramedics and fire fighters. Persons experiencing cardiac arrest will be randomly assigned to receive continuous chest compressions, or standard CPR by emergency responders. Standard CPR, the approach recommended by the American Heart Association (AHA) for use by emergency responders, includes chest compressions with short pauses for assisted breathing. This approach has been called into question by emerging data suggesting that stopping chest compressions to provide assisted breathing interrupts overall blood flow, thereby lowering survival.[1]

The AHA wants to find some evidence to justify their preferred method of combining chest compressions with ventilations.

There is no evidence that ventilations improve survival from adult cardiac arrest of cardiac origin.

There is evidence that any interruption to compressions decreases survival.

The only known interruption that does not decrease survival is defibrillation.

Not for ventilation.

Not for intubation.

Not for any medication.

Not for application of any CPR machine.

Not for transport.

Not for acupuncture.

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Trained emergency personnel will give all participants in the CCC trial three cycles of CPR followed by heart rhythm analysis and, if needed, an electrical shock (defibrillation), applied to the chest. Half will be randomly assigned to receive continuous compressions combined with pause-free rescue breathing and half will receive standard professional CPR.[1]

Why only three cycles?

This suggests that the hypothesis presumes some benefit from ventilations.

Based on what?

Apparently based on tradition and wishful thinking – a deadly combination.

Tradition and wishful thinking have been a deadly combination for thousands of years.

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The Amiodarone, Lidocaine, or neither (Placebo) for Out-Of-Hospital Cardiac Arrest Due to Ventricular Fibrillation or Tachycardia study (ALPS) will determine whether amiodarone or lidocaine improves survival-to-hospital-discharge rates for participants with shock-resistant ventricular fibrillation. Participants will receive one or the other drug or a placebo.[1]

We already know that these drugs do not improve survival from V Fib (Ventricular Fibrillation). The only questions are

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Image modified from Paramedicine 101 – 2010 AHA Updates.

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How many resuscitations does lidocaine prevent?

How many resuscitations does amiodarone prevent?

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The CCC trial will enroll up to 23,600 participants at eight major regional locations across the U.S. and Canada.[1]

That number of patients should be enough for clear results.

The ALPS trial will enroll up to 3,000 participants at nine locations across the U.S. and Canada.[1]

That ridiculously small number of patients should allow those who base treatment on tradition and wishful thinking to continue to pretend that their treatments do not make things worse.

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Almost 60 fire and EMS organizations will participate in the ALPS trial, and approximately 125 EMS organizations will participate in the CCC trial.[1]

Maybe the number 3,000 is a misprint. That would be only 50 V Fib (Ventricular Fibrillation) cardiac arrests per EMS organization.

Estimated Enrollment:             3000 [2]

How will that produce statistically significant results, while the CPR study requires 8 times as many patients?

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Footnotes:

-

[1] NIH launches trials to evaluate CPR and drugs after sudden cardiac arrest
Embargoed for Release
Thursday, January 26, 2012
11 a.m. EST Contact:
NHLBI Communications Office
(301) 496-4236
NIH
Press Release

-

[2] Amiodarone, Lidocaine or Neither for Out-Of-Hospital Cardiac Arrest Due to Ventricular Fibrillation or Tachycardia (ALPS)
ClinicalTrials.Gov
Last Updated on September 21, 2011
ClinicalTrials.gov Identifier: NCT01401647
Trial data

.

What About Nebulized Naloxone (Narcan) – Part II

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This is continuing from Part I about a recent paper looking at the use of nebulized naloxone (Narcan) to treat possible opioid OD (OverDose).

What are the indications for naloxone?

To diagnose heroin OD?

 

Absolutely not!

 

If we are that bad at assessment, that we need naloxone to identify a heroin OD, then we are not good enough at assessment to be treating patients with any medications.

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The protocol-specified nebulization of 2 mg of naloxone with 3 mL of normal saline as empiric treatment for suspected opioid overdose or undifferentiated depressed respirations as long as the patient had some spontaneous respiratory effort, no apnea, and no severe cardiorespiratory compromise (shock, impending respiratory arrest).[1]

In other words, patients who probably will not receive much benefit from naloxone.

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Excluded from analysis were cases where nebulized naloxone was given for opioid-triggered asthma and cases with incomplete outcome data.[1]

The omission of the patients (only 3 patients) with incomplete outcome data is legitimate, but not enough data is presented in the paper.

The omission of the asthma patients (21 patients) is interesting. Why not break them out into a different group and analyze with the asthmatics, without the asthmatics, and just the asthmatics? We are trying to find out what works and if it is safe, aren’t we?

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Secondary outcomes included need for rescue naloxone (IV or IM), need for assisted ventilation by bag–valve–mask (BVM) assistance or intubation, and adverse antidote events (respiratory arrest, cardiac arrest, death in the field).[1]

The word need is used rather casually. How do they define need?

Why are rescue naloxone, BVM assistance, and intubation not considered adverse antidote events, while respiratory arrest, cardiac arrest, and death are considered adverse antidote events? I do not see the distinction.

I don’t think that naloxone-induced respiratory arrest is going to catch on as a diagnosis. Maybe they are referring to patients who did not receive enough naloxone, due to respirations that are too shallow?

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We found that nebulized naloxone is a safe and effective needleless antidote for prehospital treatment of suspected opioid overdose in patients with spontaneous respirations. Eighty percent of the patients treated had some response to treatment, and only 10% of the patients were given a second dose of naloxone. No patient required intubation or BVM-assisted ventilation.[1]

Why were partial responders not given more naloxone?

Why were any of these patients given naloxone?

-

In our study, no patient signed out against medical advice and all patients were transported to the hospital.11 [1]

22% had complete response to the nebulized naloxone. 5% had complete response to the rescue naloxone.

Nobody refused treatment of transport?

How complete was the response?

Do the police threaten to arrest the patients unless they agree to transport? Why do all of the patients complete the transport?

The literature on intranasal naloxone exemplifies this problem, thus the GCS, respiratory rate (RR), and paramedic impression have been used as outcome measures by others as well.4 – 7 [1]

What about skin color and temperature?

What about pulse oximetry and waveform capnography? These are objective.

Maybe the outcome measures depend on the original indication for naloxone.

Is GCS (Glasgow Coma Score) important?

Not really.

The patient is not going to die of a depressed GCS. Depressed/absent respirations are a different story.

-

Finally, we did not compare nebulized naloxone with IV naloxone, the recognized “gold standard,” nor were we able to confirm opioid overdose through hospital records.[1]

Gold Standard?

For what?

The goal of treatment is a patient able to protect his own airway and breathing adequately, regardless of whether the patient has ever received any naloxone. Giving naloxone to a patient who meets these criteria is not good medicine.

-

To be continued in Part III.

-

Footnotes:

-

[1] Can Nebulized Naloxone Be Used Safely and Effectively by Emergency Medical Services for Suspected Opioid Overdose?
Weber JM, Tataris KL, Hoffman JD, Aks SE, Mycyk MB.
Prehosp Emerg Care. 2011 Dec 22. [Epub ahead of print]
PMID: 22191727 [PubMed - as supplied by publisher]

.

Violent Patient Tries to Jump From S.C. Chopper

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This is wrong on so many levels. I hope that the biggest problem is the accuracy of the reporting.

-

A patient who leapt from a moving car on an interstate later tried the same thing from a helicopter.[1]

Simple EMS history taking is the best way to prevent bad outcomes. My favorite question is, Has this ever happened before? A positive response to that question results in my second favorite question – What helped make things better, last time?

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Reports indicated the man suffered a head injury in a fall from a vehicle traveling about 70 mph.[1]

This isn’t rocket surgery. If someone jumped from a moving vehicle before he had a head injury, why should we assume that this will improve his thinking? This is what is known as a clue. Maybe he didn’t jump. Maybe he was pushed, but the tie goes to assuming the worst, protecting the patient, and protecting the crew.

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About five minutes into the flight, he started struggling with medics, the newspaper reported.[1]

Surprising.

I’m shocked, shocked to find that predictable behavior is going on in here!

I thought we would just put the patient in the helicopter and have an uneventful flight, but No, the patient actually needs medical attention.

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Deputies said Altoro Alveriz attempted to jump out of the helicopter, which promptly landed at Lowcountry Regional Airport.

Alveriz was then placed in a sleeve that prevented him from moving his arms and legs.[1]

When using RSI (Rapid Sequence Induction/Intubation) for head injured patients, many doctors recommend using lidocaine to protect against increased intracranial pressure from the intubation. With head injuries, increased intracranial pressure and hypoxia are the worst things we can cause.

The best way to increase intracranial pressure may be to restrain the patient without any sedation.

According to the article, what did they do for this patient?

Physical restraint without chemical restraint.

Why?

Maybe they were trying to punish the patient for being combative.[2]

Maybe they do not have standing orders for chemical restraint for these patients.[3]

Maybe they mistakenly assumed that nobody can get out of a Reeve’s sleeve.

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Image credit.

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Who knows? Maybe they did also chemically restrained him, but it was just not reported.

Violent patients should be chemically restrained for the safety of everyone. The patient, the crew, the people on the ground.

The same is true with ground transport. Violent patients should be chemically restrained for the safety of everyone. The patient, the crew, the other people on the road.

Generally, flight crews are appropriately aggressive about chemically restraining potentially combative patients before placing them anywhere near a helicopter. Why was this time different?

Droperidol, ketamine, midazolam, lorazepam, diazepam, et cetera. There are plenty of drugs that can be used to sedate patients to protect the patient from his own potential violence and from possible worsening intracranial pressure.

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Footnotes:

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[1] Violent Patient Tries to Jump From S.C. Chopper
EMSWorld.com News
Article

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[2] They can’t help it
Captain Chair Confessions
January 5, 2012
Article

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[3] There are doctors who think that protecting a patient with sedation is somehow more dangerous than allowing their unstable medical condition to progress without treatment directly causing the condition to get worse by only using physical restraints. The only appropriate word for these doctors is defendants, but too often, the bad outcomes are assumed to be inevitable. There is no good reason to believe that these bad outcomes are inevitable.

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[4]
Download YouTube Video | YouTube to MP3: Vixy
No, it isn’t a Reeve’s, but does anyone really believe that Houdini would not have been able to escape from a Reeve’s sleeve.

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Is Ketamine an EMS Wonder Drug

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Too Old To Work responded to my description of the benefits of keatamine in What I Wanted from EMS Santa But Did Not Get.

Funny, I’ve used Lidocaine and Amiodarone a number of times to terminate antiarrhythmias, although I still contend that Lidocaine works better than Amio. I’ve only used cardioversion a couple of times and only when there was no other alternative. The last time I used it, we were using Valium for sedation, it’s been that long.

That is why we ignore anecdotal evidence of benefit. When we look at numbers large enough to provide predictable results, the memories of good outcomes from amiodarone and lidocaine are found to be the result of statistical variation, or bad memory, or both. We tend to forget the times that our antiarrhythmics do not work for V Tach (Ventricular Tachycardia).

Different studies show that amiodarone is only 29% effective at terminating V Tach,[1] only 25% effective at terminating V Tach, [2], and only 15% effective at terminating V Tach within 20 minutes, but if we don’t mind waiting an hour it can be as much as 29% effective.[3]

If we are not trying to convert the rhythm promptly, should we even consider V Tach an emergency? If lights and sirens only make a difference of a minute, or two, V Tach is obviously not a lights and sirens emergency. Maybe we need a treatment that works.

Over 60% of the patients were cardioverted, for which they should receive a sedative that does not produce/worsen hypotension. We might as well start acknowledging that our anecdotes often do not match reality.

When the patient is awake and alert with a systolic blood pressure of 70, should we give a vasodilator, such as midazolam, or should we give a drug that does not decrease cardiac output, such as ketamine?

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Image credit.

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Amiodarone works just as well as Ketamine for sedation, Versed or Ativan work better for excited delirium.

Amiodarone can produce hypotension, arrhythmias, and cardiac arrest, but that is not the kind of sedation I want. Was this a typo?

Since you do not appear to have listened to any of the EMCrit podcasts I linked to, here is another opportunity to learn. Dr. Weingart describes the lack of effectiveness of benzodiazepines (midazolam [Versed], lorazepam [Ativan], and diazepam [Valium]). He does not discourage their use to minimize emergence reactions, but he does not suggest that they are appropriate as sole treatments for excited delirium, unless that is all you have available.[4]

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Fentanyl probably works better for pain management, especially cardiac related pain.

Which is great – if the patient does not require doses that produce respiratory depression, or if the only pain we treat is cardiac pain. Let me quote from the anonymous comment that you followed, but do not appear have read.

It facilitates extrication of critical patients who are still awake and who often have compound fractures. Given the choice of struggling to hold a combative head patient down while trying to get them in a c-collar and a backboard vs. IM Ketamine and a cooperative patient within a minute or two, Ill take the latter. It’s a beautiful thing when used responsibly. It certainly is safer than trying to sedate and paralyze a hypoxic patient.

If we want to be very limited in our options, then we should not ask for ketamine from our medical directors.

If we do not like using safe drugs, then we should not ask for ketamine from our medical directors.

I am stating that we should ask for ketamine from our medical directors. Our patients deserve it.

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I’m not following the last part of you post, because you haven’t set the circumstances requiring Ketamine and a NRB.

I linked to the EMCrit podcast covering DSI (Delayed Sequence Intubation). I think that podcast more than adequately describes the circumstances in under 20 minutes.[5]

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Ketamine might be an all in one wonder drug, but why do we need an all in one wonder drug when we can have a selection of wonder drugs?

No drug is a wonder drug.

Ketamine does a lot of things very well – better than the usual EMS drugs. We should not allow our lack of familiarity to discourage us from using this drug that is used frequently, safely, and effectively all over the world.

At Free Emergency Medicine Talks you should listen to Mel Herbert – Updates on Ketamine. Unfortunately, the video is not included, but the information is still very clear and very thorough.

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Ketamine is recommended for use in the patient whose stomach is not empty when, in the judgment of the practitioner, the benefits of the drug outweigh the possible risks.[6]

You may only treat patients who have been fasting, but I end up with patients with full bellies. I would prefer better ways to keep the stomach contents out of the lungs.

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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.[6]

Is any other sedative that safe?

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Footnotes:

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[1] Amiodarone is poorly effective for the acute termination of ventricular tachycardia.
Marill KA, deSouza IS, Nishijima DK, Stair TO, Setnik GS, Ruskin JN.
Ann Emerg Med. 2006 Mar;47(3):217-24. Epub 2005 Nov 21.
PMID: 16492484 [PubMed - indexed for MEDLINE]

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[2] Amiodarone or procainamide for the termination of sustained stable ventricular tachycardia: an historical multicenter comparison.
Marill KA, deSouza IS, Nishijima DK, Senecal EL, Setnik GS, Stair TO, Ruskin JN, Ellinor PT.
Acad Emerg Med. 2010 Mar;17(3):297-306.
PMID: 20370763 [PubMed - indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.

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[3] Intravenous amiodarone for the pharmacological termination of haemodynamically-tolerated sustained ventricular tachycardia: is bolus dose amiodarone an appropriate first-line treatment?
Tomlinson DR, Cherian P, Betts TR, Bashir Y.
Emerg Med J. 2008 Jan;25(1):15-8.
PMID: 18156531 [PubMed - indexed for MEDLINE]

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[4] On Human Bondage and the Art of the Chemical Takedown
EMCrit
November 13, 2011
Page with podcast and supplemental information

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[5] Delayed Sequence Intubation (DSI)
EMCrit
January 31, 2011
Page with podcast and supplemental information

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

FDA Label
DailyMed
Label

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What I Wanted from EMS Santa But Did Not Get

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Yesterday, I mentioned a bunch of things that are good, but not at the top of my list. This is what I really wanted. Maybe during my shift last night, when I heard hoof beats on the roof, I shouldn’t have thought of horse or zebras.

There is one change to my protocols that probably would not be used often, but when used would more than make up for the lack of use.

What did this rogue want?

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Ketamine.

Is it safe?

Ketamine is safe.

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Is it effective?

Ketamine is effective – for many different conditions.

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Image credit.

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Excited delirium – IM (IntraMuscular) injection that works in a few minutes and is predictable in absorption.[1]

Airway management – IM or IV and the patient will not fight with a cannula or mask. Also can be used for intubation, although a paralytic would be best to go with it. The stomach contents should remain in the stomach – and we should assume that the stomach is full of chili and beer. Paralytics keep the stomach contents from migrating.[2]

Cardioversion – since we do not carry any effective antiarrhythmics (we have amiodarone and lidocaine – they are about as effective as placebo), we should be sedating patients in preparation for elective cardioversion in the ED, with the ability to emergently cardiovert them if they suddenly deteriorate. Ketamine is less likely than other sedatives to drop the cardiac output.[3]

Pain management – Ketamine alone is used for surgery in some places without complications and without complaints of being awake and feeling the surgery. Ketamine allows the patient to maintain airway reflexes.

DSI – Another abbreviation? RSI, DFI, CFI, and now DSI? Yes. DSI (Delayed Sequence Intubation). The best airway is the one maintained by the patient with intact airway reflexes. Ketamine can allow that to happen.[2]

Imagine the patient who has a neck so short that it seems his head is being sucked into his torso, but he is breathing on his own. We could knock him down and play around with his oropharynx until he has more lunch in his lungs than oxygen, but that would not be good airway management. We could use ketamine and oxygen by mask (maybe with 15 LPM oxygen by cannula in addition to the mask) and transport him to someplace where intubation (if necessary) can be done in a more controlled environment. And when the emergency physician grabs for the video laryngoscope, that is an admission that the right decision was made.

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I know. I am crazy to think that anyone would let EMS do this.

In some places, EMS is already doing this. Safely and effectively.

Maybe I am not so crazy, but I still do not have ketamine to help my patients.

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Footnotes:

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[1] On Human Bondage and the Art of the Chemical Takedown
EMCrit
November 13, 2011
Page with podcast and supplemental information

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[2] Delayed Sequence Intubation (DSI)
EMCrit
January 31, 2011
Page with podcast and supplemental information

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[3] Procedural Sedation – Part I
EMCrit
July 26, 2010
Page with podcast and supplemental information

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What Do I Want to See Under My Tree from EMS Santa

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There is one change to my protocols that probably would not be used often, but when used would more than make up for the lack of use.

What would a rogue want? It isn’t an EMS helicopter.

I have written about so many things that are really nice treatments.

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High-dose IV (IntraVenous) NTG (NiTroGlycerin or GTN – GlycerylTriNitrate in Commonwealth countries)?

I am fortunate to have state protocols that include this, although not where I work. I can give multi-dose SL (SubLingual) NTG where I work. I can do enough with that and the short transport times, that this is not at the top of my list.

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Remove furosemide (Lasix) from the paramedic scope of practice?

It has been moved to requiring medical command permission. This is one case of the Just-Say-No aspect of on line medical command that is not horrible. Still, the better thing to do is to just trash the furosemide. Maybe with the next protocol revision it will be as the medical directors realize that it is not a good drug.

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Full standing orders for everything I have with no need to call for any dose, no matter how high, or for any mixture of opioids and sedatives at any dose?

Again, that would be nice, but it is not at the top of my list, because I already have pretty liberal standing orders and the medical command doctors have not refused any dose for me in years. Part of that is just knowing the doctors, but this would be a really good present for a lot of the medics who are new, or are new to an EMS service.

The standing orders are for musculoskeletal pain, no longer just for isolated extremity trauma (and burns and chest pain).

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Droperidol (Inapsine)?

I have written a lot about droperidol, and I will write a lot more, but I think that this is something that needs to develop a comfort level among the ED (Emergency Department) physicians before they will be comfortable allowing EMS to use droperidol. Once the doctors realize how useful it is, again (or for the first time, for the newer doctors), then it should be quickly made available to EMS.

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RSI (Rapid Sequence Induction/Intubation)?

We have etomidate (Amidate) available for services that will have at least 2 paramedics on scene, but this is not RSI. The state calls it DFI (Drug Facilitated Intubation). The dose is 0.3 mg/kg with a maximum of 30 mg. Why? Obviously, patients weighing more than 100 kg are too easy to intubate, so we will use lower per/kg doses for them. :oops:

DFI? No this is CFI – Charlie Foxtrot Intubation. It is unreasonable for me to expect anything to change with this until medical oversight becomes better. When paramedics develop some real skill at intubation, then RSI may become available to EMS in Pennsylvania.

As much as I don’t like the choice of medication, or the dosing, the biggest problem is the competence of the medics attempting intubation – averaging one per year and not practicing in between.

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What about real medical oversight?

Yes. That would be a great present – for medical directors in the area to understand how to provide oversight and to be aggressive in encouraging EMS to be better. There is already some of that, but there are other medical directors who have a long way to go. I was tempted to make this my choice, but I want to be more realistic.

Realistic in EMS? In a post about Santa?

Just more realistic. Besides, as I have already pointed out, I have a lot of what I would want, now. I am very pleased with the progress made in Pennsylvania. When I was on our county protocol committee, we had none of the things I mentioned that we have now.

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So what do I want?

I’ll tell you after I open my presents tomorrow.

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