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

Trying To Focus On What Is Important

On EMS Office Hours this week, Jim Hoffman, Josh Knapp, and I discuss Trying To Focus On What Is Important.

Why do we spend so much time on appearance, but not spend time on the things that are important to our patients?

Sure, appearance is the first thing that people will notice, but what leaves a lasting impression is how we treat patients.

Can we intubate well?

For most of us, probably not.

How many of us keep a record of any all of our skills and our success rates where everyone can see?

If we miss a bunch of IVs, do we view being assigned to the IV team as an opportunity to improve our skills and understanding, or do we view it as punishment?

Do we have a good understanding of the medications we use?

How many of us will read the package insert for any of the medications we give?

Few of us.

Do we read research to understand more about about what we do?

For most of us, probably not.

Who cares about what we are called?

We are insecure people who need constant validation of what we do, even though the only thing we seem to do well is complain about appearances.


Appearances are NOT reality.


Rather than insist on higher standards, we worry about what term should be used to describe us. We are the people who were just lucky enough to meet some lowest common denominator standards on the day we took a multiple choice test accompanied by a well rehearsed song and dance segment.

Is the patient in the scenario unstable?

Let me contemplate this, without being there, or having tested anyone on National Registry in about a decade. Yes, the patient is unstable.

Our test is prejudiced toward people who are skilled at taking tests, not people who are good at taking care of patients. That is why we take time away from teaching about patient care, so that we can teach test taking strategy.

We defend this. We become upset when it is pointed out that hairdressers require more time in school, but almost every medic student I have met has focused on just meeting the minimum number of ALS calls, the minimum number of IV starts, the minimum number of drug administrations, the minimum of everything.

What should we call people who are satisfied with being the lowest common denominator?

What should we call people who are satisfied with doing as little as possible to work on the skills that we expect patients’ lives to depend on?


How many of us insisted that the death of Curtis Mitchell was the fault of the medics for trying to work smarter and calling for a four wheel drive vehicle, rather than tying up one ambulance indefinitely and trying to shovel their way to Mr. Mitchell? The fault was the lack of planning by Public Safety Director Michael Huss, who only planned for mild winters. If we tie up EMS doing the work by hand that should be done by plows, how many other patients would die waiting for crews that would be delayed even longer?

When we are not smarter than the snow, are we smart enough to be providing patient care?

What kind of excuse is appropriate for a preventable bad outcome? Preventable if only the medic had some skill at the paramedic job requirements.

Don’t take our tubes, but don’t expect us to do any more than the minimum amount of practice.

Don’t take our RSI (Rapid Sequence Induction/Intubation), but don’t expect us to understand pharmacology.

Give us standing orders for all of our medications, but don’t expect us to understand pharmacology.

We have medical directors who assist us in avoiding competence.

How many of our medical directors, or any of the doctors in the hospital will take the time to assess what we have done and to provide feedback? And I am not referring to the clown who thinks that 2 mg morphine with a 2 mg repeat is aggressive pain management.

Assuming we are not immediately dispatched on another call, how many of us will stick around to listen when the doctor asks the patient questions, so that we can learn more about assessment?

How many of us will ask the doctor about the things we missed? We would be afraid of looking bad, but our ignorance already makes us look bad.

If we want to improve our appearance, we need to stop worrying about our uniforms, our titles, our fancy trucks, et cetera.

We need to pay more attention to our abilities.

The most important ability for anyone is not intubation, not IVs, not needle decompression, not ability to measure a drug dose precisely, et cetera.


Our most important skill is assessment.


How often are we correct in assessing what is going on with the patient?

Few of us know, because we don’t bother to try to find out.

Go listen to the podcast.


Intramuscular Midazolam for Seizures – Part III
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, Part II, Part IV, Part V, Part VI, and Images from Gathering of Eagles Presentation on RAMPART.


[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]

Free Full Text from N Engl J Med.

[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


Intramuscular Midazolam for Seizures – Part II
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] This is explained in Part III.

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


[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]

Free Full Text from N Engl J Med.

[2] MIDAZOLAM HYDROCHLORIDE injection, solution
[Hospira, Inc.]

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]

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]

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

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


Too Old To Work Gets Cantankerous

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.


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.


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


How Bad are the Drug Shortages

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 :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)

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.


[1] Current Drug Shortages
Drug Shortages
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 Search

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

[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

[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


Why are We So Afraid of Our Patients

WANTYNU asks –

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

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.


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

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

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

[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?

[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

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.

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.

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

Image modified from Paramedicine 101 – 2010 AHA Updates.

How many resuscitations does lidocaine prevent?

How many resuscitations does amiodarone prevent?

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.

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?


[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
Press Release

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


What About Nebulized Naloxone (Narcan) – Part II

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.

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.

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?

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?

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.


[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]