Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Furosemide and Drug Shortages 2


Also posted over at Paramedicine 101, which is now at EMS Blogs. Go check out the excellent material there.

I will keep pointing out the problems with furosemide (Lasix) and the evidence against it. Let’s ignore the problems with giving furosemide to patients who actually have CHF/ADHF (Congestive Heart Failure/Acute Decompensated Heart Failure). Can medics correctly identify CHF/ADHF?

The EHS ePCR database identified paramedic reports in which furosemide was administered. As furosemide only appears in the CHF/pulmonary edema protocol, paramedic differential diagnosis of this was assumed by furosemide administration. Data abstraction from the EHS ePCR and ED chart included the EP primary diagnosis, considered the gold standard. Other data points collected included: demographic information; EHS treatment administered; treatment administered in the ED; adverse events and patient disposition.[1]

They do not describe their method of selecting the charts.

Was it completely random?

Was it sequential?

How did they select their sample?

There were three objectives of this study. The first was to determine agreement between paramedic administration of furosemide with EP diagnosis of CHF. The second was to examine differences in interventions administered by paramedics and in the ED by EP diagnosis of CHF. The third objective was to identify any adverse events that occurred during patient care.[1]

How much agreement on CHF/ADHF diagnoses?

It should be noted that seven patients without an ED diagnosis of CHF received ED furosemide and 43 patients received ED nitro with only eight of those having a primary diagnosis of ACS. This data put the accuracy of the primary ED final diagnosis as a reference standard into question, as it appears CHF may have been in the differential diagnosis for many patients not ultimately diagnosed with CHF. Secondary diagnoses were not sought out and included. Therefore, paramedic accuracy reported in this study may be falsely low, if CHF was part of the EP secondary diagnoses. It should also be noted that there were two patients with a diagnosis of “shortness of breath not yet diagnosed.” It is possible that these patients did indeed have CHF, but were not diagnosed until a later time during hospital care. This needs to be considered when determining paramedic diagnostic accuracy.[1]

OK. For some reason, the emergency physicians gave furosemide to 21% of the patients they diagnosed with something other than CHF/ADHF. That may be explained by the CHF/ADHF being a secondary diagnosis.

This is something that should have been included in the study. What was being treated and for what reason. From the way they describe their data, they had the actual ED physician chart, not just a diagnosis. This is something they should include in a follow-up study, especially with a larger sample size.

Since two of the patients had the diagnosis shortness of breath not yet diagnosed I will move them to the CHF/ADHF side of the graph. After all, most of the patients were diagnosed with CHF/ADHF.

That looks so much better.

On the other hand, there are problems with the way they conclude that some patients do not have CHF/ADHF. How much higher would things be if secondary diagnoses were included?

It should be noted that seven patients without an ED diagnosis of CHF received ED furosemide and 43 patients received ED nitro with only eight of those having a primary diagnosis of ACS. This data put the accuracy of the primary ED final diagnosis as a reference standard into question[1]

What does NTG (NiTroGlycerine) have to do with ACS (Acute Coronary Syndrome), when examining CHF/ADHF treatment?

NTG is the most effective medication for hypertensive CHF/ADHF. Go listen to the EMCrit CHF/ADHF podcast if you doubt me. For those not hypertensive, this research certainly suggests that NTG should be studied.

NTG is not just for chest pain.

Data abstraction from the EHS ePCR and ED chart included the EP primary diagnosis, considered the gold standard.[1]

Maybe. Maybe not. And don’t get me started on Gold Standards.

ED mortality was higher in patients with an alternate diagnosis than those diagnosed with CHF by the EP (2/60 vs. 6/34, p=0.017). As documented on ED charts, eight patients in this sample suffered adverse events other than death. These adverse events were: hypotension (n =3), heart rate problem (n =3), electrolyte imbalance (n =1), and respiratory effort decline (n = 1). All of the patients who suffered adverse events were diagnosed with CHF by the EP. Adverse events were not associated with the amount of nitroglycerine, morphine or furosemide administered.[1]

Adverse events in the ED were documented as occurring as often as death in the ED. Almost all of the deaths were in the group not diagnosed with CHF/ADHF, but all of the adverse events occurred in the group diagnosed with CHF/ADHF.

Of the six patients with an alternate diagnosis who had an outcome of death, three were diagnosed with pneumonia. Eight adverse events other than death were identified in this sample. Interestingly, all these patients were correctly identified as having CHF, which contradicts previous research which has found adverse events were more likely in patients incorrectly treated for CHF by paramedics.11,12 This indicates that furosemide should be administered with caution, even in cases where diagnosis of CHF is correct.[1]

Where is the evidence that furosemide should be administered, even if the diagnosis of CHF/ADHF is correct?

What would we want to know?

Did the patients have peripheral edema when given furosemide by EMS. Even with peripheral edema, furosemide is far from the first line drug, but without peripheral edema, it is not going to do anything good.

These patients need the best treatment possible, not the most persistent hold out from the Dark Ages.

We have known that CHF/ADHF is not primarily a fluid overload problem since the 1980s.

Why is EMS still using furosemide?

Is there any problem with a shortage of furosemide?

Not at all, but this isn’t the study to prove it.

I hope the authors use what they learned from this to design a definitive study of the prehospital use of furosemide.

Updated 02-07-11 to correct the uselessness of the original charts I made for this post.

More details are in Corrections of Misleading Charts.

Footnotes:

[1] Correlation of paramedic administration of furosemide with emergency physician diagnosis of congestive heart failure
Thomas Dobson, Jan Jensen, Saleema Karim, and Andrew Travers.
Journal of Emergency Primary Health Care
Vol.7, Issue 3, 2009
Free Full Text . . . . . . . Free Full Text PDF

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A Prehospital Pain Management Discussion at the NAEMSP Site

Also posted over at Paramedicine 101. Go check it out at the new location at EMS Blogs.

I would have also posted this at Research Blogging, but this discussion is not the kind of research blog post that they are looking for.

Well, what needs to be said about prehospital pain management?

Drug Seekers.

Fentanyl vs. Morphine.

Fractures dispatched BLS vs. ALS.

Standing orders vs. Mother-May-I?

Nitrous oxide, etomidate, ketamine, NSAIDs (Non-Steroidal Anti-Inflammatory Drugs), relaxation, ice, acupressure, et cetera. If it might be used by EMS for pain, it is fair game for the discussion.

Legal issues – when will the lawyers start going after medical directors/medical command physicians for withholding appropriate treatment/neglect/malpractice?

Pediatric Pain Management by EMS.

And more.

There is a discussion of Prehospital Pain Management on the NAEMSP (National Association of EMS Physicians) discussion site on Google Groups. NAEMSP Dialog. Anyone can read the discussions. They are there to be a kind of reference for people working in EMS. This is what some of the top doctors, administrators, educators, street providers, and even the occasional blogger have to say on a topic.

Here is a summary of the rules on participation:

Trying to facilitate a higher level of discourse on contemporary issues in EMS. Most of the list members are physicians, managers, and educators – along with street level EMTs and paramedics with an interest in academics and policy issues.

Everyone who wants to join the list has to provide their name and affiliation; all posts are reviewed by a moderator before being allowed to circulate; and all posts must be ‘signed’. There is some descriptive language about the Dialog on the home page of the Google Group (http://groups.google.com/group/naemsp-dialog).

Go read. If you want to comment, sign up, but don’t try to push the envelope on what you can get away with. The envelope has already been pushed.

Some familiar bloggers are also participating – Adam Thompson, EMT – P from Paramedicine 101, Tom Bouthillet from Prehospital 12 Lead ECG, Mark Glencorse from Medic999, and a couple of doctors from the EMS Garage – Dr. Bryan Bledsoe and Dr. Keith Wesley. Some of the other top medical directors in the country are participating as well.

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Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – abstract


ResearchBlogging.org
Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging.

Go check out the rest of the excellent material at both sites.

Over at 510 Medic, there is an interesting abstract of a new article on treatment of tension pneumothorax. Frequency of Inadequate Needle Decompression in the Prehospital Setting.

CONCLUSIONS: In this study, 26% of patients who received needle thoracostomy in the prehospital setting for a suspected PTX appeared not to have had a PTX originally, nor had 1 induced by the needle thoracostomy. It may be prudent to evaluate such patients with bedside ultrasound instead of automatically converting all needle thoracostomies to tube thoracostomies.[1]

I have not read the full text. I do not have access to this journal. If anyone can send me the full text, I would like to address some of the details, rather than just speculate about them. Late entry – I have received the article. Thank you to Jeff Williams and Jeremy Blanchard. I will write more about the full text later on.

510 Medic makes some important points and asks some good questions. Then 510 Medic asks –

So if we subscribe to the goal of “first do no harm” and those 15 patients didn’t have a pneumothorax induced by the procedure, is their discomfort worth proper treatment for the remaining 42 patients?[2]

I think that there is a more important question.

Should we assume that the presence of a pneumothorax is an indication for needle decompression?

A pneumothorax is not the same as a tension pneumothorax. Even the definition of a tension pneumothorax is not easy to agree on. I tend to treat with opioids what many others would treat with needle decompression. I have not had any of these patients deteriorate, while in my care. They received chest tubes in the trauma center.

Should we assume that the presence of a pneumothorax is an indication for needle decompression?

57 patients with a prehospital diagnosis of tension pneumothorax. Yes, EMS does diagnose, but that is a discussion for elsewhere. Yes, these patients were diagnosed by EMS with tension pneumothorax, unless we are suspecting acupuncture, because what other prehospital indication is there for sticking a needle into a patient’s chest?

Out of 57 patients diagnosed with tension pneumothorax, only 42 patients had a pneumothorax.

How many patients had a tension pneumothorax at the time the needle was stuck into the chest wall?

How many of those patients would have been better off if treated with something other than a needle?

How many complications were there from the needle decompression?

Am I wrong to use italics to highlight the word decompression, since so many of the patients did not have anything to decompress?

We rush to perform procedures that we have little experience with. Isn’t this a situation likely to lead to misdiagnosis?

Isn’t the infrequent use of needle decompression for suspected tension pneumothorax likely to lead to operator error?

The actual occurrence of tension pneumothorax appears to be much less frequent than the prehospital diagnosis of tension pneumothorax. Isn’t that an indication of a failure to properly educate medics?

Footnotes:

[1] Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study.
Blaivas M.
J Ultrasound Med. 2010 Sep;29(9):1285-9.
PMID: 20733183 [PubMed – in process]

Free Full Text from J Ultrasound Med.

[2] Frequency of Inadequate Needle Decompression in the Prehospital Setting
510 Medic
Article

Blaivas M (2010). Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine, 29 (9), 1285-9 PMID: 20733183

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Drug Shortages Affect Those Still in the Dark Ages – Furosemide

ResearchBlogging.org

Also posted over at Paramedicine 101 and at Research Blogging.

Go check out the excellent material at both sites.

In the current JEMS, there is an embarrassing article. Drug Shortage Possible in N.Y.

It seems that the drugs that people are worried about are lidocaine, furosemide, 50% dextrose, and epinephrine 1:10,000 preloaded syringes. Here, I will discuss furosemide.

Furosemide is not appropriate for EMS patients, because there are more appropriate drugs, more appropriate other treatments, and it is too often given to patients who have pneumonia.

MANAGEMENT OF APE
Fluid accumulation in the lungs associated with APE, until recently, was attributed to excess accumulation of total body fluid. Accordingly, treatment of APE was aimed at removing excess fluid from the lungs by promoting massive diuresis. However, this explanation for APE could not reconcile the fact that APE typically occurs during early morning hours when fluid intake is minimal. The current explanation is that APE results from fluid redistribution within the body whereby a part of the intravascular volume is redistributed to the lungs as a consequence of increased intravascular pressure as outlined above.13 Primary objectives for the treatment of acute CHF are to reduce pulmonary capillary pressure, to redistribute pulmonary fluid, and to improve forward flow.12,13 These may be achieved by reducing LV preload and afterload, providing ventilatory and inotropic supports, and identifying and treating the underlying etiology of the syndrome (Table 3). It should be recognized that these treatment measures are intended for APE patients who are normotensive or hypertensive and not those who are hypotensive. The latter comprises cardiogenic shock secondary to severe LV systolic dysfunction; treatment of these critically ill patients is beyond the scope of this review.[1]

That is a big paragraph, but there is a lot of information in there. Enough to convince us that we should not be using furosemide to treat an acute onset/exacerbation of heart failure.

In the chart below, before furosemide in treatment there are plenty of other treatments. Notice that only oxygen comes before NTG (NiTroGlycerine) and the more severe the symptoms, the more NTG is given.
 

Mild symptoms – One 0.4 mg NTG spray/tab – repeated every 4 to 5 minutes.
 

Moderate symptoms – High-dose NTG, which is explained below.
 

Severe symptoms – Two to five 0.4 mg sprays/tabs at a time – repeated every 3 to 5 minutes.
 

But, but, but, but, but, . . . . . we can only give a maximum of 3 NTG – ever.

Then you need to get a better medical director, because your medical director has you killing patients.

Am I being too subtle?

Another treatment that is very effective is CPAP (Continuous Positive Airway Pressure) which is a BLS (Basic Life Support) skill, except where medical directors like to kill patients. When using CPAP (a form of NIPPV – Non-Invasive Positive Pressure Ventilation), NTG paste can be applied. Do not be shy with the paste, because nothing is absorbed well through the skin when the skin is pale. Pale means a lack of circulation. Also, since the appropriate dose is much more than standard NTG dosing, there is not much reason to hold back.

I disagree about the placement of CPAP at the bottom. CPAP should be started right away. This was published in 2003, so it is kind of old and conservative.

You call that NTG use conservative?!?!?

I do. I have given dozens of NTG in a period of 10 to 20 minutes and never had a patient experience any adverse effects while in my care or at the hospital. I have written elsewhere about the superstitious way we approach NTG.

Furosemide is in there, but only if the patient has peripheral edema. If there is no peripheral edema, is fluid overload the problem? That is a fluid redistribution problem. There is fluid in the wrong place, but that does not mean that the whole body is overloaded with fluid or that putting a bunch of fluid in the bladder is going to make things better. Moving fluid to the bladder does not mean that we are removing it from the lungs any more than we are removing fluid from anywhere else.


Click on the chart to make it bigger. I know I can’t read any of it at this size. This is from the same paper as the paragraph above.

Well, that is just one paper. Nobody else would be so irresponsible as to recommend such large doses of NTG.

Then let’s read about what they do in the ED (Emergency Department).

Most patients who experience CPE, however, do not have ECG evidence of an acute dysrhythmia or AMI. Treatment should therefore be aimed at redistributing the excessive pulmonary interstitial fluid into the systemic circulation, which improves alveolar oxygen-carbon dioxide exchange and hypoxia; therefore, pharmacologic agents that provide preload reduction and afterload reduction should be administered. In some cases, inotropic support is required also.[2]

What drugs do we use to provide preload reduction and afterload reduction?

Nitroglycerin
The most effective and rapidly-acting preload-reducing medication is nitroglycerin (NTG) [21–25]. Multiple studies have demonstrated the superiority of NTG over furosemide [21,24,26–28] and morphine sulfate [28–30] for preload reduction, symptomatic improvement, and safety. NTG can be administered in sublingual, IV, or transdermal form, although the transdermal absorption can be erratic in the patient in extremis. NTG also has the benefit of a short half-life; therefore, if the patient develops a precipitous fall in blood pressure (generally uncommon in CPE {Cardiogenic Pulmonary Edema} patients), the blood pressure should return to previous values within 5 to 10 minutes of discontinuation of administration.[2]

But what about the dose?

In one study [26], 3 mg IV boluses of NTG were administered every 5 minutes to patients who had developed CPE, a dose equivalent to a 600 mg/min infusion. This protocol was found to be safe, well-tolerated, and effective for these patients and associated with reduced need for mechanical ventilation and more rapid resolution of symptoms. Standard anti-anginal dosages of sublingual NTG with which most physicians are comfortable (ie, 400 µg every 5 minutes), has the bioequivalence of an IV NTG infusion of 60 to 80 µg/min. Physicians should, therefore, be comfortable with the safety of even higher dosages of NTG for patients who experience CPE and usually present in a hyper-adrenergic state with moderately-to-severely elevated blood pressures.[2]

That is 7 1/2 times to 10 times the standard dose of NTG – with no problems.

Maybe that maximum of 3 NTG is something that should be ignored. The AHA (American Heart Association) seems to be ignoring it. Just try to find a limit on NTG administration in the current ACLS, which is from 2005.

These papers are available in PDF format, so you can print them out and hand them to your medical director and/or to the other doctors in the ED.

These are important papers. Both are review articles. One is written for EMS, while the other is written for the ED.

If you are feeling aggressive, maybe you can write on the bottom, Call me about improving the protocols we use to treat our patients.

There is one problem with this. This will lead to fewer intubations.

The best intubation is the intubation that is prevented by excellent patient care.

Footnotes:

[1] 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

[2] 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

Mosesso VN Jr, Dunford J, Blackwell T, & Griswell JK (2003). Prehospital therapy for acute congestive heart failure: state of the art. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 7 (1), 13-23 PMID: 12540139

Mattu A, Martinez JP, & Kelly BS (2005). Modern management of cardiogenic pulmonary edema. Emergency medicine clinics of North America, 23 (4), 1105-25 PMID: 16199340

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Drug Shortages Affect Those Still in the Dark Ages – Lidocaine

ResearchBlogging.org

Also posted over at Paramedicine 101 and at Research Blogging.

Go check out the excellent material at both sites.

In the current JEMS, there is an embarrassing article. Drug Shortage Possible in N.Y.

It seems that the drugs that people are worried about are lidocaine, furosemide, 50% dextrose, and epinephrine 1:10,000 preloaded syringes. Here, I will discuss lidocaine.

Lidocaine is not appropriate for EMS patients, because there are more appropriate drugs. Lidocaine is still used for cardiac arrest, even though there is absolutely no reason to believe that it does anything positive for the patient.

There is no evidence that any antiarrhythmic drug given routinely during human cardiac arrest increases survival to hospital discharge. Amiodarone, however, has been shown to increase short-term survival to hospital admission when compared with placebo or lidocaine.[1]

In other words, amiodarone doesn’t work, but lidocaine is even worse.

Lidocaine is also used for ventricular tachycardia with similar lack of effect.

Lidocaine terminated ventricular tachycardia in four of 31 patients, ajmaline in 19 of 30 patients (P<0.001).[2]

Lidocaine is no better than holding the patients hand or any other placebo. Spontaneous remission of ventricular tachycardia should occur in more than 4 out of 31 patients.

DC shock was used in 16 nonresponders (22.9%) to procainamide and 10 non-responders (50%) to lidocaine.[3]

Only 35% of patients improved after lidocaine. Maybe they improved because of lidocaine – maybe not. More important is that 50% of patients who received lidocaine ended up being cardioverted. Did they require cardioversion because of the lidocaine?

Would you recommend a drug that leads to half of patients being cardioverted?

Footnotes:

[1] Medications for Arrest Rhythms
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.2: Management of Cardiac Arrest
Free Full Text

[2] Electrophysiological and haemodynamic effects of lidocaine and ajmaline in the management of sustained ventricular tachycardia.
Manz M, Mletzko R, Jung W, Lüderitz B.
Eur Heart J. 1992 Aug;13(8):1123-8.
PMID: 1505562 [PubMed – indexed for MEDLINE]

[3] Efficacy of procainamide and lidocaine in terminating sustained monomorphic ventricular tachycardia.
Komura S, Chinushi M, Furushima H, Hosaka Y, Izumi D, Iijima K, Watanabe H, Yagihara N, Aizawa Y.
Circ J. 2010;74(5):864-9. Epub 2010 Mar 26.
PMID: 20339190 [PubMed – indexed for MEDLINE]

Free Full Text PDF

Table 3 is from this paper. As you can see, lidocaine is a joke compared to procainamide.

Manz M, Mletzko R, Jung W, & Lüderitz B (1992). Electrophysiological and haemodynamic effects of lidocaine and ajmaline in the management of sustained ventricular tachycardia. European heart journal, 13 (8), 1123-8 PMID: 1505562

Komura S, Chinushi M, Furushima H, Hosaka Y, Izumi D, Iijima K, Watanabe H, Yagihara N, & Aizawa Y (2010). Efficacy of procainamide and lidocaine in terminating sustained monomorphic ventricular tachycardia. Circulation journal : official journal of the Japanese Circulation Society, 74 (5), 864-9 PMID: 20339190

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Intubation Education

Also posted over at Paramedicine 101. Go check out the rest of what is there.

In the article I was writing about[1] (Experts Debate Paramedic Intubation) in my post Experts Debate Paramedic Intubation – JEMS.com, there is a bit of defense of the status quo in intubation and intubation training.

We get hung up on many of the same problems. We think that there is one right way to do things, rather than accept that we are adapting what we do to the different circumstances we are faced with.

We act as if the OR (Operating Room) is the only place that we can obtain good practice. There is no evidence to support this.

There is nothing to show that OR training is superior to morgue training and mannequin training, but we act as if the decreased availability of OR time is the only reason medics can’t intubate competently.

We act as if the only problem with the way we are teaching paramedic school is that the students are not learning. As if this is not a reflection on the teaching.

Teaching means providing information to students in a way that helps the students to understand. If the students do not understand, the teacher did not teach.

Perhaps you do not believe that we do a poor job at intubation education.

Results

Nine hundred twenty-six patients had an attempted intubation. Methods of airway management were determined for 97.5% (825/846) of those transported to a hospital and 33.8% (27/80) of those who died in the field. For transported patients, 74.8% were successfully intubated, 20% had a failed intubation, 5.2% had a malpositioned tube on arrival to the ED, and 0.6% had another method of airway management used. Malpositioned tubes were significantly more common in pediatric patients (13.0%, compared with 4.0% for nonpediatric patients).

Conclusions

Overall intubation success was low, and consistent with previously published series. The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies. Our data support the need for ongoing monitoring of EMS providers’ practices of endotracheal intubation.[2]

Those numbers may be considered good in many areas – batting average, picking winning stocks, votes in an election. When it comes to airway management, we would be more appropriate if we described failure rates.

These failure rates are unacceptably high.

Overall intubation success was low, and consistent with previously published series.

In other words, the authors believe that this is the expected result of the way we train paramedics to intubate.

Can anyone show that this is not true?

The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies.

This is the expected result of the way we train paramedics to intubate.

Our data support the need for ongoing monitoring of EMS providers’ practices of endotracheal intubation.

5.2% had a malpositioned tube on arrival to the ED.

5.2% Unrecognized Esophageal Intubations!

Ongoing monitoring Watching is not enough.

We need to dramatically change the way we handle intubation education.

Footnotes:

[1] Experts Debate Paramedic Intubation – Should paramedics continue to intubate?
JEMS.com
Bryan E. Bledsoe, DO, FACEP, FAAEM | Darren Braude, MD, MPH, FACEP, EMT-P | David K. Tan, MD, FAAEM, EMT-T | Henry Wang, MD, MS | Marc Eckstein, MD, MPH, FACEP | Marvin Wayne, MD, FACEP, FAAEM | William E. Gandy, D, LP, NREMT-P
Thursday, July 1, 2010
Article

[2] A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.
Denver Metro Airway Study Group.
Colwell CB, Cusick JM, Hawkes AP, Luyten DR, McVaney KE, Pineda GV, Riccio JC, Severyn FA, Vellman WP, Heller J, Ship J, Gunter J, Battan K, Kozlowski M, Kanowitz A.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):304-10.
PMID: 19499465 [PubMed – in process]

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Comment on Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients

Also posted over at Paramedicine 101. Go check out the rest of what is there.

In response to Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients, there is a comment by medic.

thank you for your post. i’d like to add a few thoughts, and please feel free to comment on them.

Thank you.

1. i have a suspicion that pts who rate their pain 7-8/10 tend to be more honest about their pain than the ones who rate their pain 10/10 (worst pain ever), which perhaps partially explains the study’s findings when sorted by initial pain rating.

That may be. Pain is subjective. Out of 119 patients, only 5 rated their pain 7 out of 10, so this is a small fraction that may not indicate anything. If we wish to draw conclusions about patients with 7 out of 10 pain, we need to set up a much larger study and propose our hypotheses before the study is begun.

Even if a report of 7 out of 10 pain is more honest than a report of 10 out of 10 pain, does that make it any less appropriate to treat 10 out of 10 pain aggressively?

2. competence is a huge factor is any setting, not just ems. there are plenty of (supposedly better-trained) docs and nurses who are clearly retarded.

Retarded is not the right word. However many doctors, nurses, and medics just do not get it. Maybe pain management has not been explained to them in the right way.

Many doctors do seem to become much more comfortable using opioids to treat pain after experiencing severe pain themselves.

We never seem to hear about doctors becoming less comfortable using opioids after experiencing severe pain.

This suggests that there is something important that is not understood by the doctors until after experiencing severe pain.

I suspect that studying this might require a huge sample of doctors, just to be able to track the change in prescribing/ordering habits vs. personal experience of severe pain, whether their own pain or the pain of someone they care deeply about.

3. i personally have a high threshold for when i break the narcs open, as i too work in a poor area. that’s not to say poor people can’t have pain; that’s just taking into account other factors such as a seemingly higher rate of drug use/abuse.

It isn’t our pain threshold that matters, but the patients’ pain threshold.

Opioids are not the appropriate treatment for all pain, but it is appropriate to treat severe pain aggressively with opioids when nothing else works (such as when nothing else is available). Nitrous oxide is something that can be safely used that might significantly decrease the amount of morphine needed to manage severe pain.

4. once i make the decision to use narcs, i am not stingy with them as experience shows that prehospital morphine doses are clearly inadequate. the more important issue here is a training crews for a heightened awareness of the potential for respiratory depression and allergic reactions (just had one last week).

And what did you need to do for the allergic reaction? Diphenhydramine?

Just because something happened last week, does not mean that it is common. We need to be aware of the potential for allergic reactions with all of our medications.

One of the many advantages of fentanyl, over morphine, is that fentanyl is much less likely to produce an allergic reaction.

Recognizing and dealing with respiratory depression should not require anything more than competently monitoring the patient.

Many, but not all, patients will experience respiratory depression with appropriate pain management, because pain tends to stimulate a sympathetic response. Having respirations decrease to normal is a good thing, even though this is respiratory depression.

If the patient shows signs of inadequate oxygenation/ventillation due to respiratory depression, then all that needs to be done is to get the patient to talk. Find a subject that the patient is interested in, people love to talk about themselves, and get them to keep talking. Or just keep asking questions that are not answered with a nod, or shake, of the head. Ask orientation questions. Even just telling the patient to take a deep breath every so often will work.

A talking patient is a breathing patient.

5. it’s a big training issue to get crews to recognize those pts who are in pain and those who are trying to score narcs. this is where experience counts and it’s difficult to teach. that being said, it’s risky to presume that people are trying to score narcs.

We should not presume that people are trying to manipulate us to give them drugs inappropriately. We should be aggressively looking for indications that the patient has legitimate pain.

If I need to give out morphine and fentanyl to a bunch of junkies in order to avoid missing some patients with legitimate pain, then I will be the candy man.

Let me put this in perspective.

If I need to give out albuterol nebulizer treatments to a bunch of people who do not need nebulizer treatments in order to avoid missing some patients with legitimate asthma/emphysema/bronchitis, then I will be the nebulizer man.

If I need to give out IV dextrose to a bunch of people who do not need to receive dextrose through an IV in order to avoid missing some patients with legitimate hypoglycemia and an inability to take glucose by mouth, then I will be the dextrose infusion man.

If I need to take some people with minor injuries to a trauma center in order to avoid missing some critical trauma patients, then I will be the minor trauma man.

I am not encouraging over-treatment, for the sake of over-treatment. We do need to be much better at assessment, rather than treating mechanism. How much training do we have at recognizing drug seekers, who are not seeking drugs for legitimate pain? If we are trained at this in paramedic school, or on the job, what are the qualifications of the person providing this training? What research has been done to demonstrate the accuracy of the methods of differentiating between legitimate drug seekers and illegitimate drug seekers?

The best way to make someone a drug seeker may be to under-treat their pain.

Our concern needs to be much less on being police and much more on being paramedics.

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Prehospital use of analgesia for suspected extremity fractures


ResearchBlogging.org

Also posted over at Paramedicine 101 and at Research Blogging. Go check out the rest of the excellent material at both sites.

This is an older study that puts the prehospital pain management problem into a bit of perspective. While prehospital pain management has improved a lot in some places, other places may still be handling pain as described in this study. This is only ten years old. Attitudes are not changed so easily.

The authors looked at what is probably the least controversial type of pain management. If you were to ask medical directors what they feel most comfortable having paramedics use opioids to treat, the only other choice is likelty to be pain due to burns. Chest pain became a bit controversial after the CRUSADE study, but I will get to that in another post.

Over the last decade, pain and its management have received considerable attention. Most notably members of the medical profession in general and specifically emergency medical professionals undertreat pain to a considerable extent.3 [1]

While I would love to be able to defend everyone from this charge euphemistically referred to as undertreatment, the reality is that a decade later, the problem has not changed that much.

This was an observational study involving a retrospective review of all emergency medical services (EMS) runs for suspected extremity fractures[1]

During the study period, all EMS run reports were evaluated by the fire department’s quality assurance coordinator. Only reports documenting the paramedic’s impression that the patient had sustained a fracture, or suspected fracture, of any extremity were included in the database.[1]

There is no mention of any requirement to document any kind of measurement of pain. This seems to be the most significant problem with pain management in the system studied. How do we assess the quality of pain management if we do not assess pain?

The whole structure of this study revolves around the apparent inability to assess pain. There are a bunch of conclusions drawn. Here is what may be the most important omission of the study.

If we do not assess something, how do we treat it appropriately?

If a medical director does not make it clear that pain assessment and management are taken seriously, then is there much reason to expect the paramedics to be more aggressive than the medical director?

We need to provoke medical directors, emergency physicians, emergency nurses, EMTs, and paramedics to take pain seriously.

It’s not my pain.

Akron Fire EMS employs a two-tiered transport system whereby nonurgent patients who may be safely transported in a private vehicle are deemed code 1, allowing the med unit to be put back into service. Nonurgent patients who require ambulance transport to the hospital become code 2 and their care and transport to the hospital are transferred to a private ambulance. A patient requiring immediate transport, medication, or procedures rendered by a paramedic is transported directly to the hospital as a code 3.[1]

The two-tiered structure of this EMS system may unwittingly serve to negatively affect the administration of pain medication in several ways. Administering pain medication to a code 2 patient, for whom transport to the emergency department would be transferred to a private ambulance, would automatically change the run to a code 3. Upgrade to a code 3 would necessitate transport directly to the emergency department by the treating paramedic squad, extending the time required to complete the run.[1]

Another question is whether code 3 means a lights and sirens transport to the ED. What extremity fractures, other than those cutting off circulation, require such rapid and rough transport? Even fractures cutting off circulation are unlikely to benefit from the slight difference in transport time that lights and sirens would provide. Slightly faster, but much rougher and much more painful in spite of the pain medicine! Why?

How did this service do at using pain medicine to manage suspected extremity fractures, which are expected to have a high correlation with severe pain?

A total of 18 patients (1.8%) received treatment for pain; nitrous oxide was administered to 16 patients (1.6%), and morphine sulfate to two patients (0.2%).[1]

We know that 16 patients (out of a thousand patients with suspected extremity fractures) received nitrous oxide and 2 patients (out of a thousand patients with suspected extremity fractures) received morphine.

We do not know if they were being treated for pain, since there is no indication of any assessment of pain. We expect that the patients with suspected extremity fractures would have a lot of pain. If you have ever had a painful extremity fracture, you might expect all extremity fractures to be painful. You might also desire that many, most, or even all of these suspected extremity fractures be treated with pain medicine. The authors do not provide anything to support this conclusion.

Let’s look at the injuries documented.

All of them seem as if they would be painful fractures. Still, we do not know anything about the pain of these patients.

What else was done that might have acted as pain management?

Supportive medical treatment provided included air splints (25% of patients); full immobilization (19%); ice packs (17%); bandages/dressings (16%); and intravenous lines (9.4%).[1]

Air splints may help to relieve pain by positioning the extremity in a less painful, assuming there is any pain, position. Splinting may temporarily increase pain during application.

Full immobilization is unlikely to provide any pain relief. Full immobilization on a solid long spine board is expected to increase pain.[2]

Ice packs can increase pain, decrease pain, or both.

Bandages/dressings might provide some stabilization, or pressure, that decreases the sensation of pain.

Intravenous lines are often painful. If I only suspect an extremity fracture, I would not have any other justification to be starting an IV, except to have a route to deliver IV pain medication. 2 patients received IV pain medication. 94 patients received IV lines. 2/94?

Did one medic start a line, while the other medic contacted medical command. Since The care of each patient is discussed with an online medical control emergency physician in a local emergency department, the superfluous medic may use that time to get online medical control emergency physician contact out of the way, so that the medic can do something useful, such as assessing or treating the patient.

Did the online medical control emergency physician give this counter-order to the medics? Do not follow your standing orders for pain management. Do not give any pain medicine.

Were the medics, or was one of the medics, hesitant to provide any pain medicine without first contacting the online medical control emergency physician?

Are the medics routinely yelled at by emergency physicians if they administer pain medicine without requesting permission first, even though protocols allow them to give pain medicine without asking for permission?

Do administrators receive complaints from emergency physicians when medics follow standing orders for pain medicine?

The number of patients receiving morphine is so small, that I want to know what was so bizarre about these patients that these Just say No! paramedics gave morphine.

Was the morphine given on standing orders?

Was the morphine even given intentionally?

Since giving morphine for suspected extremity fractures is such a freak occurrence in this system, is there any evidence to suggest that these were not 2 medication errors?

Is the occurrence of morphine administration any less rare than the system’s occurrence of medication errors?

The use of morphine is so breathtakingly out of the ordinary in this system, that I do not see any reason to conclude that there is any connection between morphine and suspected extremity fracture. Were any other medications, aside from nitrous oxide, given to any of these patients? Were any of those medications given more frequently than morphine? 2/1,000 suspected extremity fractures.

The EMS pain control policy included standing orders for administration of either morphine sulfate (adult dose: 2–5 mg intravenous push [IVP], may repeat x 1; pediatric dose: 0.1 mg/kg) or nitrous oxide (50%), self-administered. The care of each patient is discussed with an online medical control emergency physician in a local emergency department. By protocol, analgesic therapy is contraindicated in patients with the following conditions: altered level of consciousness; alcohol or drug use; allergies to morphine or nitrous oxide; hypotension; head injury; chest injury with suspected pneumothorax; abdominal pain with possible bowel obstruction; symptomatic asthma or chronic obstructive pulmonary disease (COPD); or respiratory distress.[1]

Even with standing orders, patient care must be discussed with a doctor. In that case, are they really standing orders? There are a lot of contraindications. I almost expect to see suspected extremity fracture listed as a contraindication for morphine. How much different would the results be, if that were the case?

2/1,000 vs 0/1,000.

Is this number, 2/1,000, even close to being statistically significant?

We don’t know how many of the 1,000 patients actually had pain that would be appropriate to treat with morphine.

This study examined the use of analgesia in 1,000 prehospital patients with suspected fractures of the extremities who were treated by paramedics. Of the 1,000 patients, only a very few (1.8%) received any pain medication, although morphine sulfate and nitrous oxide were available to the paramedics by both standing order and direct physician order through online medical control.[1]

I think it is misleading to suggest that there was any encouragement by medical command to treat patients with morphine. However, I have no way of knowing if one, or both, of the patients treated with morphine only received morphine because the doctor ordered it.

My experience with online medical command has been one of repeated refusal to give orders for for pain medicine for patients with pain – pain that I would be authorized to treat on standing orders under my current protocols.

What is the difference?

The patients treated with morphine do not suffer as much. The medical command physician does not get to exercise a medical whim to deny pain medicine purely due to the physician’s lack of understanding of pain management.

The mean time spent on the scene for all patients in the study was 23 ±3.4 minutes. Scene times were significantly longer for patients who received pain medication (n = 18) 32.8 ±17.4 minutes, than for those who did not, 22.8 ±10.4 minutes (95% CI 5.22 to 14.58). Transport times to the area hospitals average 7 minutes in this system, with the three main receiving hospitals located in the same geographic area.[1]

Unless a patient is unstable (or at risk of injury if not moved), there is no good reason to transport the patient until after the pain is managed. It does not matter if this means an extra 5 minutes on scene or an extra hour on scene. More aggressive dosing (morphine 0.1 mg/kg followed by 0.05 mg/kg every 5 minutes until significant relief) and more appropriate medication (fentanyl at appropriate doses) will result in less time on scene. We should not be manipulating painful injuries until after the pain is managed, unless there is some good reason. That is rare.

When I call for orders for more pain medicine, because the standing orders have not been appropriate in managing pain, medical command often wants to know how far I am from the hospital. My response is, That depends on how quickly I get orders for appropriate pain management, because the patient is not being moved until the pain is managed. Why isn’t that obvious to everyone?

Why increase the patient’s pain to move the patient to bring the patient to the pain medicine in the hospital, when the patient can be treated just as safely, if not more safely, before being moved?

Second, the administration of nitrous oxide requires that in addition to directly transporting the patient, the paramedics must also exchange the used nitrous tank for a new one. In Akron, the only tank exchange site was located in a remote part of the city, necessitating extended duties and travel time for one of the paramedics. Upon completion of this study, replacement nitrous tanks were placed in each of the 12 fire houses to facilitate more convenient restocking.[1]

It is good to see that they are trying to make things better for patients by eliminating the excuses used by paramedics, when medics rationalize avoiding treating patients appropriately.

Managing pain in the prehospital setting may require a multifaceted approach. Pain experienced by the patient must be evaluated in an objective manner, and once assessed, managed appropriately. Prehospital care providers should be encouraged to appreciate their patients’ pain and given the tools and affirmation needed to provide the most appropriate care.[1]

Yes.

CONCLUSION
Prehospital care providers and their medical control supervisors have room to improve the quality of pain control in the prehospital setting. In this review of the use of analgesia for patients with suspected fractures of the extremities, pain medication was rarely used. Improvements in both the recognition and assessment of pain and in treating the pain in the prehospital setting are slow to be implemented. Education, pain control evaluation, protocol development, and quality assurance and audit systems are all measures that can be used to improve the quality of pain management in the prehospital setting.
[1]

All good points, but the most important point is not in there.

Pain management is about treating pain, not treating specific medical conditions.

If you look at all of the contraindications to the use of pain management in this study, there appears to be a strong bias against treating many painful conditions that are not medical contraindications. These appear to be just demonstrations of discomfort with pain management and ignorance of appropriate pain management. As critical as I am of this study, at least the authors are working to improve the way their system manages pain. Most systems seem to deny that there is a problem.

We need to educate prehospital providers to be much more aggressive with pain management.

We spend so much time worrying about paramedics being too aggressive with pain management, but nobody seems to be able to come up with any evidence to support this paranoid fantasy.

We need to provoke medical directors, emergency physicians, emergency nurses, EMTs, and paramedics to take pain seriously.

Footnotes:

[1] Prehospital use of analgesia for suspected extremity fractures.
White LJ, Cooper JD, Chambers RM, Gradisek RE.
Prehosp Emerg Care. 2000 Jul-Sep;4(3):205-8.
PMID: 10895913 [PubMed – indexed for MEDLINE]

[2] Unnecessary out-of-hospital use of full spinal immobilization.
McHugh TP, Taylor JP.
Acad Emerg Med. 1998 Mar;5(3):278-80. No abstract available.
PMID: 9523943 [PubMed – indexed for MEDLINE]

Standard backboard immobilization is not harmless and can cause significant pain, especially at the occipital prominence and lumbosacral areas. Within 10 minutes of being placed in FSI, Hamilton and Pons12 showed that volunteers developed moderate to severe pain. After 30 minutes in FSI, Chan et al.13 found 100% of volunteers complained of pain, with 55% of the group grading their pain as moderate to severe in quality. Interestingly, 29% of the subjects developed new symptoms over the course of the next 2 days. Chen et al. concluded that “the standard process of immobilization may complicate the evaluation of the trauma patient by generating additional symptoms . . . leading to unnecessary laboratory tests and radiographic studies, time of immobilization, and ultimately, health care costs.” In addition to pain, FSI can cause changes in pulmonary function. can cause pressure ulcers of the buttocks, scalp, or neck, and can increase the risk of aspiration after vomiting.13,14 Because standard FSI can compromise maternal and fetal circulation, it is relatively contraindicated in gravid women.

12 The efficacy and comfort of full-body vacuum splints for cervical-spine immobilization.
Hamilton RS, Pons PT.
J Emerg Med. 1996 Sep-Oct;14(5):553-9.
PMID: 8933314 [PubMed – indexed for MEDLINE]

13 The effect of spinal immobilization on healthy volunteers.
Chan D, Goldberg R, Tascone A, Harmon S, Chan L.
Ann Emerg Med. 1994 Jan;23(1):48-51.
PMID: 8273958 [PubMed – indexed for MEDLINE]

14 A review of spinal immobilization techniques.
De Lorenzo RA.
J Emerg Med. 1996 Sep-Oct;14(5):603-13. Review.
PMID: 8933323 [PubMed – indexed for MEDLINE]

White, L., Cooper, J., Chambers, R., & Gradisek, R. (2000). P REHOSPITAL U SE OF A NALGESIA FOR S USPECTED E XTREMITY F RACTURES Prehospital Emergency Care, 4 (3), 205-208 DOI: 10.1080/10903120090941209

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