# Another Pain Management Thread (Multi-System Trauma)



## redcrossemt (Dec 5, 2009)

Another discussion about pain management...

Took an ITLS class the past two days. I was largely unimpressed with the course content (couldn't find a single thing not in the EMT-P curriculum), but we had several very intelligent instructors and students, and several good discussions resulted.

One was whether or not to provide analgesia to the multi-system trauma patient.

Is there research out there on this?

What are hospitals doing in the trauma bay?

Would you provide analgesia to such a patient? What are contraindications? Altered mental status (screaming, not answering questions?)? Hypotension? Certain types of trauma (chest, abdominal, head)?

Obviously you have to do a good assessment prior to providing pain management... But does pain management impair the trauma center's ability to assess the patient? Was your physical assessment good enough to make this a moot point? Or does it too significantly effect continuing assessment?

Very interested to hear the thoughts and knowledge out there!


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## Epi-do (Dec 5, 2009)

Due to how close I am to 2 level 1 trauma centers, by time I get done doing everything I need to address first, I rarely have time to even consider analgesia.  With the multi-system trauma, there are typically plenty of other issues that demand my attention.  Once I get the high priority issues addressed, if I still have some time before pulling into the ER, then I would consider whether or not my patient would be a candidate for analgesia, per my local protocol.


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## Smash (Dec 5, 2009)

My extremely sleep deprived and probably largely incoherent thoughts on this are:  Everyone deserves pain relief.  People who have polytrauma will still have pain, even if altered.  Now obviously we want to be careful we don't obtund them further, but that doesn't mean withholding pain relief.  We have a number of different options available, so type of injury and hypotension don't really matter, we will manage those things concurrently.  

Head injuries will likely get RSI and one of the premeds we use is fentanyl, so they will get a bit of that, possibly before we have the rest set up depending on how agitated they are.

Pain relief will not impair my assessment, nor the assesment at the trauma center, and in actual fact will probably make assessment easier by removing some of the affective aspect of pain in the patient.  CT scans, x-rays, FAST, MRIs all that sort of thing, as with the old saw about abdo pain, make it entirely appropriate to relieve pain in multi trauma patients as assessment is done with these tools to a large extent.

There are studies on this exact matter, I can't remember authors/journals off the top of my head, but the consensus is that analgesia is definitely beneficial.  Israel has produced some good ones I think, or at least I think I think.  There are studies in adults and pediatrics, and all need pain relief.  Z's keep coming to mind.  Zempskey (spelling?) has published a lot in Pediatrics journal on pain relief.

Pain relief here is recognized as an essential, high priority part of care of the injured patient by ER, OR, ICU and ambulance and is aggressively persued.  It is not optional, it is an absolute neccesity, and any paramedic who does not provide pain relief in a timely and appropriate fashion can expect to have some scrutiny from the medical directors.


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## Smash (Dec 7, 2009)

Really?  Noone else?  


I thought it was an interesting question redcross...


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## Melclin (Dec 7, 2009)

Well, not that its not a good question, but I'm not sure there is that much room for discussion.

How many people don't think it's an important issue? Morphine will probably tank the BP a little, so that has to be taken into consideration (by using fentanyl probably), but each case is different so its a little hard to discuss without some more meat on the bones.

We all know, hopefully that adequate pain relief doesn't impair the ability to asses pain, especially in multitrauma when they're off to the imaging department anyway. So not really any room for discussion there either.



> ...medical, legal, and ethical experts also have firmly and consistently come down in favor of pain relief in the prehospital setting


Thomas SH, Shewakramani S. Prehospital Trauma Analgesia. Journal of Emergency Medicine. 2008;35(1):47-57.



> Others have concluded that appropriate pain management inthese patients would not alter their diagnosis *and may, in fact, produce a more reliable physical examination*.


Alonso-Serra HM, Wesley K. 2003. PREHOSPITAL PAIN MANAGEMENT. Prehospital Emergency Care 7(4):482-488



The whole, 'pain relief skews diagnosis, was only really ever to do with abdo pain anyway' as far as I'm aware, and that has been continually refuted:

-Zoltie N, Cust MP. Analgesia in the acute *abdomen*. Ann R Coll Surg Engl. 1986;68:209-10.

-Vermeulen B, Morabia A, Unger PF, et al. Acute *appendicitis*: influence of early pain relief on the accuracy of clinical and US findings in the decision to operate—a randomized trial. Radiology. 1999;210:639-3.

-LoVecchio F, Oster N, Sturmann K, et al. The use of analgesics in patients with acute *abdominal* pain. J Emerg Med. 1997;15:775-9.

-Pace S, Burke TF. Intravenous morphine for early pain relief in patients with acute *abdominal* pain. Acad Emerg Med. 1996;3:1086-92.

I'm pretty sure no one is going to receive a multitrauma to a major trauma service and then start yelling at the paramedic because they can't properly diagnose the pt's various problems due to a bit of fentanyl. It all been said in the other thread (I assume, I didn't read it all). MRI, CT, X-ray, blood panels, FAST U/S and good clinical judgment can all overcome any minor issue that might be caused by good pain relief.


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## redcrossemt (Dec 10, 2009)

Melclin said:


> Well, not that its not a good question, but I'm not sure there is that much room for discussion.
> 
> How many people don't think it's an important issue? Morphine will probably tank the BP a little, so that has to be taken into consideration (by using fentanyl probably), but each case is different so its a little hard to discuss without some more meat on the bones.
> 
> ...



So, the situation we talked about was a patient is possibly in compensated shock, or maybe just having a stress reaction, with a HR of 120 and a BP of 110/70, alert and oriented times however many you choose, multi-systems trauma, tender distended abdomen, femur fracture, whatever.

The opponents say that giving pain medication would precipitate loss of compensatory vasoconstrict mechanisms, resulting in decreased perfusion and the move towards decompensated shock.

I argued to medicate with a short-acting drug like fentanyl until they are comfortable, or you start to lose perfusion or mental status.


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## MrBrown (Dec 10, 2009)

For musculoskeletal pain we have ketamine which if anything, has a slightly hypertensive effect so won't have the vasodialatory properties that morphine does.

We also have midazolam and I've seen that used for fractures ontop of morphine but midaz is not an analgesic but 2-3mg of that gets the patient nicely stoned so they just blank out and don't remember.

I have seen better results with ketamine tho.


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## Melclin (Dec 11, 2009)

Midaz will tank the blood pressure though, esp on top of morphine. It's interesting that you are allowed to use it for analgesia brown, I asked about it once, especially in light of the muscle spasms that make a lot of orthopedic pain and apparently we have been expressly told not to do that. Sigh. 

Fentanyl is best because it doesn't not cause the same histamine release other other natural opiates. Again nothing new. 

A dissociative like ketamine is seems to be the new deal for best practice. None of this is new. 

I suppose you might run into a problem should your service be backward enough to only carry morphine. If its the histamine release that's doing their BP in, then I always thought an anti histamine might help (high level of evidence I know, but when I've been hitting the codeine a little hard come flu season, a bit of phenergan always helps the itches h34r: ), but I think I heard somewhere that it doesn't work for whatever reason.


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## MrBrown (Dec 11, 2009)

Midaz ontop of morph is contraindicated in a shocked patient so would may not be used for your multi-system trauma but has been used for analgesia in multiple long bone fractures quite well.

It is not my first choice as midazolam is not an analgesic and in this case is really I think being used more for its sedative and amnesic properties than analgesia.

Self limiting histamine release from morphine shouldn't really cause any hypotension and I've only seen it cause a bit of a rash or some N&Vs.  Hypotension I'd consider only to come from an anaphylactic reaction.

Fentanyl is good, we only have it for RSI now but I hear its coming down to replace morphine in general use.


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## BLSBoy (Dec 11, 2009)

What about Etomidate for the sedation?
Maybe 0.10mg/kg rather then the 0.30mg/kg we use for RSI?

On the the original question (kinda), I prefer Fent over Morphine in almost any case, other then slightly HTN with MI and no previous hx of bad reaction to Morphine. 
With Morphine (esp in RVI and trauma) you have to worry about the histamine response (as already noted) and possible allergic reactions. 
Tanking their pressure and/or sending them into anaphalyxis is no bueno. Not to mention some pts (myself included) vomit when first administered morphine. Now you gotta break out the Zofran before you give the Morphine. 

Nah, I'll stick with Fent. Shorter acting (can rebolus if needed), no where near the BP effects or allergic reaction you would have to worry about with Morphine. 


Pain relief is in my first list of things to do. C-Spine, Airway, Breathing, Circulation, DCAP-BTLS, PAIN RELIEF. 
Be a trauma pt, I'm sure you will understand.


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## rhan101277 (Dec 11, 2009)

Well like others said try not to give them so much they are obtunded.  Then it is hard to discern whether the medicine did this or that this is altered mental status that is occuring due to injury.  Again it goes back to good assessment, give a good report.  Although from what I have seen, I doesn't seem that the CRN or the emergency room physician put much stock in your info.  I guess the more you roll in there and the more years that go by, maybe they rely on your a little more.

It is easy to say, well these meds caused this but you can't know for sure.


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## redcrossemt (Dec 12, 2009)

rhan101277 said:


> Well like others said try not to give them so much they are obtunded.  Then it is hard to discern whether the medicine did this or that this is altered mental status that is occuring due to injury.  Again it goes back to good assessment, give a good report.  Although from what I have seen, I doesn't seem that the CRN or the emergency room physician put much stock in your info.  I guess the more you roll in there and the more years that go by, maybe they rely on your a little more.
> 
> It is easy to say, well these meds caused this but you can't know for sure.



Etomidate might be a good option, but anecdotally it has seemed hard to control the level of sedation in the field. In addition, it's very short acting, so I'm not sure you could use it for analgesia without a pump.


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## Smash (Dec 12, 2009)

There are also concerns with etomidate and adrenal insufficiency in shocked patients, even when used as a single does for RSI.  This was first recognized in septic shock patients, but it has been extrapolated that it _may_ be a problem in trauma patients also.

Versed in conjunction with morphine is very effective for procedural sedation or in settings of intractable pain, particularly with muscle spasm such as dislocations.  I would be very, very hesitant to use that combination in a polytrauma patient.


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## redcrossemt (Dec 12, 2009)

Smash said:


> There are also concerns with etomidate and adrenal insufficiency in shocked patients, even when used as a single does for RSI.  This was first recognized in septic shock patients, but it has been extrapolated that it _may_ be a problem in trauma patients also.



I just heard that a couple weeks ago. Was told that poor outcomes were linked to even one dose of etomidate in patients suffering from shock. Looked up some research, and here it is for everyone's reference:

Good lit review from the British Journal of Anaesthesia with many good references: http://bja.oxfordjournals.org/cgi/content/full/97/1/116


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## Smash (Dec 12, 2009)

Good editorial.  This is one of the reasons we use versed for induction with fentanyl for premed in RSI.  The other reason is that versed was something all our medics are already familiar with so there was less outlay required for education/training/stocking of rigs.  Our HEMS medics carry a wider range of agents including propofol, but they are exposed to a different, often more diverse range of patients, have long transports and they also have a reasonable amount more training and education than our road medics.

Versed is not a bad drug in this setting: it has a reasonably quick onset and short duration (not as quick or short as etomidate, but acceptable), it is reasonably easy to titrate, it is reasonably predictable in it's effects, and whilst it may decrease BP it's effects are usually not that drastic.

Adrenal insufficiency is a really interesting problem, and I suspect we see it a bit more than we may realize.  Post arrest adrenal insufficency is pretty common and may account for a reasonable number of post-ROSC patients in whom we have trouble maintaining BP with inotropes.  Of course adrenal insufficiency is common in septic patients as well, which is why we add low dose steroids to the mix when we run inotropes on these patients.


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## MissMedicCMO (Dec 27, 2009)

Smash said:


> My extremely sleep deprived and probably largely incoherent thoughts on this are:  Everyone deserves pain relief.  People who have polytrauma will still have pain, even if altered.  Now obviously we want to be careful we don't obtund them further, but that doesn't mean withholding pain relief.  We have a number of different options available, so type of injury and hypotension don't really matter, we will manage those things concurrently.
> 
> Head injuries will likely get RSI and one of the premeds we use is fentanyl, so they will get a bit of that, possibly before we have the rest set up depending on how agitated they are.
> 
> ...



Agreed on head injuries..they are more then likely going to get intubated..per RSI..UNLESS you work for a service that unfortuantly doesn't allow RSI..


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## MissMedicCMO (Dec 27, 2009)

Agreed on head injuries..they are more then likely going to get intubated..per RSI..UNLESS you work for a service that unfortuantly doesn't allow RSI.. We use RSI..but fentanyl is not a drug used in RSI for us..Lido to decrease icp and etomidate/succs or versed/succs... But RSI can be a scary thing so know when to use it and when to not.  Hypotension...no Im not going to give it for pain..protocols...and that would be dumb... and if their pressure is stable and they have fractures etc..then yes they are in pain and I would want meds if my femur was snapped in half so I would give them fentanyl or something of that nature..


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## reaper (Dec 28, 2009)

Question- You still have Lido in your RSI protocols?


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## MissMedicCMO (Dec 28, 2009)

reaper said:


> Question- You still have Lido in your RSI protocols?



Yes we still have lido in our RSI protocols..Why are there new studies suggesting its not good for decresing ICP prior to RSI?


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## reaper (Dec 28, 2009)

There are studies that show it is of no use in decreasing ICP. 
I have not worked a system that had it in their RSI protocols, in years.

I was just wondering.


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## MissMedicCMO (Dec 28, 2009)

interesting....didnt know that but im a newer medic too.  thats how we were taught in class also. Even our flight medics in surrounding areas use it.  But Im in Indiana and Ive heard that Indiana is behind the times as far as ems.


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## rhan101277 (Dec 29, 2009)

How about morphine administration.  Say it is someone that has something like a dislocated knee.  Who knows how long he will wait for pain meds at the ER.  Do you give him maybe 5mg morphine IM, that way it last longer instead of IV?


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## triemal04 (Dec 29, 2009)

rhan101277 said:


> How about morphine administration.  Say it is someone that has something like a dislocated knee.  Who knows how long he will wait for pain meds at the ER.  Do you give him maybe 5mg morphine IM, that way it last longer instead of IV?


Or you could just give it IVP and then reduce the dislocation.  Much more easy and beneficial in that situation.

Otherwise, initially your goal is to reduce the pt's pain...that will be accomplished much faster if the drug is given intravenously vs IM.  Your concern is valid, but, (and this will depend on your local hospitals) if you're giving morphine as your analgesic, then if you give a dose as you arrive at the hospital, they'll most likely be ok.  But, if where you go has a history of extended waiting times for in-hospital care, then it might be more appropriate to give a final dose IM, as long as the pt needed it and could tolerate it.


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## Melclin (Dec 29, 2009)

Woah, lignocaine for ICP management? Is that in the same textbook as leeches for a fever and per rectal tobacco smoke during cardiac arrest?  I kid I kid, but that's some old stuff there.


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## Scott33 (Jan 1, 2010)

reaper said:


> There are studies that show [Lidocaine] is of no use in decreasing ICP.



I have never heard of Lidocaine _decreasing_ ICP - only minimizing any further increase in it.


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## AKidd (Jan 1, 2010)

The biggest issue with ketamine, although uncommon in lower doses not used for sedation, is the "emergence reaction".  This may well mask or skew neurological status assessment, but withholding all types of pain management in polytrauma is questionable in the best of situations.  

Definitely an interesting thread.


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## Akulahawk (Jan 1, 2010)

rhan101277 said:


> How about morphine administration.  Say it is someone that has something like a dislocated knee.  Who knows how long he will wait for pain meds at the ER.  Do you give him maybe 5mg morphine IM, that way it last longer instead of IV?





triemal04 said:


> Or you could just give it IVP and then reduce the dislocation.  Much more easy and beneficial in that situation.
> 
> Otherwise, initially your goal is to reduce the pt's pain...that will be accomplished much faster if the drug is given intravenously vs IM.  Your concern is valid, but, (and this will depend on your local hospitals) if you're giving morphine as your analgesic, then if you give a dose as you arrive at the hospital, they'll most likely be ok.  But, if where you go has a history of extended waiting times for in-hospital care, then it might be more appropriate to give a final dose IM, as long as the pt needed it and could tolerate it.


If you wait too long after the patella dislocates, you're going to have to give more than morphine to reduce it. Think muscle relaxant... Remember, the quads will contract in an attempt to splint the injury... Once that occurs, a pretty significant amount of force will be required to reduce that dislocation, as you'd generally have to push the patella back over the lateral femoral condyle, against some pretty heavily contracted quads.

In my experience, EMS doesn't arrive on scene quickly enough and isn't trained/authorized to reduce these dislocations.


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## triemal04 (Jan 2, 2010)

Akulahawk said:


> If you wait too long after the patella dislocates, you're going to have to give more than morphine to reduce it. Think muscle relaxant... Remember, the quads will contract in an attempt to splint the injury... Once that occurs, a pretty significant amount of force will be required to reduce that dislocation, as you'd generally have to push the patella back over the lateral femoral condyle, against some pretty heavily contracted quads.
> 
> In my experience, EMS doesn't arrive on scene quickly enough and isn't trained/authorized to reduce these dislocations.


Not necessarily and never that I've seen.  I'm suppose it could be possible, but given the position that the leg end's up in with (lateral) patellar dislocations, that would take a long time, and it's not really necessary to move the upper leg to reduce it, though it does make it easier.  A more likely issue would be swelling, but even that will take long enough that a field reduction is still usually possible.

The biggest complications that would prevent a field reduction are fractures of either the patella itself, or the epicondyles on the femur/tibia.  Beyond that the risks are damage to the surrounding tissue/ligaments (which a reduction will help) and the small possibility of bone fragments being left in the knee.

Luckily for the people that this happens to it often self-reduces, and, as the knee isn't like most other joints in the body, a reduction in the field after appropriate pain meds is still very possible.

http://www.athleticadvisor.com/Injuries/LE/Knee/Patella/patella_dislocations.htm
http://emedicine.medscape.com/article/90068-overview
http://wildernessmedicinenewsletter.wordpress.com/2006/11/11/reducing-a-dislocated-patella/


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## Akulahawk (Jan 2, 2010)

The athletic advisor site has some pretty good basic info about patellar dislocations. However, most of the patellar dislocations I've ever heard about occur because of an impact or a VERY high Q angle. Those dislocations that I've heard about from non-contact events would generally have a previous history of dislocations. 

Many dislocations do spontaneously reduce. For those I'd have to reduce manually, I'd be more worried about reducing those that occurred due to an impact, as this increases the likelihood of a lateral condylar fracture. Reduction of the dislocation without pain meds is most possible within minutes after the dislocation. As swelling and muscle spasm begins, it will become more and more unlikely to reduce the dislocation without meds. 

The emedscape article is actually pretty good for discussing the factors and some evaluation techniques. It should be noted that it does NOT get into evaluating patellar dislocation vs ACL/MCL/Medial Meniscus injuries, that can also occur with a similar mechanism stated in the first article.

The wilderness medicine article does state kind of how to do it, but it leaves out a step... and that is controlling the patella as it begins to reduce. You do NOT want it to pop back over the lateral condyle in an uncontrolled manner, if you can help it. 

Once muscle spams get going, it's not going to be easy to straighten the leg and therefore, it won't be an easy reduction. It'll get worse once any significant swelling occurs as that won't allow the joint to completely straighten. Combine that with muscle spasming... and you might begin to see why medication assistance (muscle relaxers specifically) become useful in reducing these.

Patellar Dislocations are pretty far from multi-system trauma though. If, by chance, I found a trauma patient that also happened to have a patellar dislocation, chances are, I'm not going to worry about reducing it. I've got other things I need to get to first...


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## LondonMedic (Jan 2, 2010)

I've used all sorts of things for analgesia from proper anaesthesia through to paracetamol but I've found that one of the easiest and most effective is good splinting/traction and good positioning for transport.


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## FLEMTP (Jan 2, 2010)

Im curious if anyone out there carries Nitrous oxide for pain management? One of the previous services I worked at carried it... and it was great for pain management.. Seems like it used to be more popular in the past and now has gone by the wayside. 

Personally.. for multisystem trauma pain management I like to use .3mg/kg of Etomidate, and then 2mg/kg of Succs   I kid i kid...

Seriously though, we carry fentanyl and morphine for pain management. My personal drug of choice for pain, especially multisystem trauma type pain is Fentanyl. We can give as much as we see fit provided it doesnt cause the patient to become obtunded. Our protocol states 2mcg/kg but then again we can do pretty much anything we need to outside of the protocol provided we can justify it.


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## BLSBoy (Jan 2, 2010)

FLEMTP said:


> Seriously though, we carry fentanyl and morphine for pain management. My personal drug of choice for pain, especially multisystem trauma type pain is Fentanyl. We can give as much as we see fit provided it doesnt cause the patient to become obtunded. Our protocol states 2mcg/kg but then again we can do pretty much anything we need to outside of the protocol provided we can justify it.



Um, are you hiring?


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## FLEMTP (Jan 2, 2010)

haha i wish we were.. we just hired 12.. and when we do open up applications... we get approx 600 applications per open position.

You're welcome to look us up though!

http://www.lee-ems.com/ems/default.htm


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## LondonMedic (Jan 3, 2010)

FLEMTP said:


> Im curious if anyone out there carries Nitrous oxide for pain management? One of the previous services I worked at carried it... and it was great for pain management.. Seems like it used to be more popular in the past and now has gone by the wayside.


London Ambulance carry and use quite a lot of it, it's also pretty popular in the ER setting over here for rapid-onset, short-duration analgesia for moderate to severe musculo-skeletal pain.


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## MrBrown (Jan 3, 2010)

FLEMTP said:


> Im curious if anyone out there carries Nitrous oxide for pain management? One of the previous services I worked at carried it... and it was great for pain management.. Seems like it used to be more popular in the past and now has gone by the wayside.



Yes, we carry nox (and methyoxyflurane) as basic level inhalation analgesia and they work very well.

Considering it was Wells who first use N20 in 1844 wow, what, 160+ years later it seems the US hasn't caught on that its good for crews who are unable to give intravenous analgesia as upposed to what you have now which is um, nothing!


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## LondonMedic (Jan 3, 2010)

MrBrown said:


> Considering it was Wells who first use N20 in 1844 wow, what, 160+ years later it seems the US hasn't caught on that its good for crews who are unable to give intravenous analgesia as upposed to what you have now which is um, nothing!


I'd argue that it's also a good tool to be used instead of, or to complement, IV opioids and should be part of ALS kit.


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## FLEMTP (Jan 3, 2010)

Seems to be more the norm to use NOX overseas.. not so common in the states...


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## VentMedic (Jan 3, 2010)

FLEMTP said:


> Seems to be more the norm to use NOX overseas.. not so common in the states...


 
NOX? That just refers to a broad category of nitrogen oxides and is generally used in reference to Nitrogren Dioxide (*NO2*) by the EPA. *NO2* is not a gas that is desirable. It is also one of the monitoring alarms when delivering *NO* (nitric oxide).


*N2O* is nitrous oxide.

*NO* is nitric oxide which you will see on specialty transport or with some home care patients who have pulmonary hyptension.

*N2* is nitrogen which you may see on specialty transport doing subambient therapy for congenital heart defects.

And then you also have the many different diving mixtures which EMS providers along the coasts of Florida should be familiar with.

Thus, watch your terminology since I do know there are a lot of medical and dive gases used in your area. It is very easy to confuse the terms and confusing the gases might not be beneficial.


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## FLEMTP (Jan 3, 2010)

VentMedic said:


> NOX? That just refers to a broad category of nitrogen oxides and is generally used in reference to Nitrogren Dioxide (*NO2*) by the EPA. *NO2* is not a gas that is desirable. It is also one of the monitoring alarms when delivering *NO* (nitric oxide).
> 
> 
> *N2O* is nitrous oxide.
> ...



yeah.... um.. ok.. cuz any of that matters in an online forum...Im well aware of the different gasses.. i was attempting to make a quick reply from my blackberry.. but hey.. if you get off on that kinda stuff..then hey.. have at it...


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## VentMedic (Jan 3, 2010)

FLEMTP said:


> yeah.... um.. ok.. cuz any of that matters in an online forum...Im well aware of the different gasses.. i was attempting to make a quick reply from my blackberry.. but hey.. if you get off on that kinda stuff..then hey.. have at it...


 
Since some of the specialty trucks in Florida (and other states) can carry 4 or 5 different medical gases it would be wise to know the difference. There are also several members of this forum that are just starting out and may not be aware of some of these gases when they are asked to help transport a specialty team. If you also look around at some of the home care patients you come into contact with, you may find that tank a might look like "O2" but isn't Oxygen.

When you are working with medical gases, DO NOT EVER ASSUME you know what is in that tank especially if you do not know the terminology.

I guess we now know why some of the medical gases aren't widely used in EMS in the U.S.


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## FLEMTP (Jan 3, 2010)

VentMedic said:


> Since some of the specialty trucks in Florida (and other states) can carry 4 or 5 different medical gases it would be wise to know the difference.  There are also several members of this forum that are just starting out an may not be aware of some of these gases when they are asked to help transport a specialty team.  If you also look around at some of the home care patients you come into contact with, you may find that tank a might look like "O2" isn't Oxygen.
> 
> When you are working with medical gases, DO NOT EVER ASSUME you know what is in that tank especially if you do not know the terminology.
> 
> I guess we now know why some of the medical gases aren't widely used in EMS in the U.S.



Wow.. you know.. i didnt realize how truly anal retentive you are until i started reading some of your other posts... Your high and mighty attitude really isnt very becoming.... 

Besides.. i find it more entertaining to just guess at whats in various tanks.. makes live interesting and ensures i'll have a job... 

(now why do i have a funny feeling ventmedic will take that as a completely true and honest statement.. and that he has NO idea what sarcasm is)


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## VentMedic (Jan 3, 2010)

FLEMTP said:


> Wow.. you know.. i didnt realize how truly anal retentive you are until i started reading some of your other posts... Your high and mighty attitude really isnt very becoming....
> 
> Besides.. i find it more entertaining to just guess at whats in various tanks.. makes live interesting and ensures i'll have a job...
> 
> (now why do i have a funny feeling ventmedic will take that as a completely true and honest statement.. and that he has NO idea what sarcasm is)


 
Anal retentive? No. I would prefer some do not make a bad medical error because of misinformation you have given. 

What medical director would want to give additional responsibility to someone who thinks NOX, NO, N2O and NO2 are all the same gas?

Medicine is not a joke.  Mix up any of those gases and you can seriously harm a patient.


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## FLEMTP (Jan 3, 2010)

VentMedic said:


> Anal retentive?  No.  I would prefer some do not make a bad medical error because of misinformation you have given.
> 
> What medical director would want to give additional responsibility to someone who thinks NOX, NO, N2O and NO2 are all the same gases?



never said i thought they were all the same gases... i used the same abbreviation another poster used... and as I said.. i was typing a quick reply on my blackberry... sorry if that rubs you the wrong way... but deal with it.. im not here to make you happy. 

It seems to me that you take things WAY too seriously.. this is the internet after all... if i want to tell people the cure for cardiac arrest is prunes... then i'll do just that... get over it...


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## VentMedic (Jan 3, 2010)

FLEMTP said:


> never said i thought they were all the same gases... i used the same abbreviation another poster used... and as I said.. i was typing a quick reply on my blackberry... sorry if that rubs you the wrong way... but deal with it.. im not here to make you happy.
> 
> It seems to me that you take things WAY too seriously.. this is the internet after all... if i want to tell people the cure for cardiac arrest is prunes... then i'll do just that... get over it...


 
Are you honestly so reckless in your charting as well?  Do you not understand why you can not type wrong information and just expect everyone to know what you meant?    

If you tell me you are from Lee County EMS I will be very disappointed.


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## FLEMTP (Jan 3, 2010)

VentMedic said:


> Are you honestly so reckless in your charting as well?  Do you not understand why you can not type wrong information and just expect everyone to know what you meant?
> 
> If you tell me you are from Lee County EMS I will be very disappointed.



Dude.. you need to CHILL out...seriously...get yourself a script for some xanax....

Ive been in EMS for 12 years now.. im sure if there was an issue with something i do on the job.. I think id know by now..


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## VentMedic (Jan 3, 2010)

FLEMTP said:


> Dude.. you need to CHILL out...seriously...get yourself a script for some xanax....
> 
> Ive been in EMS for 12 years now.. im sure if there was an issue with something i do on the job.. I think id know by now..


 
If you have been in EMS that long you should know the importance of proper documentation and checking meds as well as medical gases. Do you know what could happen to a child that is given NO instead of N2? 

Could it be that you might work for a department that has few quality standards? Again, I hope it is not Lee County EMS or I will be very disappointed and maybe some issues will have to be addressed. I also hope you are not representing the attitude of your entire agency when it comes to medical accuracy.

It are those who display a reckless disregard for knowing what they are saying and writing that have given EMS in Florida a bad reputation. It also makes one look ignorant when discussing patient care and medications with other medical professionals.


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## FLEMTP (Jan 3, 2010)

VentMedic said:


> If you have been in EMS that long you should know the importance of proper documentation and checking meds as well as medical gases. Do you know what could happen to a child that is given NO instead of N2?
> 
> Could it be that you might work for a department that has few quality standards? Again, I hope it is not Lee County EMS or I will be very disappointed and maybe some issues will have to be addressed. I also hope you are not representing the attitude of your entire agency when it comes to medical accuracy.
> 
> It are those who display a reckless disregard for knowing what they are saying and writing that have given EMS in Florida a bad reputation. It also makes one look ignorant when discussing patient care and medications with other medical professionals.



LMAO...maybe some issues need to be addressed? by whom? You? lol... id like to see that IF you can get the stick out of your rectum...

Like I said you need to chill out.. you REALLY need to chill out.. I feel bad for you ... I never knew someone could take something like the internet SO SERIOUS lol... its sad really... 

its also sad that ive been on this forum all of 2 days.. and ive already got someone on my ignore list... i hope not everyone here is so uptight and anal retentive.. otherwise my membership here would be rather short....


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## VentMedic (Jan 3, 2010)

FLEMTP said:


> LMAO...maybe some issues need to be addressed? by whom? You? lol... id like to see that IF you can get the stick out of your rectum...
> 
> Like I said you need to chill out.. you REALLY need to chill out.. I feel bad for you ... I never knew someone could take something like the internet SO SERIOUS lol... its sad really...
> 
> its also sad that ive been on this forum all of 2 days.. and ive already got someone on my ignore list... i hope not everyone here is so uptight and anal retentive.. otherwise my membership here would be rather short....


 
So you just came on this forum to literally BS about nothing and toss around information that is misleading, false and potentially dangerous? Using correct medical abbreviations and the correct medications or medical gases is not an option but should be expected.

Believe it or not there are those on this forum who do not take being a Paramedic as a joke. There are some professional Paramedics even in the state of Florida although it may seem they might be harder to find in some parts of the state.


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## 18G (Jan 3, 2010)

FLEMTP... sounds like a losing battle... I knew what you meant and Im sure others did too. Nobody should be taking what they read on this or any other forum and putting it into practice without first verifying its accuracy. 

Some people I guess just like to make waves and exert their intellect in an ignorant manor.


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## Sasha (Jan 3, 2010)

FLEMTP said:


> Seriously though, we carry fentanyl and morphine for pain management. My personal drug of choice for pain, especially multisystem trauma type pain is Fentanyl. We can give as much as we see fit provided it doesnt cause the patient to become obtunded. Our protocol states 2mcg/kg but then again we can do pretty much anything we need to outside of the protocol provided we can justify it.



I'm so jealous of your protocols.


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## FLEMTP (Jan 3, 2010)

18G said:


> Some people I guess just like to make waves and exert their intellect in an ignorant manor.



+1 on that! B)


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## FLEMTP (Jan 3, 2010)

Sasha said:


> I'm so jealous of your protocols.



Sasha ... where in florida do you work? Maybe you could come do a ride here sometime.. check it out.. im sure we'll be hiring again and could use some good medics!


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## Sasha (Jan 3, 2010)

FLEMTP said:


> Sasha ... where in florida do you work? Maybe you could come do a ride here sometime.. check it out.. im sure we'll be hiring again and could use some good medics!



Central FL. Don't toy with my emotions. I would kill to ride with Lee County. I would kill many many people to work there.


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## VentMedic (Jan 4, 2010)

18G said:


> FLEMTP... sounds like a losing battle... I knew what you meant and Im sure others did too. Nobody should be taking what they read on this or any other forum and putting it into practice without first verifying its accuracy.
> 
> Some people I guess just like to make waves and exert their intellect in an ignorant manor.


 
Did you really?

Then why didn't you correct him? If he was to administer the wrong gas on a child would you just allow him since you knew he really meant to use the other one?

Do you think stating "I meant something else and everyone should know I meant that" is a good excuse in court? 

It is just as easy to type the corrrect letters on a Blackberry as it is the incorrect ones.

What about the medical error concerning epinephrine and the changes in Massachusetts not too long ago? Any one of those medics could have prevented that. 

Why do some always support passing along bad information?

That is why we have "lido number the heart" and "CPAP pushes lung water" as accepted explanations.

Is it really that difficult for Paramedics in the U.S. to learn proper definitions and terminology as well as writing them correctly? 

Why do you call it ignorant for someone not to want those in EMS to screw up their careers and patients or make themselves look ignorant by repeating crap they have read on an EMS forum?

I would not feel very comfortable allowing a Paramedic, who doesn't understand why correct information is important, to give Fentanyl or any other medication.


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## Sasha (Jan 4, 2010)

> That is why we have "lido number the heart"



I always like lido to give the heart the number 4.


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## VentMedic (Jan 4, 2010)

Sasha said:


> I always like lido to give the heart the number 4.


 
Oops.

So much for spell check. 

"lido numbs the heart"

At least I can admit I made a typo and not just state everyone should have known what I meant.


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## medichopeful (Jan 4, 2010)

FLEMTP said:


> I feel bad for you ... I never knew someone could take something like the internet SO SERIOUS lol... its sad really...



It's NOT the internet SHE is taking so seriously.  It's the subject.  Did that ever cross your mind?


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## Sasha (Jan 4, 2010)

VentMedic said:


> Oops.
> 
> So much for spell check.
> 
> ...



Yes, but I DID know what you meant with the typo, just teasing you  It was a funny typo.


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## 18G (Jan 4, 2010)

The point is you unnecessarily went into a rant about something that wasn't even worth ranting about. If you thought he made a mistake why not just ask for clarification instead of becoming condescending and insinuating that the poster is incompetent.

And while I dont agree with the statement that "lido numbs the heart", I do understand where that over simplification comes from. Lidocaine does not numb the heart literally like numbness in an extremity, etc, but lidocaine does increase the threshold for ventricular ectopy and arrhythmia and in a sense makes the heart "numb", since it makes the heart not respond to ectopic foci. If your hand is numb, it cannot feel and will not respond. The same concept when people say "numbs the heart". They are just saying lido makes the heart less responsive to ectopic foci and arrhythmia. Not the best way to describe lidocaines mechanism, but is somewhat accurate. 

CPAP does not directly "push lung water" but does contribute to making the fluid retreat out of the airways and back across the pulmonary membrane where it belongs. So again, not the best descriptor of its action, but not totally inaccurate either.


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## FLEMTP (Jan 4, 2010)

Sasha said:


> Central FL. Don't toy with my emotions. I would kill to ride with Lee County. I would kill many many people to work there.



Sasha... send me a PM.. im curious to know who you work for now.. I worked in orlando previously...

And if you want to come ride along with us for a shift.. Im sure we could set it up... I think the main requirement is that you've been through HIPPA...and being a EMS provider... we ALL know that we've been bored to death with that one..


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## VentMedic (Jan 4, 2010)

18G said:


> The point is you unnecessarily went into a rant about something that wasn't even worth ranting about. If you thought he made a mistake why not just ask for clarification instead of becoming condescending and insinuating that the poster is incompetent.
> 
> And while I dont agree with the statement that "lido numbs the heart", I do understand where that over simplification comes from. Lidocaine does not numb the heart literally like numbness in an extremity, etc, but lidocaine does increase the threshold for ventricular ectopy and arrhythmia and in a sense makes the heart "numb", since it makes the heart not respond to ectopic foci. If your hand is numb, it cannot feel and will not respond. The same concept when people say "numbs the heart". They are just saying lido makes the heart less responsive to ectopic foci and arrhythmia. Not the best way to describe lidocaines mechanism, but is somewhat accurate.
> 
> CPAP does not directly "push lung water" but does contribute to making the fluid retreat out of the airways and back across the pulmonary membrane where it belongs. So again, not the best descriptor of its action, but not totally inaccurate either.


 
Yes, a perfect example of the point I was trying to make. There is very little understanding of pharmacology and no understanding of hemodynamics pertaining to preload and afterload.


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## VentMedic (Jan 4, 2010)

FLEMTP said:


> Sasha... send me a PM.. im curious to know who you work for now.. I worked in orlando previously...
> 
> And if you want to come ride along with us for a shift.. Im sure we could set it up... I think the main requirement is that you've been through *HIPPA*...and being a EMS provider... we ALL know that we've been bored to death with that one..


 
HIPAA - *H*ealth *I*nsurance *P*ortability and *A*ccountability *A*ct


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