# What to do after max dose of Amiodarone?



## mgaska84 (Aug 28, 2012)

Ive always had this question with no clear answer.  When working a code and you've reached the max dose, and you're still working the code, do you switch to Lidocaine or do you do an amio infusion?  Thoughts?


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## sirengirl (Aug 28, 2012)

mgaska84 said:


> Ive always had this question with no clear answer.  When working a code and you've reached the max dose, and you're still working the code, do you switch to Lidocaine or do you do an amio infusion?  Thoughts?



So I'm to understand that you're working a code and have already bolused your 300, and 150 of ami? Going by current ACLS per AHA you would just continue on with epi only (5 cycles cpr, rhythm check, defib if applicable, 5 cycles CPR, rhythm check, Epi if applicable, defib if applicable, repeat etc).

I have been taught that if ROSC after your 2 boluses of Ami, you will want to do 1 more round of CPR (per new AHA ACLS standards), then hypothermia protocol (that is a local standard) and then consider hanging a maintenence infusion of the AMI (as here I was taught that the 2 boluses would "count" as the loading dose).


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## mgaska84 (Aug 28, 2012)

Yes thats what I was taught as well, if ROSC than do one more round of CPR and hang an infusion of AMI.  Thanks for the clarification!


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## GaMedic (Aug 28, 2012)

My protocol wont allow me to stop or call it. So I would just keep doing Epi q 3-5, CPR and defib (if shockable rhythm) while working through my H's & T's until I reached the ER.


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## TomB (Aug 28, 2012)

If the patient is in referactory VF hook up a second defibrillator and give a double shock. By the time you've given two doses of amiodarone you've probably shocked at least 6 times (probably more). The patient doesn't need more drugs. The patient needs more electricity (or better CPR or a shorter peri-shock pause).


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## abckidsmom (Aug 28, 2012)

sirengirl said:


> So I'm to understand that you're working a code and have already bolused your 300, and 150 of ami? Going by current ACLS per AHA you would just continue on with epi only (5 cycles cpr, rhythm check, defib if applicable, 5 cycles CPR, rhythm check, Epi if applicable, defib if applicable, repeat etc).
> 
> I have been taught that if ROSC after your 2 boluses of Ami, you will want to do 1 more round of CPR (per new AHA ACLS standards), then hypothermia protocol (that is a local standard) and then consider hanging a maintenence infusion of the AMI (as here I was taught that the 2 boluses would "count" as the loading dose).



Have I missed something?  If you get ROSC, keep doing CPR for one more round?


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## GaMedic (Aug 28, 2012)

TomB said:


> If the patient is in referactory VF hook up a second defibrillator and give a double shock. By the time you've given two doses of amiodarone you've probably shocked at least 6 times (probably more). The patient doesn't need more drugs. The patient needs more electricity (or better CPR or a shorter peri-shock pause).



Stacked shocks??????


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## Medic Tim (Aug 28, 2012)

GaMedic said:


> Stacked shocks??????



double sequential defibrillation

http://www.emsworld.com/article/10318805/hold-the-coroner


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## mgaska84 (Aug 28, 2012)

Not a whole 2 minutes of CPR, but finish the cycle that you're currently on


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## Hunter (Aug 28, 2012)

abckidsmom said:


> Have I missed something?  If you get ROSC, keep doing CPR for one more round?



Prime the pump. Helps prevent the heart from going back into previous rhythm


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## WTEngel (Aug 28, 2012)

Wrong all the way around.

After you have exhausted amiodarone, you may switch to another anti-dysrhythmic. 

I typically switch to mag sulfate, because generally if amiodarone does not work, lidocaine has not been shown to be any more or less effective, so my determination is that the patient could possibly be in a subtle polymorphic v-tach that I failed to identify on the first analysis. Administer the 1-2 grams of mag sulfate over 3-5 minutes and see if they convert.

If the mag fails, or I am certain it is not polymorphic (Torsades) then procainimide is an option also. Sotalol is another option, based on patient presentation.

So a code could run like this:

Shock--->Epi--->CPR for 2 minutes and analyze
Shock--->300 mg Amiodarone--->CPR for 2 minutes and analyze
Shock--->Epi--->CPR for 2 minutes and analyze
Shock--->150 mg Amiodarone--->CPR for 2 minutes and analyze
Shock--->Epi--->CPR for 2 minutes and analyze
Shock--->Mag or Procainimide or Sotalol--->CPR for 2 minutes and analyze
Etc...Etc...Etc...

Continue alternating vasopressor and anti-dyrhythmic therapy until patient converts, changes rhythms, resuscitation is terminated, or patient politely asks you to stop chest compressions.

Any ACLS instructor who is teaching that after you have exhausted amiodarone, you give epi exclusively is 100% incorrect. Just because AHA does not list alternative medications on the algorithm card does not mean they are no longer an option. 

Check out section 8 of the Circulation Journal article from November of 2010 detailing the changes to ACLS.


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## WTEngel (Aug 28, 2012)

sirengirl said:


> I have been taught that if ROSC after your 2 boluses of Ami, you will want to do 1 more round of CPR (per new AHA ACLS standards), then hypothermia protocol (that is a local standard) and then consider hanging a maintenence infusion of the AMI (as here I was taught that the 2 boluses would "count" as the loading dose).



I think you misunderstood what they were saying, or they misunderstood what they were teaching.

If after your second dose of amiodarone (which should be given early after the shock to allow for 2 minutes of circulation with good CPR) at the next rhythm check you see a rhythm that could produce a pulse, you check for a pulse and go immediately into post resuscitation care if a pulse is in fact present. If a pulse is not present, you transition to the PEA/Asystole algorithm.

Now, where it gets hairy, and where most instructors miss the mark, is that we are no longer to check for a pulse immediately after shocking. We immediately resume CPR after defibrillation and treat based on the rhythm we analyzed prior to the shock.

The reason this is applicable is, for example, if immediately after the shock, in the brief moment between when the shock was delivered and CPR was resumed, you happened to notice an organized rhythm on the monitor, you are to ignore that, and continue treating based on the rhythm you analyzed prior to the shock. This is because the overwhelming evidence demonstrates that very nearly 100% of patients who convert from VF/VT convert into PEA, meaning that a pulse check and delaying resumption of CPR would most likely result in them being refractory.

So, to recap, if at the end of two minutes of CPR you analyze and see an organized rhythm, check for a pulse, and if a pulse is detected, go into ROSC algorithm (not resumption of CPR.)

If you happen to momentarily catch the patient converting between the shock and the chest compressions resuming, always treat based on rhythm analyzed prior to the shock and anticipate ROSC on the next analysis.


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## abckidsmom (Aug 28, 2012)

WTEngel said:


> I think you misunderstood what they were saying, or they misunderstood what they were teaching.
> 
> If after your second dose of amiodarone (which should be given early after the shock to allow for 2 minutes of circulation with good CPR) at the next rhythm check you see a rhythm that could produce a pulse, you check for a pulse and go immediately into post resuscitation care if a pulse is in fact present. If a pulse is not present, you transition to the PEA/Asystole algorithm.
> 
> ...



Thanks for that.  I completely misunderstood what they were getting at.

Most recently my ROSCs have been detected by EtCO2 changes.  It's fairly unmistakable.


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## jwk (Aug 28, 2012)

Medic Tim said:


> double sequential defibrillation
> 
> http://www.emsworld.com/article/10318805/hold-the-coroner



I guess it can't hurt, since they're "dead" anyway.  But this is anecdotal evidence at best, hardly something to hang your hat on.  

Old farts like me remember some of the old giant ER LifePak debrillators that could go to 500 joules.  There's a reason everything has been dialed back down.  Not everything functions along the lines of "if a little is good a lot must be better".


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## WTEngel (Aug 28, 2012)

abckidsmom said:


> Thanks for that.  I completely misunderstood what they were getting at.
> 
> Most recently my ROSCs have been detected by EtCO2 changes.  It's fairly unmistakable.



Yes...excellent point that I forgot to mention. EtCO2 changes are reliable enough to be considered a "sign of life."

Generally we look at a sudden increase of 20-25 mmHg or more in order to be considered remarkable.

Be careful to consider what medications you have just pushed also. Bicarb administration (not routinely recommended anymore) can lead to variances in EtCO2, perfusion status not withstanding.


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## TomB (Aug 28, 2012)

jwk said:


> I guess it can't hurt, since they're "dead" anyway.  But this is anecdotal evidence at best, hardly something to hang your hat on.



It's not like there's a mountain of high quality to support epinephrine, amiodarone, lidocaine, magnesium sulfate, sotalol, procainamide, or any other intervention save high quality chest compressions and defibrillation. If the patient is in refractory VF there's a good chance that a critical mass of the myocardium is not being depolarized, whether due to poor pad placement, skin prep, body habitus, heart anatomy, whatever (as opposed to recurrent VF which is a different problem). So it seems to me that in this case "more is better" meaning more current and more coverage from a second set of pads.


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## WTEngel (Aug 28, 2012)

TomB said:


> It's not like there's a mountain of high quality to support epinephrine, amiodarone, lidocaine, magnesium sulfate, sotalol, procainamide, or any other intervention save high quality chest compressions and defibrillation.



This is true...however the area of resuscitation outcomes research is growing. I am looking forward to some eye opening ROC data in 2015...


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## GaMedic (Aug 28, 2012)

Medic Tim said:


> double sequential defibrillation
> 
> http://www.emsworld.com/article/10318805/hold-the-coroner



Hrm interesting. I will def read about it. Thanks for the link!


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## TomB (Aug 28, 2012)

WTEngel said:


> This is true...however the area of resuscitation outcomes research is growing. I am looking forward to some eye opening ROC data in 2015...



I think there's already lots of eye opening data. Drugs don't work. Early CPR, defibrillation, and expert post-resuscitation care are key, including early identification of STEMI, PCI, therapeutic hypothermia, and CABG or ICD placement if necessary.


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## GaMedic (Aug 28, 2012)

WTEngel said:


> Wrong all the way around.
> 
> After you have exhausted amiodarone, you may switch to another anti-dysrhythmic.
> 
> ...



Yes you are correct but I think my response was alil vague, I consider Mag,Calcium chloride etc to fall into when trying to rule out causes. My instructor swears by Mag Sulfate.. He claims to have got more people back after giving mag than anything.. Torsades is a fun one I remember the 1st time I ever saw it was when I was doing mega code practice for my ACLS test and my instructor decided to throw me a curve ball... Fun times..


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## Hunter (Aug 28, 2012)

jwk said:


> I guess it can't hurt, since they're "dead" anyway.  But this is anecdotal evidence at best, hardly something to hang your hat on.
> 
> Old farts like me remember some of the old giant ER LifePak debrillators that could go to 500 joules.  There's a reason everything has been dialed back down.  Not everything functions along the lines of "if a little is good a lot must be better".



I've has a medical director instruct me to get another lifepack and shock at 720, however the patient converted into asystole befor the second lifepack arrived.


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## sirengirl (Aug 28, 2012)

WTEngel said:


> If after your second dose of amiodarone (which should be given early after the shock to allow for 2 minutes of circulation with good CPR) at the next rhythm check you see a rhythm that could produce a pulse, you check for a pulse and go immediately into post resuscitation care if a pulse is in fact present. If a pulse is not present, you transition to the PEA/Asystole algorithm.



Assuming that they are now in an organized rhythm.

My post was based entirely on the presumption that we are staying within a pulseless VT/V-Fib rhythm the entire time. Obviously is this is a megacode and we are getting organized rhythms without pulses then we weill go PEA/Asystole route.


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## WTEngel (Aug 28, 2012)

sirengirl said:


> I have been taught that* if ROSC after your 2 boluses of Ami, you will want to do 1 more round of CPR (per new AHA ACLS standards)* then hypothermia protocol (that is a local standard) and then consider hanging a maintenence infusion of the AMI (as here I was taught that the 2 boluses would "count" as the loading dose).



I am not sure I understand what you are trying to say. The way I read your post, it sounds like you are saying there needs to be another 2 minutes of CPR after ROSC has been achieved. Is this what you are saying, or is something getting lost in communication?

If I misread, then I apologize.


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## WTEngel (Aug 28, 2012)

TomB said:


> I think there's already lots of eye opening data. Drugs don't work. Early CPR, defibrillation, and expert post-resuscitation care are key, including early identification of STEMI, PCI, therapeutic hypothermia, and CABG or ICD placement if necessary.



I completely agree with everything you are saying. 

Implementing changes based on these results could have a direct impact on how we view the effect (or lack thereof) of various treatments which have been considered the mainstay of ACLS care of the past 25 years. 

I fully buy into the idea that there is little evidence to support or not support various medication therapies...however with the knowledge that our fundamentals (good strong BLS, v/q matching, etc.) have been so poor for so long, it is hard to determine how much we really want to trust data obtained previous to this new big push for the things you mentioned in your post. 

I will be very interested to see what changes come around the bend based solely on the fact that we can now analyze the effect of interventions and there influence on outcome with the knowledge that the basic fundamentals are being performed effectively. 

Until we reach that point however, any study that does not ensure good strong BLS is in place during resuscitative care is borderline futile based solely on the fact that it is nearly impossible to guarantee with any consistency whether it is the BLS or the new interventions which are harming or helping our patients.


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## Handsome Robb (Aug 28, 2012)

abckidsmom said:


> Most recently my ROSCs have been detected by EtCO2 changes.  It's fairly unmistakable.





WTEngel said:


> Yes...excellent point that I forgot to mention. EtCO2 changes are reliable enough to be considered a "sign of life."
> 
> Generally we look at a sudden increase of 20-25 mmHg or more in order to be considered remarkable.
> 
> Be careful to consider what medications you have just pushed also. Bicarb administration (not routinely recommended anymore) can lead to variances in EtCO2, perfusion status not withstanding.



Alright so I'm not crazy. We check for pulses if we get a large jump in EtCO2. Just had a total "oh :censored::censored::censored::censored: I've been doing it wrong this whole time!? How'd I misunderstand that?" moment. 

WT, other than bicarb what would cause a change in EtCO2 besides ROSC? Changing blood chemistry with bicarb seems like a no brainer but now that I'm thinking about it I can't think of anything off the top of my head that would do it as well. 

We carry mag but only for TDP, I suppose we could call for it if the pt was in refractory VF and we had maxed out on ami boluses. Only other antidysrhythmic we carry is lido.


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## WTEngel (Aug 28, 2012)

Bicarb is the big one that sticks out in my head. That is the only one I routinely mention when I teach anyway...

Mag can be used for VF or VT, but it seems like the only condition where the evidence indicates it is truly superior to any other drug is in polymorphic VT (TDP). As far as having to call for orders to give it for VF but not for TDP, in the heat of battle, those squiggly lines can get awfully difficult to interpret sometimes...

The thing that I don't like about mag is that most people tend to push it too fast. It is supposed to be given over 3-5 minutes during arrest. How often do you think that actually happens, especially in the field? My reasoning on this is that we should push slowly until conversion, then stop and hang a drip. The lower the amount necessary for conversion the better. 

Pushing too fast leads to the risk of conversion with dramatic bottoming out of blood pressure, meaning they will effectively be in PEA until you either start pressors/inotropes or the mag wears off to the point that there SVR increases enough to begin producing a pulse again.

This is my thoughts on the matter anyway. To be honest I really rank lido and amio about the same on effectiveness scales, although I use amio nearly 100% of the time, because it is what we have, and it seems to work well enough...nothing better or worse available. 

I think there is a lot to be studied regarding the effectiveness of epi as a vasopressor as pH decreases in the patient who is in arrest. In fact, some studies have shown that the effects of vasopressin appear to be unaltered in the acidic patient, where the effects of epi tend to decrease dramatically. This could lead one to think that instead of considering vasopressin early in the code, perhaps we should be considering it later?


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## sirengirl (Aug 28, 2012)

WTEngel said:


> I am not sure I understand what you are trying to say. The way I read your post, it sounds like you are saying there needs to be another 2 minutes of CPR after ROSC has been achieved. Is this what you are saying, or is something getting lost in communication?
> 
> If I misread, then I apologize.



That is the impression that I was given by my instructors, however the extent I the conversation on it was right before our ACLS certification exam as a, "oh hey we also do this, to prime the pump with ATP, so remember that." I always thought a full 5 to be excessive but it seemed to be what they expected in our scenarios. I'd like to do some research on it and ask around with other medics in the area.

Also, agreed on the point with vasopressin later on in the sequence. I tink the problem with that is knowing how far down the sequence to use it- it does, after all, take the place of 2 epis.... (an as an aside, does anyone know why the heck it comes packaged 20units in 1mL?!)


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## WTEngel (Aug 28, 2012)

Your instructors were wrong, or you misunderstood them regarding the ROSC and continuation of CPR.

Vasopressin only takes the place of one epi, either the first or second dose, but not both.

Might want to read up in the book or the journal article I mentioned earlier. It is packed full of useful info.


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## sirengirl (Aug 28, 2012)

WTEngel said:


> Your instructors were wrong, or you misunderstood them regarding the ROSC and continuation of CPR.
> 
> Vasopressin only takes the place of one epi, either the first or second dose, but not both.
> 
> Might want to read up in the book or the journal article I mentioned earlier. It is packed full of useful info.



Vividly remember the "1st and 2nd" bit. Clarified it as such with my preceptor during ride time. However I agree with you and in fact all the literature says "first or second" which is why I have discussed it with numerous medics. Either it is a local thing here where I am at, or we are all illiterate. Which may well be the case.


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## WTEngel (Aug 28, 2012)

Illiterate FTW!

I am giving you a hard time of course, but here it is, from the horse's mouth.

From the AHA Circulation Journal article published in November 2010:

"1 dose of vasopressin 40 units IV/IO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest"


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## Handsome Robb (Aug 28, 2012)

Our protocol is Epi q3-5 OR Vasopressin 40 IU IV or 80 IU ETT once, not as a replacement does. 

I've given mag once for TDP and I know I pushed it too fast, somewhere in the realm of 60-90 seconds. I'm almost wondering if that's what happened seeing as she went from TDP to PEA at the next rhythm check then to asystole. In the big scheme of things we started in asystole -> PEA -> TDP with a long downtime ~20 minutes until ALS. Had an engine crew with an AED at around 10 minutes. 

As far as ami vs. lido I've never given lido. The only time we give it is if we can't get access then we give it down the tube or we give it for R-on-T PVCs so I can't comment on how well it works. 

Thank you!


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## Farmer2DO (Aug 29, 2012)

mgaska84 said:


> Ive always had this question with no clear answer.  When working a code and you've reached the max dose, and you're still working the code, do you switch to Lidocaine or do you do an amio infusion?  Thoughts?



Bretylium Tosylate!

Just kidding.  Mostly.

Anyone ever use it before it left our boxes?  (Yes, I'm that old.)



abckidsmom said:


> Most recently my ROSCs have been detected by EtCO2 changes.  It's fairly unmistakable.



Same here.  Worked a traumatic cardiac arrest last year where the closest facility (by far) was not a trauma center.  Intubated, good lines, and as we were pulling into a parking spot, ETCO2 went from about 30 to over 100.  Let me tell you, they were less than happy when we walked in with a recently resuscitated trauma arrest.



WTEngel said:


> Mag can be used for VF or VT, but it seems like the only condition where the evidence indicates it is truly superior to any other drug is in polymorphic VT (TDP). As far as having to call for orders to give it for VF but not for TDP, in the heat of battle, those squiggly lines can get awfully difficult to interpret sometimes...



Our protocols state that we can use mag in cardiac arrest for "any suspected hypomagnesemic state".  Our medical director says that you can suspect that on any refractory VF/VT arrest.  Our EMS physicians give a fair amount of leeway if you're trying to reason your way through it with a little common sense.



> This is my thoughts on the matter anyway. To be honest I really rank lido and amio about the same on effectiveness scales, although I use amio nearly 100% of the time, because it is what we have, and it seems to work well enough...nothing better or worse available.



We still carry both, but amio is our first line always.  Except when the guy with the AICD said "I'm in V tach, and it's too slow to trigger my AICD.  It's happened before.  Lidocaine always converts me."  While I was pulling out my lidocaine, I was calling.



> I think there is a lot to be studied regarding the effectiveness of epi as a vasopressor as pH decreases in the patient who is in arrest. In fact, some studies have shown that the effects of vasopressin appear to be unaltered in the acidic patient, where the effects of epi tend to decrease dramatically. This could lead one to think that instead of considering vasopressin early in the code, perhaps we should be considering it later?



Excellent point.  They took our vasopressin out; one of the opinions our medical director has (which I don't necessarily agree with) is that a simpler drug box with less drugs is always better.  I think he's the best thing to happen to our system since, well, ever, but I just don't agree with that.


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## Doczilla (Aug 29, 2012)

NVRob said:


> Our protocol is Epi q3-5 OR Vasopressin 40 IU IV or 80 IU ETT once, not as a replacement does.
> 
> I've given mag once for TDP and I know I pushed it too fast, somewhere in the realm of 60-90 seconds. I'm almost wondering if that's what happened seeing as she went from TDP to PEA at the next rhythm check then to asystole. In the big scheme of things we started in asystole -> PEA -> TDP with a long downtime ~20 minutes until ALS. Had an engine crew with an AED at around 10 minutes.
> 
> ...



I've given it for multifocal PVC's in a guy with a REALLY low BP due to internal bleeding to prevent a worse arrythmia while we were setting up a walking transfusion. Worked like a charm.


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## WTEngel (Aug 29, 2012)

I am 50/50 on your medical director's opinion that less drugs are better in some cases.

With the current evidence being what it is, there doesn't seem to be any compelling reason to keep it. Will that change in the coming years? Perhaps. 

Most of the time when teaching ACLS, we will tell the students about the vasopressin consideration, and then tell them to shelf that information, because they will not be required to reproduce it, and most likely will not be using it during a code.

Regarding the walking blood bank, the results from studies being done with military are pretty impressive. Wish we could implement something like that on the civilian side...


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## Veneficus (Aug 29, 2012)

WTEngel said:


> Regarding the walking blood bank, the results from studies being done with military are pretty impressive. Wish we could implement something like that on the civilian side...



I think it would be great.

But logisitically impossible.

I am still hoping the British attempt to use DNA technology to reproduce unlimited quantities of typed blood in a lab works out, but I haven't heard anything about it since the project was funded.


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## Doczilla (Aug 29, 2012)

Well, remember that we had 

A: a roster of blood types, and kits to confirm. 
B: the donors were soldiers, who go through pretty comprehensive blood work before deploying 
C: a seven hour evac time. 

It's a pretty extreme thing to do outside of a level III or IV facility, but we had no choice. 

Also, I think systems should still carry lido, for other reasons as well. 

One of them is that renal failure and amiodarone don't mix. It has the half life of gamma radiation.


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## WTEngel (Aug 29, 2012)

I agree...logistically impossible...

We still have mismatches and incorrect type being administered in the hospital (rarely) with all the safeguards in place...I could reasonably assume the risk would rise with a walking blood bank. 

With the walking blood bank in the military, is the product ever stored, or is it direct from donor to lab to patient? What is the turnaround time from donation to administration?

I am familiar with the concept, not with the process though...


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## Doczilla (Aug 29, 2012)

There's kits that Chinook makes, complete with typing kits, donor bag, Y tubing, etc. 

There's preservatives in the bag, but its meant to be taken from one table to the other. (I.e donor to patient.) 

Did a little over a half dozen last year. The last one was from a 30 tablet salicylate O.D, and the transfusions had to be topped off with a vasopressin drip.


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## WTEngel (Aug 29, 2012)

Fascinating.

The advances in trauma care over the next 10 years will be remarkable. Unfortunately they had to be learned in such a hostile manner.


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## Veneficus (Aug 29, 2012)

WTEngel said:


> Fascinating.
> 
> The advances in trauma care over the next 10 years will be remarkable. Unfortunately they had to be learned in such a hostile manner.



If you are interested in trauma, this is definately worth every penny.

http://www.amazon.com/War-Surgery-A...ll&keywords=war+srgery+in+iraq+andafghanistan


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## Doczilla (Aug 29, 2012)

Yes.... I didn't think it was possible to attatch an external fixator on what looks like 5lbs of ground beef.


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## Handsome Robb (Aug 29, 2012)

Veneficus said:


> If you are interested in trauma, this is definately worth every penny.
> 
> http://www.amazon.com/War-Surgery-A...ll&keywords=war+srgery+in+iraq+andafghanistan



Bookmarked for when I have some spare cash. Thanks for the link.


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## p3medic (Aug 29, 2012)

Doczilla said:


> v
> 
> One of them is that renal failure and amiodarone don't mix. It has the half life of gamma radiation.




Lido and hyperkalemia don't mix either, just a thought.


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## RocketMedic (Aug 29, 2012)

Doczilla said:


> There's kits that Chinook makes, complete with typing kits, donor bag, Y tubing, etc.
> 
> There's preservatives in the bag, but its meant to be taken from one table to the other. (I.e donor to patient.)
> 
> Did a little over a half dozen last year. The last one was from a 30 tablet salicylate O.D, and the transfusions had to be topped off with a vasopressin drip.



The walking blood bank is hugely dependent on good screening and identification before deployment. It neatly sidesteps a lot of problems with blood storage, but it may not be realistic for many organizations.


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## Doczilla (Aug 29, 2012)

p3medic said:


> Lido and hyperkalemia don't mix either, just a thought.



Just curious, can you elaborate on how a sodium channel blocker does not mix with hyperkalemia? What is the physiologic basis?


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## Cup of Joe (Aug 30, 2012)

Doczilla said:


> Just curious, can you elaborate on how a sodium channel blocker does not mix with hyperkalemia? What is the physiologic basis?



Would it have something to do with decreasing the threshold for the action potential by allowing the cells to hyperpolarize easier?  Which could lead to arrhythmias?

Just my guess...here to learn


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## Veneficus (Aug 30, 2012)

Doczilla said:


> Just curious, can you elaborate on how a sodium channel blocker does not mix with hyperkalemia? What is the physiologic basis?



Na/K pump.


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## Doczilla (Aug 30, 2012)

Awww, I was hoping to "enrich the forum" with a good pimping.  oh well.


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## Veneficus (Aug 30, 2012)

Doczilla said:


> Awww, I was hoping to "enrich the forum" with a good pimping.  oh well.



Sometimes less is more 

But if you really want, there are a few NA driven renal pumps too.


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## Doczilla (Aug 30, 2012)

Yes, it (sodium potassium pump) is the single most important ATP requiring process in the body. A lot of people don't understand it though.


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## Veneficus (Aug 30, 2012)

Doczilla said:


> Yes, it (sodium potassium pump) is the single most important ATP requiring process in the body. A lot of people don't understand it though.



Because it is often taught by people who don't understand it.

Sort of like Ph.

Students in medic class go crazy over learning Ph. But when you learn it in Gen Chem, then it is not so bad.


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## WTEngel (Aug 30, 2012)

Same thing with dimensional analysis, pharmacology, ACLS, PALS....I could go on and on...all too often we see things being taught by those who have yet to master it themselves.

I do not have a HUGE issue with this, as a general understanding will get you most of the way in paramedic school...however most of these instructors are reluctant to admit when they are in over their head and end up giving false information. That is where my issue with the process begins. 

No one ever completely masters everything...good instructors know this and refer students appropriately. The majority of instructors however just go with the flow, make something up, or worst of all, simply think they understand it and preach their false information as if it is gospel.


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## Pavehawk (Aug 30, 2012)

WTEngel said:


> Same thing with dimensional analysis, pharmacology, ACLS, PALS....I could go on and on...all too often we see things being taught by those who have yet to master it themselves.
> 
> I do not have a HUGE issue with this, as a general understanding will get you most of the way in paramedic school...however most of these instructors are reluctant to admit when they are in over their head and end up giving false information. That is where my issue with the process begins.
> 
> No one ever completely masters everything...good instructors know this and refer students appropriately. The majority of instructors however just go with the flow, make something up, or worst of all, simply think they understand it and preach their false information as if it is gospel.



We are havng this problem in my paramedic class right now. We have several instructors who are less then up to date on their knowledge base. It is making things a tiny bit awkward to have to approach one on break and let them know that albuterol does NOT turn into epi in the body and that's how it works... the problem is that most of the students don't know the difference and some of the ones who do don't care they just want the card so they can get a fire department job..  sigh... somethings never change


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## clearblueskies (Sep 13, 2012)

If you get to the max dose and you have ROSC then you need to start a drip. This is why you need to carry enough to mix a drip large enough to get you to the hospital. If you do NOT get ROSC you need to switch to some other drug like Lidocaine.


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