# How liberal are you with antiemetics?



## Fox800 (Jun 4, 2010)

A while back we had a thread with several medics advocated withholding antiemetics from drunk patients to "teach them a lesson". I figured we could expand that conversation a little. How liberal or conservative are you when it comes to antiemetics? Do you give them preemptively (pt. hasn't vomited yet but feeling queasy)? Do you give them before backboarding patients that are intoxicated and queasy (think airway compromise once you've got them strapped to your cot and alone in the back). What does your service carry?

Personally, I give Zofran out very frequently. If someone is nauseated, they're getting Zofran (usually). I give it preemptively to make my patients more comfortable, prevent airway issues, and make life easier for my partner who would have to clean up the vomit in the truck. Keeps my uniform clean, too. Our protocol is ondanestron 4mg IV/IM.


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## TransportJockey (Jun 4, 2010)

When I've worked under a scope I can give them, I was pretty liberal with them. I don't wanna have to clean up the mess, plus it keeps my patients a little more comfortable


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## reaper (Jun 4, 2010)

If they need it, they get it.


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## dmiracco (Jun 4, 2010)

Fox800

I agree with all your reasoning of why to give it and how often. We can give zofran or phenergan its the medics preference. 
ME personally if you havent yacked but fell like it Ill probably give zofran but if you are currently yacking Ill probably give you phenergan.


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## Shishkabob (Jun 4, 2010)

We used to have Phenergan that we could give IV/IM.  New protocols came out and now we replaced Phenergan with Zofran IV.


Sad thing is, according to our protocols, Zofran is "Not indicated" for pedis... just adults.  Now I don't have an anti-emetic for kids.  Guess I'll have to call med control if I get a pedi who's nauseated and see if they'll clear pedi Zofran.

One part of our protocols says 2-4mg IV, and 4mg deep IM, but every other part states only IV Zofran, so I'll have to clear that up with a supervisor...




I'd MUCH rather have PO Zofran.


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## dmiracco (Jun 4, 2010)

Ya that sucks and you can give zofran to peds typically its weight based until you reach 4mg the adult dose. 
We also carry zofran ODT and we give 8mg for adult because typically the range is 4-8mg. Typically for peds its 8-30kg you can give up to 4mg.


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## Fox800 (Jun 4, 2010)

Linuss said:


> We used to have Phenergan that we could give IV/IM.  New protocols came out and now we replaced Phenergan with Zofran IV.
> 
> 
> Sad thing is, according to our protocols, Zofran is "Not indicated" for pedis... just adults.  Now I don't have an anti-emetic for kids.  Guess I'll have to call med control if I get a pedi who's nauseated and see if they'll clear pedi Zofran.
> ...




I hope that was a mistake/oversight by your medical director(s), and if not then that's a huge FAIL. :excl:


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## Sandog (Jun 4, 2010)

> A while back we had a thread with several medics advocated withholding antiemetics from drunk patients to "teach them a lesson".



This thinking seems rather unethical to me. Considering that the AMA has recognized Drug dependency and alcoholism as a disease.



> "The AMA endorses the proposition that drug dependencies, including alcoholism, are diseases and that their treatment is a legitimate part of medical practice."


http://en.wikipedia.org/wiki/Disease_theory_of_alcoholism

If one considers that the Disease theory of alcoholism to be real, then would not this person deserve the same considerations and care that would be shown to a patient with cancer?


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## NomadicMedic (Jun 4, 2010)

I'm in the same boat, pretty liberal with antiemetics. Even a hint of "quease" gets a dose. The last place I at used 12.5mg of Anzemet as the front line antiemetic. I hadn't heard if it 'til i got there. 

Worked great.

(I also had phenergan in my box, but only used it when I wanted to potentiate a little Morphine for a fracture PT.)


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## 8jimi8 (Jun 4, 2010)

Linuss said:


> We used to have Phenergan that we could give IV/IM.  New protocols came out and now we replaced Phenergan with Zofran IV.
> 
> 
> Sad thing is, according to our protocols, Zofran is "Not indicated" for pedis... just adults.  Now I don't have an anti-emetic for kids.  Guess I'll have to call med control if I get a pedi who's nauseated and see if they'll clear pedi Zofran.
> ...



Why would you give a PO anti-emetic?  That doesn't make any sense to me whatsoever, bro!


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## lightsandsirens5 (Jun 4, 2010)

Fox800 said:


> *I hope that was a mistake/oversight by your medical director(s),* and if not then that's a huge FAIL. :excl:


 
Is that not a rather large fail in and of itself? Especially on a med/dose protocol.


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## Shishkabob (Jun 4, 2010)

Lets see,

Don't need an IV
Don't need to stick a patient with a needle
It works. 
I can load it on any patient that complains of nausea at anytime.


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## Fox800 (Jun 4, 2010)

8jimi8 said:


> Why would you give a PO anti-emetic?  That doesn't make any sense to me whatsoever, bro!



I know they make a fast-dissolving Zofran, it melts in your mouth. At least that's what one service I used to work for uses.


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## Fox800 (Jun 4, 2010)

lightsandsirens5 said:


> Is that not a rather large fail in and of itself? Especially on a med/dose protocol.



Indeed it is, friend.


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## 8jimi8 (Jun 4, 2010)

Linuss said:


> Lets see,
> 
> Don't need an IV
> Don't need to stick a patient with a needle
> ...



sublingual makes sense, but I never undrstood giving enteral medications to people who were about to throw up.  See what I'm getting at?


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## Fox800 (Jun 4, 2010)

8jimi8 said:


> sublingual makes sense, but I never undrstood giving enteral medications to people who were about to throw up.  See what I'm getting at?



Um, yes.


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## BLSBoy (Jun 4, 2010)

You say you feel queezy, I am on the line for orders for Zofran (thank you NJ MICU protocol.....<_<)


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## Fox800 (Jun 4, 2010)

You guys have to call for orders for Zofran? Wow.


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## BLSBoy (Jun 4, 2010)

Jersey.......


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## 8jimi8 (Jun 4, 2010)

Fox800 said:


> Um, yes.





sorry fox800 i meant that towards my buddy Linuss


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## redcrossemt (Jun 5, 2010)

Quite liberal. 

We have standing orders for 4mg IV or IM. The protocol suggests calling for orders of a repeat dose of 4 more if it doesn't help.

For kids under 12 y/o it is also post-radio, but suggests 0.1mg/kg IV or IM.


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## FLEMTP (Jun 5, 2010)

Fox800 said:


> A while back we had a thread with several medics advocated withholding antiemetics from drunk patients to "teach them a lesson". I figured we could expand that conversation a little. How liberal or conservative are you when it comes to antiemetics? Do you give them preemptively (pt. hasn't vomited yet but feeling queasy)? Do you give them before backboarding patients that are intoxicated and queasy (think airway compromise once you've got them strapped to your cot and alone in the back). What does your service carry?
> 
> Personally, I give Zofran out very frequently. If someone is nauseated, they're getting Zofran (usually). I give it preemptively to make my patients more comfortable, prevent airway issues, and make life easier for my partner who would have to clean up the vomit in the truck. Keeps my uniform clean, too. Our protocol is ondanestron 4mg IV/IM.




We carry phenergan 25 mg carpujets. I give it out like candy. If someone says they are nauseated, they get it. I dont like people throwing up, and the trucks we have (freightliner chassis & the newer ones are F450 extended cabs but the box is the same dimentions) cause motion sickness... 

well.. thinking about it.. its either the trucks.. or the partner I work with lol...

the only exception is if someone is already pretty sedated by something else.. alcohol, benzodiazapines, etc im more cautious giving it. I dont wanna sedate them right into the ICU


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## 8jimi8 (Jun 5, 2010)

FLEMTP said:


> We carry phenergan 25 mg carpujets. I give it out like candy. If someone says they are nauseated, they get it. I dont like people throwing up, and the trucks we have (freightliner chassis & the newer ones are F450 extended cabs but the box is the same dimentions) cause motion sickness...
> 
> well.. thinking about it.. its either the trucks.. or the partner I work with lol...
> 
> the only exception is if someone is already pretty sedated by something else.. alcohol, benzodiazapines, etc im more cautious giving it. I dont wanna sedate them right into the ICU



So how much are you pushing of the 25mg?


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## redcrossemt (Jun 5, 2010)

FLEMTP said:


> the only exception is if someone is already pretty sedated by something else.. alcohol, benzodiazapines, etc im more cautious giving it. I dont wanna sedate them right into the ICU



Good point! There are relative contraindications, as with any medication, so I'm not sure "candy" is a good analogy. And, that's why I like ondansetron... Much less sedating, if at all. Our only absolute contraindication is prior allergic (or other poor) reaction to 5-HT3 antagonists (the "trons" or similar).


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## FLEMTP (Jun 6, 2010)

8jimi8 said:


> So how much are you pushing of the 25mg?



We don't really have a "protocol" persay.. because we don't use protocols. We have medical guidelines, but we can step outside of those as we please (without having to call a doc) as long as it is medically justified and/or appropriate and its not something insane that we haven't had the appropriate training for ( like performing a thoracostomy)

So... my answer to you is:

12.5mg initially.. and if it is a long transport... and they vomit after they've had the meds on board for about 30 minutes or so.. then i'll consider giving another 12.5.

For people that have drug elimination issues, (ie: liver & kidney problems or elderly) i knock it down to 6.25

No matter what the dosing is, I like to dilute it out and give it nice and slow. It can cause some venous irritation when given too fast.


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## 8jimi8 (Jun 6, 2010)

In the hospital we give 6.25, I have once given 12.5, but it was an out of range order that my charge questioned.  The doc explained that we used to give 25 all the time and that she would be fine


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## the_negro_puppy (Jun 7, 2010)

What about nausea + vomiting due to suspected food poisioning.

Withold anti-emetics due to vomiting being bodies way of removing toxins?


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## 8jimi8 (Jun 7, 2010)

the_negro_puppy said:


> What about nausea + vomiting due to suspected food poisioning.
> 
> Withold anti-emetics due to vomiting being bodies way of removing toxins?



it seems like you answered your own question, no?

if suspected food poisoning, then don't give anti-emetics.  Maybe i'm wrong?


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## MrBrown (Jun 7, 2010)

We have ondansetron PO for Technician while Paramedic and above have it IV.

It is indicated for severe nausea and/or vomiting, one wafer or 4mg IV.

How do we feel about prophylactic anti emetics before using opiate analgesia? It's common practice here and the Clinicial Management Group absolutely hate it (as there is no evidence of benefit) but nertz to them.

Absence of evidence does not mean evidence of absence!


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## 8jimi8 (Jun 7, 2010)

MrBrown said:


> We have ondansetron PO for Technician while Paramedic and above have it IV.
> 
> It is indicated for severe nausea and/or vomiting, one wafer or 4mg IV.
> 
> ...



again, i have to ask WHY DO YOU GIVE SOMETHING ENTERAL TO SOMEONE WHO FEELS ABOUT TO VOMIT??????

someone explain this to me, Vene?

IM i can understand, IV i can understand.  Brown: there is no evidence that opiates cause nausea as a side effect?? is that what you mean to say?

as far as pain control, i like phenergan + opioids, synergism of analgesia + prophylaxis/relief on the nausea


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## Melclin (Jun 7, 2010)

We're a bit behind the times with the anti-emetics here. 

We have metoclopramide (IV/IM) and Prochlorperazine (IM). Neither can be given to children (<15 by our definition) but some feel uncomfortable giving it to anybody under about 22 unless its an issue of prophylaxis in spinal immobilization. Metoclopramide gets handed out at the drop of a hat, prochlorperazine seems rarely used, mostly because I think it exists in the minds of most ambos as the drug u use when u can't use metoclop, and you NEED an anti-emetics...which is not often. 

So we have two anti-emetics that have a range of common, crappy side affects and are questionable efficacy wise not to mention we have nothing for children :wacko:


We really need ondansetron.


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## Smash (Jun 7, 2010)

MrBrown said:


> How do we feel about prophylactic anti emetics before using opiate analgesia? It's common practice here and the Clinicial Management Group absolutely hate it (as there is no evidence of benefit) but nertz to them.



I would have to side with your medical group on this, it does not strike me as a particularly smart way of treating patients.  The number of people who experience nausea as a result of morphine is very low (<5%).  All drugs (including ondansetron) have potential side effects or interactions with other drugs, so unless there is a reason to give them (and chances are there won't be), why add more pharmacology to the patient?

A much larger percentage of patients have allergic or anaphylactic reactions to antibiotics.  If then (for arguments sake) you were to administer antibiotics to someone, would you give them prophylactic epinephrine, phenergan and dexamethasone?

There is also a reasonable body of evidence that shows that anti-emetic prophylaxis is ineffective at preventing nausea or vomiting post morphine administration (including at least one placebo controlled RCT that I am aware of) so personally I would wait to see what my patient needs before giving them more drugs.


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## redcrossemt (Jun 8, 2010)

8jimi8 said:


> again, i have to ask WHY DO YOU GIVE SOMETHING ENTERAL TO SOMEONE WHO FEELS ABOUT TO VOMIT??????



Are people actually doing swallow-whole PO? Or are you who say PO referring to the rapidly disintegrating tablets? Technically I believe it's still PO, but for nausea do you really need to start an IV or stick everyone if they aren't vomiting yet?


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## LucidResq (Jun 8, 2010)

8jimi8 said:


> it seems like you answered your own question, no?
> 
> if suspected food poisoning, then don't give anti-emetics.  Maybe i'm wrong?



I ended up in the ER on Friday for moderate-severe abd pain and N/V. Probably due to bad shrimp (or prairie dog ghosts but that's another story), but I went in because I was getting pretty dehydrated (hadn't kept anything down, including water/fluids for over 12 hours) and the pain was severe enough to keep me from sleeping it off. 

Among other things I got IV Zofran almost immediately and was sent home with prochlorperazine. And thank God.  I'd rather wait for that stuff to come out the other end.... I had already gotten most, if not all, of it up already anyways. 

Even in a case where someone may have had some bad food and is just queasy but hasn't vomited yet, I think that vomiting it up probably wouldn't make a big difference especially if we're talking food that's actually contaminated. I might be wrong though... 

I believe with many foodborne illnesses, dehydration is usually the biggest threat... unless we're talking enterohemorrhagic E.Coli which does all kinds of crazy hemolytic stuff too. :wacko: But I digress...


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## redcrossemt (Jun 8, 2010)

I wanted to and forgot to mention the food poisoning thing earlier...

I similarly to Lucid have been sick before - in my case with a long bout of salmonella poisoning traced to a local restaurant. I'm fairly sure that vomiting didn't help me kick it. I would guess that the bacteria involved in most true food poisoning cases are colonizing the GI tract but not specifically only the stomach where vomit would be coming from. Even if bacteria were only in the stomach, I think antiemetics would be preferred over getting rid of some of the bacteria that will quickly recolonize.

Zofran ODTs were my best friend during my salmonella spell. And back to my earlier point, the dissolving tablets do work effectively and quickly, all without IV access or a shot. Now don't get me wrong, if the patient is dehydrated or needs an IV for another reason please give me the ondansetron IV. Otherwise though, I'll take the ODT.


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## alphatrauma (Jun 8, 2010)

Fox800 said:


> A while back we had a thread with several medics advocated *withholding antiemetics from drunk patients to "teach them a lesson".* Personally, I give Zofran out very frequently. If someone is nauseated, they're getting Zofran (usually). I give it preemptively to make my patients more comfortable, prevent airway issues, and make life easier for my partner who would have to clean up the vomit in the truck. Keeps my uniform clean, too.



I do not (nor does my Medical Director) advocate giving EtOH or drug intoxicated, actively vomiting, patients anti-emetics in the field. I would ask anyone who does to lay out their rationale, as it pertains to medical risk/benefit/positive patient outcomes... not the cleanliness of their rig or uniform. 

Hopefully you are forming a differential diagnosis prior to administration. 




LucidResq said:


> Even in a case where someone may have had some bad food and is just queasy but hasn't vomited yet, I think that vomiting it up probably wouldn't make a big difference especially if we're talking food that's actually contaminated. I might be wrong though...
> 
> I believe with many foodborne illnesses, *dehydration is usually the biggest threat...*



Which can usually be corrected with IV hydration



jtpaintball70 said:


> *I don't wanna have to clean up the mess*



Worse reason ever for giving a medication (well, maybe 2nd worse)



FLEMTP said:


> No matter what the dosing is, I like to dilute it out and give it nice and slow. It can cause some venous irritation when given too fast.



Sad thing is, I've seen providers slamming Zofran like it was Adenocard.



8jimi8 said:


> again, i have to ask WHY DO YOU GIVE SOMETHING ENTERAL TO SOMEONE WHO FEELS ABOUT TO VOMIT??????



 x2




I spent a couple years working with primary care physicians in an urgent care setting, and it never ceased to amaze me how people refuse to let their body do it's job. Instant gratification is the order of the day, as busy schedules do not provide the convenience for rest and time to recuperate. And we wonder why it takes so long to get better. Don't get me started on the overuse/misuse of antibiotics.

Back on track... Ask yourself, why is your intoxicated patient vomiting? Alcohol is a POISON (as far as the body is concerned), when the body's ability to metabolize it has been exceeded - *toxicity*. Will someone PLEASE explain to me how suppressing the the vomit reflex is a good thing in this particular patient. Yes there are exceptions (varicies/caustic substances/bleeding), but these are not the bulk of those presenting. As far as airway is concerned... fowlers/semi-fowlers anyone? I think there may be a suction canister somewhere on the truck.

There are MANY excellent uses for Odanestron/Zofran, but making the poster child for this application _an intoxicated patient_, is pure lunacy. I will go on record as saying that withholding treatment from a patient who needs it is unacceptable... but so is the other extreme - delivering care/treatment that is unwarranted for the sake of convenience.


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## 1badassEMT-I (Jun 21, 2010)

I would use it if I could push it.......I can give fentanyl and morephine that can make you sick as hell but I cant give zofran to ease the effects of them. GO figure.... Got to love WV protocols.


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## 1badassEMT-I (Jun 21, 2010)

alphatrauma said:


> I do not (nor does my Medical Director) advocate giving EtOH or drug intoxicated, actively vomiting, patients anti-emetics in the field. I would ask anyone who does to lay out their rationale, as it pertains to medical risk/benefit/positive patient outcomes... not the cleanliness of their rig or uniform.
> 
> Hopefully you are forming a differential diagnosis prior to administration.
> 
> ...



Well said!


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## MrBrown (Jun 21, 2010)

1badassEMT-I said:


> I would use it if I could push it.......I can give fentanyl and morephine...



Should I really trust you to administer something that you can't spell properly?

... but then again, should you trust me in that orange jumpsuit with "DOCTOR" written on it? .... 

Seriously tho.


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## 1badassEMT-I (Jun 21, 2010)

MrBrown said:


> Should I really trust you to administer something that you can't spell properly?
> 
> ... but then again, should you trust me in that orange jumpsuit with "DOCTOR" written on it? ....
> 
> Seriously tho.



It is early here I am still drinking coffee to wake up ...... OK I will take the E out of morphine....


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## tah06090 (Jun 24, 2010)

Zofran just became a regular paramedic drug here and was finally made a standing order for 4mg only but before it was a critical care drug only with direct order gotta love VT


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## TransportJockey (Jun 24, 2010)

tah06090 said:


> Zofran just became a regular paramedic drug here and was finally made a standing order for 4mg only but before it was a critical care drug only with direct order gotta love VT



That's kind weird... back home in NM all anti-emetics fall under the intermediate scope


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## tah06090 (Jun 24, 2010)

Vermont is very restrictive were broken into districts and 3 of the districts up north arent allowed to have paramedics med directors say no and in one of those districts is the largest city in vermont this state drives me crazy ill have my medic in 4 months which i have to take in NH cause VT has no medic programs then im outta here


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## rfrielly (Jun 24, 2010)

Fox800 said:


> You guys have to call for orders for Zofran? Wow.



Wonder why?


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## rfrielly (Jun 24, 2010)

alphatrauma said:


> Sad thing is, I've seen providers slamming Zofran like it was Adenocard.



Sad thing is I dont know why. But also have seen it done like that.


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## exodus (Jun 24, 2010)

tah06090 said:


> Zofran just became a regular paramedic drug here and was finally made a standing order for 4mg only but before it was a critical care drug only with direct order gotta love VT



it's 4mgIVP BHO here...


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## tah06090 (Jun 24, 2010)

Thats nothing we gotta call for status epilepticus to get valium its direct order and up until last year adenosine was direct order standing protocol now is give the 6mg then call for repeat doses of the 12mg 12mg


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## jjesusfreak01 (Jun 24, 2010)

In Wake County NC the medics don't have to call for anything really...


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## Fox800 (Jun 27, 2010)

alphatrauma said:


> I do not (nor does my Medical Director) advocate giving EtOH or drug intoxicated, actively vomiting, patients anti-emetics in the field. I would ask anyone who does to lay out their rationale, as it pertains to medical risk/benefit/positive patient outcomes... not the cleanliness of their rig or uniform.
> 
> Hopefully you are forming a differential diagnosis prior to administration.
> 
> ...



No thank you. I'd rather let it sit and let them sleep it off at the hospital than explain to my medical director/a jury why my unconscious/unresponsive drunk patient aspirated vomit with subsequent sequelae. Airway compromise is a life threat, and not one that I'm willing to accept an increased risk.


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## alphatrauma (Jun 27, 2010)

Fox800 said:


> No thank you. I'd rather let it sit and let them sleep it off at the hospital than explain to my medical director/a jury why my *unconscious/unresponsive* drunk patient aspirated vomit with subsequent sequelae. Airway compromise is a life threat, and not one that I'm willing to accept an increased risk.



I'd argue that you would have a more difficult time explaining why you didn't intubate... Zofran is the last thing this patient needs.


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## Fox800 (Jun 27, 2010)

alphatrauma said:


> I'd argue that you would have a more difficult time explaining why you didn't intubate... Zofran is the last thing this patient needs.



Let me rephrase...decreased LOC but will not tolerate an OPA or tube.


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## somePerson (Jul 13, 2010)

rfrielly said:


> Wonder why?




Not like the base nurses know much more. We just got zonfran a year ago and it's a BHO. As soon as the nurse hears n/v they automatically give you an order for it, even if you never had the intention of asking for it.


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## Hellsbells (Jul 27, 2010)

> No thank you. I'd rather let it sit and let them sleep it off at the hospital than explain to my medical director/a jury why my unconscious/unresponsive drunk patient aspirated vomit with subsequent sequelae. Airway compromise is a life threat, and not one that I'm willing to accept an increased risk





> Let me rephrase...decreased LOC but will not tolerate an OPA or tube.



So, do ypu mean to say that a vomiting pt with with a decreased LOC will no longer be at risk for aspiration with the simple application of an anti-emetic? In my opinion, if the pt has a decreased LOC, but will not tolerate an OPA, then they still have a gag reflex and can probably be put in the recovery position and if monitored, probably pose little little risk for aspiration.


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## MediMike (Jul 27, 2010)

I think that protection of the airway is the number one priority here.  If I've got a patient who is actively vomiting and unable to protect their own airway I'm going to intubate. Plain and simple. 

Fowler's, Semi-Fowler's, and the classic Recovery Position are great if the patient is conscious enough to manage their own airway, otherwise you'd better have an NG/OG tube down there if you're not going to tube them.  Also, you've got a system where you can't intubate? I believe an anti-emetic would be very appropriate.  

So....to answer the OP's statement, we only use Zofran in my region.  Any time I bring a patient down from the ski slopes, have an inebriated patient on a backboard, or anyone who feels the slightest bit queasy I will throw our 4mg on.  If my patient has a hx of nausea with opiates and I'm going to treat with analgesia I will prophylatically treat with 2mg, then provide the other 2 as needed.

By the way...Hi all! Glad to join!


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## emt/ff71185 (Jul 29, 2010)

alphatrauma said:


> I'd argue that you would have a more difficult time explaining why you didn't intubate... Zofran is the last thing this patient needs.



I would venture to say that giving Zofran is a lot less invasive than intubating a patient.  If we look at the big picture, you can give Zofran and the patient has less of a risk of aspiration and will sleep it off in the ER or you can intubate and now this patient is most likely going to be admitted to the hospital on a ventilator.  Not to mention the risks of intubation on alcoholics.  Less go with the FAR less invasive treatment.


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