# So I'm sitting in AMLS class...



## Aidey (Mar 24, 2011)

and I'm going to either have a stroke or piss everyone off.

There is only so often I can hear "HIGH FLOW O2!!!" before I start getting urges to strangle someone with the NRB tubing.

I really have no idea why I'm in this class beyond it will look good on my resume. Sigh.


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## Veneficus (Mar 24, 2011)

Aidey said:


> and I'm going to either have a stroke or piss everyone off.
> 
> There is only so often I can hear "HIGH FLOW O2!!!" before I start getting urges to strangle someone with the NRB tubing.
> 
> I really have no idea why I'm in this class beyond it will look good on my resume. Sigh.



Apparently there is nothing advanced about that class or it is being taught by a protocol monkey or EMT-Basic.


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## fast65 (Mar 24, 2011)

I was reading the description of it on the NAEMT website and it said it teaches to "think outside of the box", apparently not...


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## usalsfyre (Mar 24, 2011)

The card classes are pretty much a waste of time after you've taken them. The AHA and NAEMT have sold EMS on the idea of BS certifications hook, line and sinker. The only one I've enjoyed lately was ACLS EP, and even that was just a very, very basic course in concepts surrounding periarrest and preventing full arrest.


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## Veneficus (Mar 24, 2011)

usalsfyre said:


> The card classes are pretty much a waste of time after you've taken them. The AHA and NAEMT have sold EMS on the idea of BS certifications hook, line and sinker. The only one I've enjoyed lately was ACLS EP, and even that was just a very, very basic course in concepts surrounding periarrest and preventing full arrest.



Then you have a standing invite to come and have EP class with us in Ohio this summer.

I'll bet my collegues and I can make it worth your while.


Just the idea of a 2 day course in "advanced medical life support" should sound stupid.


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## Aidey (Mar 24, 2011)

The main problem is the updated class materials aren't available yet, so we are using to 2006-2007 stuff. The scenarios in the book talk about stacked shocks and drugs down the tube. 

It has potential, especially if they focused more on pathophys of stuff we don't see often or abnormal presentations of stuff we do see. Right now it is feeling like a review class.


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## Veneficus (Mar 24, 2011)

Aidey said:


> The main problem is the updated class materials aren't available yet, so we are using to 2006-2007 stuff. The scenarios in the book talk about stacked shocks and drugs down the tube.
> 
> It has potential, especially if they focused more on pathophys of stuff we don't see often or abnormal presentations of stuff we do see. Right now it is feeling like a review class.



That stuff should have been out by 06


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## Aidey (Mar 24, 2011)

Ahhhhhhhh!

Septic shock with a BP of 68/P - 300ml bolus, if it doesn't work, go to dopamine!
(But wait, you can't have a BP of 68/P because you can't have a radial pulse with a BP under 70).

Mag for asthma? Huh how does that work? Glucagon for BB OD? Does that work?

I will not have a stroke....I will not have a stroke.


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## usalsfyre (Mar 24, 2011)

Aidey said:


> Ahhhhhhhh!


My reaction to certain CE sessions as well.



Aidey said:


> Septic shock with a BP of 68/P - 300ml bolus, if it doesn't work, go to dopamine!
> (But wait, you can't have a BP of 68/P because you can't have a radial pulse with a BP under 70).


This is just bad medicine. From inadequate fluid resuscitation to a poor choice of pressor it stinks all the way around. What's really scary is it's being taught a gospel to medics who will go back and practice this way.



Aidey said:


> Mag for asthma? Huh how does that work? Glucagon for BB OD? Does that work?


Let me guess, the instructors are medics who have "been around the block" (what they don't realize is the block is on Sesame Street).



Aidey said:


> I will not have a stroke....I will not have a stroke.


Don't forget adequate sedation for agitation, including your own!


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## usalsfyre (Mar 24, 2011)

Veneficus said:


> Then you have a standing invite to come and have EP class with us in Ohio this summer.
> 
> I'll bet my collegues and I can make it worth your while.
> 
> ...



Generous offer and I wish I could. I wouldn't say the class I took was a waste by any means, the part I enjoyed the most is the fact that it was physician led, meaning when we did delve into more advanced topics the instructors could keep up. It just seemed that outside of 3 or 4 of the scenarios most people with exposure to medicine at a higher level were able to pick up where the scenario was leading you pretty easily. 

AMLS is a way for someone to sell books and cards, and a merit badge for medics and services. If you could learn how to manage medical emergencies in two days then why would we need physicians.


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## medicRob (Mar 24, 2011)

Veneficus said:


> Apparently there is nothing advanced about that class or it is being taught by a protocol monkey or EMT-Basic.



My PHTLS was taught by an MD, EMT-P, the AMLS I want to attend will be taught by him as well. He pissed a bunch of the medics off in PHTLS, I overheard comments like
"We dont need to know that", "That is too much damn detail for something as simple as dropping an airway"... I assume it was in response to his riveting explanation of cellular physiology and molecular biology.


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## usalsfyre (Mar 24, 2011)

medicRob said:


> My PHTLS was taught by an MD, EMT-P, the AMLS I want to attend will be taught by him as well. He pissed a bunch of the medics off in PHTLS, I overheard comments like
> "We dont need to know that", "That is too much damn detail for something as simple as dropping an airway"... I assume it was in response to his riveting explanation of cellular physiology and molecular biology.



Yeah but when the guy that wrote the text book is faculty it would make sense it's going to be a decent class .


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## medicRob (Mar 24, 2011)

usalsfyre said:


> Yeah but when the guy that wrote the text book is faculty it would make sense it's going to be a decent class .



bwahahha, you got me there.


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## Aidey (Mar 24, 2011)

fast65 said:


> I was reading the description of it on the NAEMT website and it said it teaches to "think outside of the box", apparently not...



That is what they keep telling us. It would be a heck of a lot easier if 1. They taught disease pathologies that are "outside of the box" and 2. If any of the scenarios had solutions that were not the most common/obvious disease. 




usalsfyre said:


> This is just bad medicine. From inadequate fluid resuscitation to a poor choice of pressor it stinks all the way around. What's really scary is it's being taught a gospel to medics who will go back and practice this way.
> 
> ....
> 
> ...



Everyone was like "the lungs! the lungs!" over 300 ml of fluid. If 300mls overloads your septic shock patient, you have more problems than you think you do. Unfortunately dopamine is all we have, unless we want to call for orders for an epi drip. 

The instructors 1/2 way admitted that the class is outdated and there have been changes, but they are sticking to the power point like glue. 

Versed is a good thing


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## medicRob (Mar 24, 2011)

Aidey, would you like me to find out when Dr Guy is teaching the course again? I would be more than happy to get you some details. He wrote the PHTLS textbook and several other books, he is our burn director, and a paramedic.


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## usalsfyre (Mar 24, 2011)

Yeah there's some paranoia among medics over fluid, I've never figured out why. Not counting renal failure and already overloaded patients I've yet to find anyone who can't take a liter like a champ. Heck I gave 1100mls of LR to an early sepsis patient over 40 minutes yesterday.

I guess we're lucky, we've got levo. They should still teach the appropriate med though, even if it's not commonly carried.


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## medicRob (Mar 24, 2011)

usalsfyre said:


> I guess we're lucky, we've got levo. They should still teach the appropriate med though, even if it's not commonly carried.



They should also teach the importance of MAP instead of referring to it as that "little number in parenthesis".


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## usafmedic45 (Mar 24, 2011)

Veneficus said:


> Then you have a standing invite to come and have EP class with us in Ohio this summer.
> 
> I'll bet my collegues and I can make it worth your while



Oh really?


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## usafmedic45 (Mar 24, 2011)

> Not counting renal failure and already overloaded patients I've yet to find anyone who can't take a liter like a champ.



Trauma patients? 



> My PHTLS was taught by an MD, EMT-P



Was it Corey by any chance? 



> Septic shock with a BP of 68/P - 300ml bolus, if it doesn't work, go to dopamine!
> (But wait, you can't have a BP of 68/P because you can't have a radial pulse with a BP under 70).



....and if they lose their fingers from excessive vasoconstriction, at least you didn't give them *gasp!* "pulmonary edema"! *shock!* *horror!*


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## medicRob (Mar 24, 2011)

usafmedic45 said:


> Was it Corey by any chance?



Nope, Dr. guy, not Dr. Slovis, but Slovis is a genius!


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## usafmedic45 (Mar 24, 2011)

medicRob said:


> Nope, Dr. guy, not Dr. Slovis, but Slovis is a genius!



Ah....Corey is a genius.  A very peculiar and, at times, eccentric genius.  He's a very interesting and fun guy to talk to.


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## medicRob (Mar 24, 2011)

usafmedic45 said:


> Ah....Corey is a genius.  A very peculiar and, at times, eccentric genius.  He's a very interesting and fun guy to talk to.



Did you catch him at an EM conference?


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## Aidey (Mar 24, 2011)

medicRob said:


> Aidey, would you like me to find out when Dr Guy is teaching the course again? I would be more than happy to get you some details. He wrote the PHTLS textbook and several other books, he is our burn director, and a paramedic.



Thanks, but I can't travel very far for classes and stuff currently. I'm waiting to hear on a job offer, so making plans to fly anywhere for a class months in advance isn't really a good idea. 

Although it is _*very *_tempting. It was bugging me why I knew his name and 2 seconds of google told me he is the MD with the awesome pod casts. I've never gotten into pod casts because I find it hard to retain info I hear without a visual competent included. However, I may have to start making exceptions.


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## medicRob (Mar 25, 2011)

Aidey said:


> Thanks, but I can't travel very far for classes and stuff currently. I'm waiting to hear on a job offer, so making plans to fly anywhere for a class months in advance isn't really a good idea.
> 
> Although it is _*very *_tempting. It was bugging me why I knew his name and 2 seconds of google told me he is the MD with the awesome pod casts. I've never gotten into pod casts because I find it hard to retain info I hear without a visual competent included. However, I may have to start making exceptions.



Listen to "Vandy ICU Rounds" podcast. You will love it.  

Also, emCrit is good.

Dr. Guy is also the author of the PHTLS Textbook


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## BEorP (Mar 25, 2011)

Aidey said:


> Mag for asthma? Huh how does that work? Glucagon for BB OD? Does that work?



Isn't there at least some evidence that supports glucagon for beta blocker overdose? http://www.ncbi.nlm.nih.gov/pubmed/6144498

It doesn't seem like many people in Australia are familiar with this use, but I heard about it previously from physicians in both Canada and the US.


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## Aidey (Mar 25, 2011)

I took ITLS when I was in medic school several years ago, but not PHTLS. I passed up PHTLS for AMLS, and I'm kind of regretting it. A few of the people in the AMLS class were talking about the "new" guidelines of permissive hypotension and not automatically c-spining everyone who looked at a crack in the side walk the wrong way. It would have been nice to spend 16 hours listening to good medicine. 

I had a bit of a moment in class today when Ehlers-Danlos was mentioned, and I was the only one who came up with what it was.* I have a feeling I'm going to end up being unhappy if I stay a paramedic forever.


*Well, at least I was the only one that answered after one of those long awkward silences when the instructor said they were drawing a total blank on it.


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## Aidey (Mar 25, 2011)

BEorP said:


> Isn't there at least some evidence that supports glucagon for beta blocker overdose? http://www.ncbi.nlm.nih.gov/pubmed/6144498
> 
> It doesn't seem like many people in Australia are familiar with this use, but I heard about it previously from physicians in both Canada and the US.



Yes, there is. I was repeating comments made by my classmates.


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## medicRob (Mar 25, 2011)

Aidey said:


> I took ITLS when I was in medic school several years ago, but not PHTLS. I passed up PHTLS for AMLS, and I'm kind of regretting it. A few of the people in the AMLS class were talking about the "new" guidelines of permissive hypotension and not automatically c-spining everyone who looked at a crack in the side walk the wrong way. It would have been nice to spend 16 hours listening to good medicine.
> 
> I had a bit of a moment in class today when Ehlers-Danlos was mentioned, and I was the only one who came up with what it was.* I have a feeling I'm going to end up being unhappy if I stay a paramedic forever.
> 
> ...



medicRob owes you a conference. I will make sure that you get to see Dr. Slovis or Dr. Guy speak at some point in the next year. They usually travel.


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## usafmedic45 (Mar 25, 2011)

medicRob said:


> Did you catch him at an EM conference?



I was actually introduced to him by a mutual friend (an EM doc from on the east coast) at a conference a few years back.


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## usafmedic45 (Mar 25, 2011)

> I had a bit of a moment in class today when Ehlers-Danlos was mentioned, and I was the only one who came up with what it was.* I have a feeling I'm going to end up being unhappy if I stay a paramedic forever.



If you want to totally show off, thats when you start discussing the different varieties of Ehlers-Danlos and their clinical implications.  LOL


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## Epi-do (Mar 25, 2011)

BEorP said:


> Isn't there at least some evidence that supports glucagon for beta blocker overdose? http://www.ncbi.nlm.nih.gov/pubmed/6144498
> 
> It doesn't seem like many people in Australia are familiar with this use, but I heard about it previously from physicians in both Canada and the US.



I have actually given it once.  It did improve my patient's blood pressure.  Her pressure started out somewhere around 50/nothing and was low 90's systolic by the time we rolled into the ER.  The hardest part was getting a line on her since her pressure was so low.  I ended up having one shot at an EJ.  

When we got into the ER, the RN asked why I had given her so much glucagon, so I had to explain to her that it was for the OD.  The doc was on the phone, going back and forth between poison control and the pharmacy to figure out what to do for her.  They ended up putting her on a glucagon drip, an epi drip, and giving her D5W.

Once I got back to the firehouse, I did some research to find out why the glucagon works.  From the very basic understanding that I got from what I read, glucagon uses a "back door" approach to have a similar effect upon the heart as a beta agonist.  It binds to the glucagon receptors in the heart and increases heart rate and myocardial contractility, and improves atrioventricular conduction.


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## Aidey (Mar 25, 2011)

usafmedic45 said:


> If you want to totally show off, thats when you start discussing the different varieties of Ehlers-Danlos and their clinical implications.  LOL



I think I would have been lynched. I admit I know what it is because I had a patient with it. I can tell you there are different types, and some are more serious than others but I don't remember what they are.


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## medicRob (Mar 25, 2011)

As for Ehlers-Danlos, there used to be 10 classifications, they took it down to either 6 or 7 types, the only ones I can remember are

dermatosporaxis, kyphoscoliosis, and vascular.


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## Aidey (Mar 25, 2011)

*headdesk*
*headdesk*
*headdesk*
*headdesk*

/repeat


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## usalsfyre (Mar 25, 2011)

Aidey said:


> *headdesk*
> *headdesk*
> *headdesk*
> *headdesk*
> ...



(draws up the ketamine in the MAD device) "You may feel a little funny after this..."


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## MrBrown (Mar 25, 2011)

usalsfyre said:


> (draws up the ketamine in the MAD device) "You may feel a little funny after this..."



Ambulance Oscar 10 on location.

*Brown mounts kerb in Brown's rapid response unit, grabs the green thomas pack and looks at the fire hydrant spewing water into the air, oh dear, did Brown hit that, hmm that is what happens when you let Brown drive!

How much ketamine should we use? Brown has 400mg in 4ml here, think that will be enough? 

Now, whats this funny business, a BP of 68/P is entirely possible, we do not have dopamine so Brown doesn't know a whole lot about it, we have magnesium for asthma and glucagon is a recognised treatment for a beta blocker overdose?


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## Aidey (Mar 25, 2011)

Apparently septic shock should be treated like hypovolemic shock - permissive hypotension and all.


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## Veneficus (Mar 25, 2011)

Aidey said:


> Apparently septic shock should be treated like hypovolemic shock - permissive hypotension and all.



What???!!!


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## usalsfyre (Mar 25, 2011)

The fail is strong here...


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## Aidey (Mar 25, 2011)

Trust me Vene, I know. I nearly picked a fight, then backed down and got lectured on how it is our job to treat the symptoms and transport. We aren't there to treat the underlying problem, and shouldn't waste time trying to figure out what it is. 

I nearly walked out.


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## Veneficus (Mar 25, 2011)

Aidey said:


> Trust me Vene, I know. I nearly picked a fight, then backed down and got lectured on how it is our job to treat the symptoms and transport. We aren't there to treat the underlying problem, and shouldn't waste time trying to figure out what it is.
> 
> I nearly walked out.



And this cretin is teaching...

There is no hope for EMS.


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## MrBrown (Mar 25, 2011)

Brown is lost a bit .... was it being taught a BP of 68P was not possible and mag and glucagon were not permissible for asthma and beta blocker overdose?

Did Brown miss something?


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## usafmedic45 (Mar 25, 2011)

> was it being taught a BP of 68P was not possible



There's an old myth that persists in the US that you can "estimate" a BP based upon the presence or absence of various peripheral and central pulses.   The most common variation I hear is that you have to have a pressure of 60mmHg systolic for femoral,  70mmHg systolic for radial, 80 for brachial and 40 or 50 mmHg for carotid pulses to be present.  It's like the myth of clinically relevant hypoxic drive: it just refuses to die.


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## usafmedic45 (Mar 25, 2011)

> I admit I know what it is because I had a patient with it.



I used to date a girl with the "benign" hypermobile form.  Softest hands on the planet and flexible enough to....well....let's just leave it at that.  



> dermatosporaxis, kyphoscoliosis, and vascular.


Arthrochalasis, classical and hypermobile are the other three.  However, it is common for there to be "mixed" forms.


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## medicRob (Mar 25, 2011)

usafmedic45 said:


> There's an old myth that persists in the US that you can "estimate" a BP based upon the presence or absence of various peripheral and central pulses.   The most common variation I hear is that you have to have a pressure of 60mmHg systolic for femoral,  70mmHg systolic for radial, 80 for brachial and 40 or 50 mmHg for carotid pulses to be present.  Ic drive: it just refuses to die.



I remember a "Beyond the Basics" article on Vital Signs in EMS World (Then EMS Magazine) that touched on the topic, and I quote: 

"   EMS personnel are frequently taught that pulse location (radial, brachial, femoral or carotid) correlates with the estimated systolic blood pressure. It is postulated that a systolic blood pressure of 80-90 mmHg is needed to produce radial pulses, a systolic blood pressure of 70 mmHg is needed to produce femoral and brachial pulses, and a systolic blood pressure of 60 mmHg is needed to produce carotid pulses. Be careful when interpreting this finding. One article found that trauma patients with a radial pulse had a mean systolic blood pressure (SBP) of 72.5 mmHg; *83% of the trauma patients with a radial pulse had a SBP of less than 80 mmHg.* *Trauma patients with a femoral and carotid pulse had a mean SBP of 66.4 mmHg*; *83% of the trauma patients with a femoral or carotid pulse had a SBP less than 70 mmHg*. It is necessary to have a SBP of 60 mmHg to produce a carotid pulse."1


References

1. Deakin CD, Low JL. Accuracy of the advanced trauma life support guidelines for predicting systolic blood pressure using carotid, femoral, and radial pulses: observational study. BMJ 321, 673-674, 2000.

Article Source: 
http://www.emsworld.com/print/EMS-World/Beyond-the-Basics--Interpreting-Vital-Signs/1$4655


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## Aidey (Mar 25, 2011)

Done, thank goodness. Not sure it was worth the resume padding. 

usaf...*shakes head* 

Rob, I'm totally stealing that duck quote.


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## medicRob (Mar 25, 2011)

Aidey said:


> Done, thank goodness. Not sure it was worth the resume padding.
> 
> usaf...*shakes head*
> 
> Rob, I'm totally stealing that duck quote.



Thank Justin Schorr (The Happy Medic) for that one.


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## usalsfyre (Mar 25, 2011)

I hope the course eval reflected your true feelings?


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## Scott33 (Mar 25, 2011)

medicRob said:


> I remember a "Beyond the Basics" article on Vital Signs in EMS World (Then EMS Magazine) that touched on the topic, and I quote:
> 
> "   EMS personnel are frequently taught that pulse location (radial, brachial, femoral or carotid) correlates with the estimated systolic blood pressure. It is postulated that a systolic blood pressure of 80-90 mmHg is needed to produce radial pulses, a systolic blood pressure of 70 mmHg is needed to produce femoral and brachial pulses, and a systolic blood pressure of 60 mmHg is needed to produce carotid pulses. Be careful when interpreting this finding. One article found that trauma patients with a radial pulse had a mean systolic blood pressure (SBP) of 72.5 mmHg; *83% of the trauma patients with a radial pulse had a SBP of less than 80 mmHg.* *Trauma patients with a femoral and carotid pulse had a mean SBP of 66.4 mmHg*; *83% of the trauma patients with a femoral or carotid pulse had a SBP less than 70 mmHg*. It is necessary to have a SBP of 60 mmHg to produce a carotid pulse."1
> 
> ...




Here is a little more of Charles Deakin's study. Amazing to think it was conducted over a decade ago, but to be fair, it's not just the US that still teach it. 

http://www.bmj.com/content/321/7262/673.full.pdf


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## medicRob (Mar 25, 2011)

Scott33 said:


> Here is a little more of Charles Deakin's study. Amazing to think it was conducted over a decade ago, but to be fair, it's not just the US that still teach it.
> 
> http://www.bmj.com/content/321/7262/673.full.pdf



Thanks, Scott33. I am kind of ashamed to say that I have never read this particular study in its entirety, only excerpts seen in selected articles such as the one I referenced above by Mistovich, Limmer, and Krost.


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## EMTinNEPA (Mar 25, 2011)

Aidey said:


> Mag for asthma? Huh how does that work? Glucagon for BB OD? Does that work?



Magnesium sulfate can act as a bronchodilator and is associated with a lower rate of hospital admission.  While is it shown to be effective in treating bronchospasm, it's not indicated in mild asthma exacerbations.

Glucagon has long been an "accepted" off the label medication for a beta blocker overdose.  There are paramedics in parts of this state that actually start glucagon drips on beta blocker ODs.


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## Veneficus (Mar 25, 2011)

EMTinNEPA said:


> Magnesium sulfate can act as a bronchodilator and is associated with a lower rate of hospital admission.  While is it shown to be effective in treating bronchospasm, it's not indicated in mild asthma exacerbations.



It also blunts T cell response.

Mag is one of the oldest drugs known to man and has a myriad of uses. My favorite is to sedate psych patients with it. Though Psych doesn't like that at all since they sleep for about 20 hours.



EMTinNEPA said:


> Glucagon has long been an "accepted" off the label medication for a beta blocker overdose.  There are paramedics in parts of this state that actually start glucagon drips on beta blocker ODs.



With perhaps the exception of accidental OD in peds, I don't think it is a good idea to start acutely reversing beta blockers in the field. Especially on people who have been on them for significant time.


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## usalsfyre (Mar 25, 2011)

Per one of our ED docs poison control isn't even recommending glucagon in beta blocker overdose anymore, it's high dose insulin and glucose.


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## Aidey (Mar 25, 2011)

EMTinNEPA said:


> Magnesium sulfate can act as a bronchodilator and is associated with a lower rate of hospital admission.  While is it shown to be effective in treating bronchospasm, it's not indicated in mild asthma exacerbations.
> 
> Glucagon has long been an "accepted" off the label medication for a beta blocker overdose.  There are paramedics in parts of this state that actually start glucagon drips on beta blocker ODs.



So yeah...I was being b!tchy and mocking my classmates.


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## usafmedic45 (Mar 26, 2011)

> My favorite is to sedate psych patients with it. Though Psych doesn't like that at all since they sleep for about 20 hours.



Really?  Man I need to remember that the next time I need to catch up on sleep. LOL


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## EMTinNEPA (Mar 26, 2011)

Aidey said:


> So yeah...I was being b!tchy and mocking my classmates.



Oh.  My bad.


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