# Ideal Drug Box



## redcrossemt (Feb 28, 2010)

If you were redesigning your agency or system drug box, what would you put in it? I think we can assume the ACLS drugs (epi, vasopressin, atropine, amiodarone/lidocaine, adenosine, dopamine) are there. ? on procainamide...

I would argue for:

zofran
aspirin
nitro SL + IV
cardizem
narcan
albuterol
ipatroprium
diphenhydramine
pepcid
solumedrol
terbutaline
oxytocin
furosemide
fentanyl
morphine
toradol
versed
haldol
etomidate
rocuronium
magnesium sulfate
sodium bicarbonate
calcium chloride
sodium nitrate
sodium thiosulfate
glucagon
D50
acetaminophen
thiamine
labetalol


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## Shishkabob (Feb 28, 2010)

Everything you said and:

Bretylium

I heard it was fantastic when we could actually get it.


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## reaper (Mar 1, 2010)

Everything you listed. Minus the Bretylium!!!!!!!!!


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## Smash (Mar 1, 2010)

Linuss said:


> Everything you said and:
> 
> Bretylium
> 
> I heard it was fantastic when we could actually get it.



Fantastic at having utterly no effect on survival you mean?  Or fantastic at having lots of adverse effects?

There is a reason why we can't get it anymore you know.


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## MrBrown (Mar 1, 2010)

Adenosine
Adrenaline 
Amiodarone 
Aspirin 
Atropine 
Clopidogrel 
Dextrose 10%
Diphenhydramine 
Fentanyl
Glucagon 
GTN 
Heparin 
Hydrocortisone 
Ketamine 
Methoxyflurane 
Midazolam 
Naloxone 
Oxycotin 
Ondansetron
Rocuronium 
Salbutamol 
Streptase 
Suxamethonium


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## triemal04 (Mar 2, 2010)

redcrossemt said:


> If you were redesigning your agency or system drug box, what would you put in it? I think we can assume the ACLS drugs (epi, vasopressin, atropine, amiodarone/lidocaine, adenosine, dopamine) are there. ? on procainamide...
> 
> I would argue for:
> 
> ...


Add in D25, reglan, phenergan, nitrous oxide, proparacaine, replace calcium chloride with calcium gluconate, and, unless you have a different use for them, replace the sodium nitrate and thiosulfate with a cyanokit.


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## redcrossemt (Mar 4, 2010)

triemal04 said:


> Add in D25, reglan, phenergan, nitrous oxide, proparacaine, replace calcium chloride with calcium gluconate, and, unless you have a different use for them, replace the sodium nitrate and thiosulfate with a cyanokit.



Fair enough.

Do you use reglan a lot? Or phenergan preferentially over ondansetron?


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## redcrossemt (Mar 4, 2010)

MrBrown said:


> Adenosine
> Adrenaline
> Amiodarone
> Aspirin
> ...



Why sux and roc?

Does anyone use streptase or another thrombolytic a lot for STEMI? Can they still do PCI after that (I'm thinking risk of bleeding - but I don't know much about it)? 

Forgot about clopidogrel. +1 there.


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## Bloom-IUEMT (Mar 4, 2010)

redcrossemt said:


> If you were redesigning your agency or system drug box, what would you put in it? I think we can assume the ACLS drugs (epi, vasopressin, atropine, amiodarone/lidocaine, adenosine, dopamine) are there. ? on procainamide...
> 
> I would argue for:
> 
> ...



Just curious: are medics trained in all these drugs or is this idealistic wish list?  Not very much familiar with oxytocin other than its role in inducing labor....so would there be an instance where you'd want to induce labor on a patient??


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## redcrossemt (Mar 4, 2010)

Bloom-IUEMT said:


> Just curious: are medics trained in all these drugs or is this idealistic wish list?  Not very much familiar with oxytocin other than its role in inducing labor....so would there be an instance where you'd want to induce labor on a patient??



All of these drugs are utilized by paramedics in different parts of the world working for different services.

Oxytocin increases uterine tone and can be used to control post-partum hemorrhage.


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## triemal04 (Mar 4, 2010)

redcrossemt said:


> Fair enough.
> 
> Do you use reglan a lot? Or phenergan preferentially over ondansetron?


I actually don't carry phenergan currently; my only option is zofran, which, much as I like it, is much less effective after the pt has already begun to vomit.  Phenergan on the other hand seems to be effective regardless.  Of course it's harder on the veins and has some interactions that aren't always the best, so having multiple options would be better.

Same with reglan; I don't carry it, but have had multiple interactions with MD's and PA's who swear by it for treating nausea caused by migraines.  And based on my own experiences in treating that type of nausea with zofan...it doesn't always work.


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## MrBrown (Mar 4, 2010)

redcrossemt said:


> Why sux and roc?



For RSI


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## redcrossemt (Mar 4, 2010)

MrBrown said:


> For RSI



Hehe, good one! 

I was asking, why carry both?

The one thought I have is the duration of rocuronium is scary! You have 20-60 minutes depending on dose that you can't do a neuro exam.


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## Melclin (Mar 4, 2010)

Interesting that no one has mentioned ceftriaxone. Prehospital sepsis management seems to be pretty low down the list of priorities in the US. Mortality from sepsic shock increases 7.6% for every hour antibiotics are delayed (1). Have a look at this article (2) for an good argument for enhanced prehospital sepsis management. We carry ceft here for sepsis, although our sepsis education and guidelines remain in their infancy.

(1) Kumar A, Roberts D, Wood K, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the determinant of survival in human septic shock. Crit Care Med 2006;34:589–96.

(2) Robson W, Nutbeam T, Daniels R. Sepsis: a need for prehospital intervention? Emerg Med J. 2009;26:535–538.


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## Melclin (Mar 4, 2010)

redcrossemt said:


> Hehe, good one!
> 
> I was asking, why carry both?
> 
> The one thought I have is the duration of rocuronium is scary! You have 20-60 minutes depending on dose that you can't do a neuro exam.



Our MICA trucks carry both sux and pancuronium. Sux as an induction agent and panc for continuing paralysis should you need it. Panc also for continuing paralysis in therapeutic hypothermia.


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## redcrossemt (Mar 5, 2010)

Melclin said:


> Our MICA trucks carry both sux and pancuronium. Sux as an induction agent and panc for continuing paralysis should you need it. Panc also for continuing paralysis in therapeutic hypothermia.



Any reason, other than what I mentioned, for not carrying just rocuronium? From the research I can find, the onset is about the same. Some say the intubating conditions are better with sux, but some say not... I think the data there is pretty subjective.


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## redcrossemt (Mar 5, 2010)

Melclin said:


> Interesting that no one has mentioned ceftriaxone.



Ceftriaxone is a great choice to add! Totally forgot about this, but it is becoming a bigger thing, at least in CCT. Ceft is a great start, but also may also want quinolones, macrolides, and/or aminoglycosides for broad spectrum coverage since many of our patients are from nursing homes and have complicated infections of multiple or unknown source/system.

Any thoughts on carrying multiple antibiotics and administering for sepsis from an unknown organism?

Are you drawing cultures before administration??


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## Smash (Mar 5, 2010)

redcrossemt said:


> Any reason, other than what I mentioned, for not carrying just rocuronium? From the research I can find, the onset is about the same. Some say the intubating conditions are better with sux, but some say not... I think the data there is pretty subjective.



Safety.  Sux has a duration of about 5 minutes, which is shorter than the safe period of apnoea a well de-nitrogenated, healthy adult can sustain.  If you use the rocuronium for your initial paralytic and you find yourself in a can't intubate/can't ventilate situation, you are faced with the very real prospect of having to cut the patients throat if you don't have any luck with a backup airway device.  With sux you just have to wait a few minutes, let them breathe on their own and off to hospital.

My service carries sux and panc also.  Aside from the refridgeration issues (not a big deal with new rigs having fridges; that or throwing out the drugs each week) panc is good because it does not require any reconstitution, is easy to administer and has (for our purposes) an acceptable duration of action.

As for antibiotics, cefazoin, cefataxine, ceftriaxone, something along those lines is good (we carry ceftriaxone).  A third gen cephalosporin should provide adequate cover initially, and ceftriaxone is good because it can get into the CSF without too much trouble.  
We aren't aiming for killing off the bugs, just bacteriostasis to slow things down before we can work out the targeted regimine of antibiotics, and 1 gram of ceftriaxone is acceptable for this (although there is some suggestion that 2gm might be better)  Cultures will then be grown to work out exactly what we need so I don't know that a scattershot approach without knowing what to use is the best approach.
Whether we give the AB's or not depends on an awful lot of factors, not least of which is the time to hospital.  We don't want to mess up any labs, but nor do we want to leave the patient without baceriostasis, particularly if they are unlucky enough to have got themselves some neisseria meningitidis on board.  If we suspect an aggressive micoorganism like N. Meningitidis we will get straight on to the ABs + fluid + inotropes + intubation and ventilation.

I still haven't figured out why we want bretylium yet...


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## Melclin (Mar 5, 2010)

redcrossemt said:


> Any reason, other than what I mentioned, for not carrying just rocuronium? From the research I can find, the onset is about the same. Some say the intubating conditions are better with sux, but some say not... I think the data there is pretty subjective.



I couldn't say with any authority. Sux is whats used in EDs all over the country. It may just be that its the status quo and they extended it to MICA when RSI came in. 



redcrossemt said:


> Ceftriaxone is a great choice to add! Totally forgot about this, but it is becoming a bigger thing, at least in CCT. Ceft is a great start, but also may also want quinolones, macrolides, and/or aminoglycosides for broad spectrum coverage since many of our patients are from nursing homes and have complicated infections of multiple or unknown source/system.
> 
> Any thoughts on carrying multiple antibiotics and administering for sepsis from an unknown organism?
> 
> Are you drawing cultures before administration??



I would suggest a respiratory quinolone like levofloxacin seeing as though community acquired pneumonia (CAP) constitutes the majority of sepsis case seen in the prehospital environment. But to be honest I don't know a great deal about this. Its my understanding that the particular drug used would be tailored to the local florae.

Perhaps also doxycylcine given its potential in both resp and urinary tract infections (septic nursing home patients with CAP or UTIs would constitute the bulk of sepsis case I would think).

Although, I'm not sure of the necessity of utility of carrying such drugs on the average 000 truck. What I am more interested in is the idea of starting the management of the 'sepsis six' in the prehospital environment, in the hopes of expediting the process of the first 6 hours of evaluation and resuscitation, which in turn will expedite their ICU care should they need it.

1) ~100% O2 (currently we actually don't carry NRBMs, which I would like changed, personally).

2) Blood cultures (we don't currently draw blood cultures. I believe we should for two reasons. Firstly, it expedites a diagnosis if we can roll in the ED door with a bag ready to run off to the lab even while we're still waiting for a bed. Secondly, a blood culture taken before the ceftriaxone prevents the ED from encountering problems identifying the type of infection from sterile blood samples taken soon after the initial cef).

3) IV antibiotics (we have cef, for now I feel this is adequate, but the culture of not using it in the ambulance service needs to be addressed, Ambulance paramedics here, still do not appear to understand the way sepsis can creep up on you).

4)Fluid resuscitate (MICA can fluid resus a septic patient, basics cannot, although, you could easily argue dyhydration, or just plain step outside the guidelines - as long as you can back it up then that's fine. 2-3 rounds of 20mls/kg of a crystaloid appears to be the go in sepsis, and basics here are experienced in this modality for other conditions).

5)Serum Lactate and haemoglobbin. (obviously difficult in the prehospital environment. Although, there are relatively cheap, reliable portable lactate measuring tools apparently, and the suggest algorithm for sepsis triage (bellow) requires a lactate level).

6)Urinary cath + urin output (perhaps in rural mega transport time areas but otherwise I'd say this one can be left out [thoughts?], given that its a sterile and sometimes time consuming procedure).


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## redcrossemt (Mar 5, 2010)

Melclin said:


> I couldn't say with any authority. Sux is whats used in EDs all over the country. It may just be that its the status quo and they extended it to MICA when RSI came in.



I think safety is one part - as Smash described. The other is continuing assessment. I would recommend, with this in mind, carrying sux as the primary paralytic for RSI, with an intermediate duration agent (like rocuronium or vecuronium) as an alternate (sux contraindicated) and for maintaining paralysis.

Would stay away from pancuronium outside of the hospital ICU... Duration is about 2 hours! Roc or vec, you can just bolus every 20-40 minutes as needed, which shouldn't be too many doses even for rural transports.

As far as sepsis, good talk here. I would really like to see us drawing the cultures before starting antibiotics, and a clear evidence-based approach to what antibiotics to start based on the likely source of infection. I think it's reasonable for us to carry 2-3 antibiotics used alone or in concert with each other depending on the case. At the same time, there has to be some consideration to not going overboard due to the toxic effects of some of these antibiotics, and the risk of resistance, until the organism is identified.


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## Melclin (Mar 5, 2010)

Indeed. I am enjoying this thread. 

I agree with you about the panc, redcross. 

On inspection of my copy of Robers and Heges Clinical procedures in Emergency medicine, "_One consensus panel recommends pancuronium for maintaining paralysis, except in patients with cardiac disease or
hemodynamic instability.[115] The panel recommended vecuronium for the latter patient groups_"

For what its worth (from a student), I'm going to go with Sux and Rocuronium on account of roc's increasing popularity in the ED as the initial paralytic in RSI, when sux is contraindicated (which gives us more options) and the possibility of adding suggamadex to the list down the line for reversing its action (if that's possible, you might do away with sux altogether). Also panc causes cardiovascular troubles - "_Many patients experience an increase in heart rate, blood pressure, and cardiac output because of the vagolytic effect of the drug...[recommended for use] except in patients with cardiac disease or hemodynamic instability_" , which you might think would be a significant portion of our patients.  

Fentanyl and midaz for analgesia and sedation here. I was at a conference on trauma last year where RSI came up. An intensivist was concerned with the use of midazolam in the pre-hospital environment for Stephen Barnard's RSI trial in head injured pts for fear of hypotension. Dr Barnard was not concerned about its side affects, but many others seemed to be. Some were in favour of a worrisome method know as "sux and an apology". I need not explain this, I think. Seems like a good reason to use etomidate.

So my wish list so far, not taking into account the practicality of price or education:

*ACLS*
-Adrenaline
-Atropine
-Sodium Bic
-Magnesium Sulfate
-Calcium gluconate
-Vasopressin 

*OtherCardiac drugs*
-ASA
-GTN (SL and IV [we don't currently have IV GTN at any level, which I think is a bit poor, I'm sure a good MICA paramedic could handle an nitro infusion)
-Clopidogrel 
-Heparin (probably not LMWH on account of its age limit and creatinine clearance guided dosage..might be bit problematic in th prehospital environment).
-Amiodarone
-Lignocaine 
-Tenecteplase.
-Metaraminol
-Verapamil
-Perhaps dobutamine & noradrenaline 

*Asthma/COPD*
-Salbutamol (neb and IV)
-Ipratropium
-Heliox

*Analgesia, Sedation & Paralytics*
-Fentanyl (IV & IN)
-Morphine
-Midazolam
-Methoxyflurane
-Ketamine
-An NSAID, (preferably IV) which one though I couldn't say, perhaps Parecoxib Sodium
-Etomidate 
-Suxamethonium
-Rocuronium 
-Sugammadex (not FDA approved as far as I know, so you yanks can't have any)

*Volume fillers/infusions fluids*
-Lactated Ringers
-Saline
-D5W

*Diabetic*
-Glucose paste
-Glucagon
-Dextrose 10% (yanks need to get on the 10% band wagon) 

*Others*
-Ceftriaxone
-Dexamethazone
-Haloperidol
-Prochorperazine
-Ondansetron
-Promethazine
-Benzotropine
-Naloxone


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## MrBrown (Mar 5, 2010)

A very good discussion; I would like to ammend my list and add ceftriaxone


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## Smash (Mar 5, 2010)

redcrossemt said:


> Would stay away from pancuronium outside of the hospital ICU... Duration is about 2 hours!



I can't find any sources that give 2 hours for duration of pancuronium.  40-60 minutes is what I have been aware of, and this fits in very well with our geography, transport times and so on.  Even with shorter transport times in the city center, when you factor in the fact that the patient will have to be intubated (and paralysed) before going to the Donut of Death to be scanned anyway, we still have no concerns over the duration of panc.  Keeping in mind of course that we are not sedating, paralysing and intubating Joe Bloggs who bumped his head and is a bit confused therefore requiring neuro assessment immediately; these patients have smashed heads or catastrophic strokes and more than likely are going to need a chunk 'o head pulled out in the near future.

My experience with panc is that the cardiovascular effects are not particularly significant.  Of course the demographics of those who are smashing their heads is young and otherwise healthy, and this is the primary population getting paralyzed.  

This is not to say that I disagree with having other agents, merely that panc is effective and safe as used here.  Vec or Roc should be included for situations or patients in whom other agents are not appropriate.



			
				MelClin said:
			
		

> Some were in favour of a worrisome method know as "sux and an apology".



Surely you kid?!  The whole point of RSI in the head injured patient is to minimize further insult to ICP.  Unsedated administration of sux is hardly going to achieve that.  In fact it is tantamount to torture!  Etomidate would be a good option though.  Again, solely from my experience, I have not noticed significant cardiovascular effects from versed in these patients when we follow our (very conservative) guidelines.  Again, both options would be nice.



> Verapamil[/QUOTE
> 
> Not adenosine?  I realise that the reversion rates are essentially the same, but does not the safety profile of adenosine recommend it more highly?


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## Melclin (Mar 5, 2010)

Smash said:


> I can't find any sources that give 2 hours for duration of pancuronium.  40-60 minutes is what I have been aware of, and this fits in very well with our geography, transport times and so on.  Even with shorter transport times in the city center, when you factor in the fact that the patient will have to be intubated (and paralysed) before going to the Donut of Death to be scanned anyway, we still have no concerns over the duration of panc.  Keeping in mind of course that we are not sedating, paralysing and intubating Joe Bloggs who bumped his head and is a bit confused therefore requiring neuro assessment immediately; these patients have smashed heads or catastrophic strokes and more than likely are going to need a chunk 'o head pulled out in the near future.
> 
> My experience with panc is that the cardiovascular effects are not particularly significant.  Of course the demographics of those who are smashing their heads is young and otherwise healthy, and this is the primary population getting paralyzed.
> 
> ...



Regarding the Bernard's presentation, it was a while ago now, and you must also remember I'm really well out of my depth when discussing such things seriously. However, on inspection of my notes from the presentation, I see that I have noted the audience member's queries which is convenient:

"- is sux without sedation acceptable to prevent hypotension 2ndry to midaz?
 - in a pt with lowered GCS, how do you know they are such because of head injury and not because of hypotension - in which case sedation for RSI would make problem worse"

Would they not be concerned about midaz dropping the BP bellow around 90, what with the increase in mortality in TBI? I understand that if they had a very high BP as you may expect in some TBI, that would be fine and even desirable. I think/assume their concern was for people who weren't necessarily experiencing that hypertension, including pts who were perhaps hypovolaemic from haemorrhage. I realise coma due to haemorrhage is a contraindication to RSI, but I can see that there might be a grey area- where they have been bleeding earlier and they are bordering on hypotension but they would still benefit from RSI for their TBI - that could prove dangerous. As well as the problem suggested in my second dot point - that it may be the hypotension, not the TBI responsible for the low GCS, in which case you are doing more harm than good. 

I have looked over the Victorian RSI guidelines and they dictate reduced doses of midaz for lower BPs, which I didn't previously realise (you may already be aware of this if they happen to be your guidelines as well  ). So that seems pretty reasonable. Still, as you say, I presume it would be nice to have etomidate as an option, even if midaz is very unlikey to cause problems. This is after all a "wish list", not a realistic request  

Ketamine is another induction agent and alternative too etomidate that we haven't really discussed. Seeing as though its in our imaginary bag for analgesia anyway, perhaps we don't need etomidate.


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## redcrossemt (Mar 5, 2010)

Smash said:


> I can't find any sources that give 2 hours for duration of pancuronium.  40-60 minutes is what I have been aware of, and this fits in very well with our geography, transport times and so on.



If you are using the lower maintenance dose the duration is 40-60 minutes as you state. If you are using the intubating dose (0.1mg/kg), the duration is ~100 minutes per the prescribing information and 90-120 minutes per several studies.


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## redcrossemt (Mar 5, 2010)

Melclin said:


> Ketamine is another induction agent and alternative too etomidate that we haven't really discussed. Seeing as though its in our imaginary bag for analgesia anyway, perhaps we don't need etomidate.



I think it's reasonable to carry both ketamine and etomidate. Ketamine can screw with a patient's hemodynamics, although in the opposite way of midazolam, but is a good choice for those with reactive airway disease, and for kids in general.


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## MrBrown (Mar 5, 2010)

redcrossemt said:


> I think it's reasonable to carry both ketamine and etomidate. Ketamine can screw with a patient's hemodynamics, although in the opposite way of midazolam, but is a good choice for those with reactive airway disease, and for kids in general.



We carry ketamine and use it both as an RSI induction agent (1.5mg/kg) and as combination analgesia with morphine at lower doses, say 10-20mg prn.

I am not convinced (and am not overly sure why) that ketamine produces the same sort of "sleep" as etomidate/propofol but I stand to be proven either way.


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## Jon (Mar 5, 2010)

I see Versed on the list... don't see Ativan. Why? At least Versed+Ativan? Ativan for agitation/sedation, and Versed for sedation for cardioversion.

Why Pepcid?






triemal04 said:


> I actually don't carry phenergan currently; my only option is zofran, which, much as I like it, is much less effective after the pt has already begun to vomit.  Phenergan on the other hand seems to be effective regardless.  Of course it's harder on the veins and has some interactions that aren't always the best, so having multiple options would be better.
> 
> Same with reglan; I don't carry it, but have had multiple interactions with MD's and PA's who swear by it for treating nausea caused by migraines.  And based on my own experiences in treating that type of nausea with zofan...it doesn't always work.



Alright - That was a big question in my mind - trying to figure out justification to carry 3 instead of 1.
If you had to pick one, anyone against Zofran?



Melclin said:


> <Snip>
> *Volume fillers/infusions fluids*
> -Lactated Ringers
> -Saline
> ...



Why D5W, LR, and NSS. What population gets what?

And why D10? I've got D10 for infants... D50 for adults.





I have to agree - this is a GREAT discussion - Espicially with the international discussion.


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## fma08 (Mar 5, 2010)

Melclin said:


> Indeed. I am enjoying this thread.
> 
> I agree with you about the panc, redcross.
> 
> ...



Do you guys routinely administer anitbiotics down there? And any particular reason for the use of a cephalosporin over another class?


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## Smash (Mar 5, 2010)

Verapamil isn't a drug that we see very often any more, does it get used very often?  It has a rather nasty side effect profile, hence the use of adenosine these days.  Adenosine is also a little more versatile.



Melclin said:


> "- is sux without sedation acceptable to prevent hypotension 2ndry to midaz?



Holy crap no!  If you want to prevent hypotension secondary to versed in the head injured patient, you use etomidate!  Paralysis without sedation is criminal and counterproductive.



> - in a pt with lowered GCS, how do you know they are such because of head injury and not because of hypotension - in which case sedation for RSI would make problem worse"
> 
> Would they not be concerned about midaz dropping the BP bellow around 90, what with the increase in mortality in TBI? I understand that if they had a very high BP as you may expect in some TBI, that would be fine and even desirable. I think/assume their concern was for people who weren't necessarily experiencing that hypertension, including pts who were perhaps hypovolaemic from haemorrhage. I realise coma due to haemorrhage is a contraindication to RSI, but I can see that there might be a grey area- where they have been bleeding earlier and they are bordering on hypotension but they would still benefit from RSI for their TBI - that could prove dangerous. As well as the problem suggested in my second dot point - that it may be the hypotension, not the TBI responsible for the low GCS, in which case you are doing more harm than good.



That is certainly a potential issue, which is why any hemodynamic compromise such as tension pneumothorax needs to be ruled out early in the piece and aggressive BP management undertakne.  If the altered GCS is due solely to blood loss then it is probably not a good idea to RSI.  If you aren't sure though, sometimes you have to take an educated guess at what the likely cause of the altered LOC is going to be.  Interestingly enough a study done on head injury and bleeding showed that the best route is probably still that of permissive hypotension, even bearing in mind the normally poor outcomes with hypotension in TBI.  It is thought that improved cerebral blood flow as opposed to pressure is responsible, but I dare say a lot more study is required.  Bourguignon in Archives of Surgery I believe, can't remember the date.



> Ketamine is another induction agent and alternative too etomidate that we haven't really discussed. Seeing as though its in our imaginary bag for analgesia anyway, perhaps we don't need etomidate.



More options are always better!



> And any particular reason for the use of a cephalosporin over another class?


 Cephalosporins are effective against a very wide range of bacteria, can penetrate the CSF and other areas well (or at least ceftriaxone can) and are thus a good choice when we suspect sepsis, but don't yet know the specific organism.

I think the link might have been posted elsewhere, but the Surviving Sepsis campaign publishes guidelines periodically, the latest being 2009 Link Here


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## Shishkabob (Mar 5, 2010)

Why don't more people have Nitrous Oxide in there?!  Fantastic drug for minor trauma.


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## Smash (Mar 5, 2010)

Linuss said:


> Why don't more people have Nitrous Oxide in there?!  Fantastic drug for minor trauma.



Speak to the FDA about that...  Yes it is a very good drug.  Like bretylium.  No, wait a minute...


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## Shishkabob (Mar 5, 2010)

So you deny that nitrous oxide is a good pain management drug?  Explain your reasoning.


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## Melclin (Mar 5, 2010)

Smash said:


> Verapamil isn't a drug that we see very often any more, does it get used very often?  It has a rather nasty side effect profile, hence the use of adenosine these days.  Adenosine is also a little more versatile.
> 
> *Oh, very interesting. I wonder why it is that we don't use it then. I fear that it maybe to do with our service's apparent fear of short onsets. Thanks for that.
> *
> ...





fma08 said:


> Do you guys routinely administer anitbiotics down there? And any particular reason for the use of a cephalosporin over another class?



Not routinely. Its primarily for mennigococcal septicaemia but listed as, also "for use in other sepsis - consult with clinician" which means we call a especially experienced and well educated medic for a consultation on the severity of the sepsis and the appropriateness of using ceft for the specific infection. The receiving hospital will probably also want to have a say, because we'll ruin their blood cultures if we give ceft, so teh patient has to be super sick to warrant it. Which is why I'd like to see us taking blood cultures, so we can give more ceft and not be upsetting the management of pts later down the track. 

Ceftriaxone is a standard first line broad spectrum antibiotic. Its probably also cheap :wacko:



Jon said:


> Why D5W, LR, and NSS. What population gets what?
> 
> And why D10? I've got D10 for infants... D50 for adults.



The NS vs LR is a contentious issue. I've heard many things and read many papers making good points, but I don't think its a done deal either way even in specific patterns of illness/injury. LR due to its ph and lower sodium levels may be more preferable in large volume infusions. But then pushing a solution containing lactate on a person who's lactate levels are rising because of anerobic respiration...probably not a good idea. LR, so I've read is the fluid of choice in burns + more minor trauma still requiring volume filling. NS in sepsis and severe/moribund trauma, dehydration etc. What I was really getting at in posting both though was that no one had listed fluids under their drug list and I wanted to make a point that the choice of fluids may be just as important as amiodarone vs lignocaine etc.

D5W is for mixing drugs. 

D10% -- Moore C, Woollard M: Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial. _Emerg Med J_. 22(7):512–515, 2005.  You get lower post treatment glucose levels which reduces the "seesawing" (what comes up must come down) of the BGL as we would say - so you can titrate to a good BGL. Plus at a lower concentration, you don't have to be too worried about necrosis from a dodgy cannulation. 



Linuss said:


> So you deny that nitrous oxide is a good pain management drug?  Explain your reasoning.



I wouldn't want my ambulance filling with nitrous. You must have some sort of filter or something right? I don't need a nitrous/o2 mix because I feel I've got the bases covered with methoxyflurane, IV NSAID, morph, fent and ketamine and it would be a pain in the arse carrying around a bloody great tank of nitrous.


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## Shishkabob (Mar 5, 2010)

The nitrous tank is the same size as an O2 tank on the stretcher.

And the benefit of nitrous is rapid onset, patient administered to desired effect, and no needles.  I've had patients in a decent amount of pain but refuse morphine due to an IV needing to be started... I offered them nitrous oxide and they loved it.


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## Melclin (Mar 5, 2010)

Linuss said:


> The nitrous tank is the same size as an O2 tank on the stretcher.
> 
> And the benefit of nitrous is rapid onset, patient administered to desired effect, and no needles.  I've had patients in a decent amount of pain but refuse morphine due to an IV needing to be started... I offered them nitrous oxide and they loved it.



Exactly, a whole other bloody tank to carry around. Methoxyflurane and IN fent are both rapid onset, Methoxyflurane just as much as nitrous (but I realise you can't use it in the states). IN fentanyl can control quite severe pain, its quick, and no needles. 

Not to mention the OH&S problems caused by an ambulance full of nitrous. Do u have some kind of filter or something?


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## Bloom-IUEMT (Mar 6, 2010)

Linuss said:


> So you deny that nitrous oxide is a good pain management drug?  Explain your reasoning.



Too many medics where getting high :glare:


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## Smash (Mar 6, 2010)

Linuss said:


> So you deny that nitrous oxide is a good pain management drug?  Explain your reasoning.



Reading comprehension FTW!


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## Shishkabob (Mar 6, 2010)

Smash said:


> Reading comprehension FTW!



No, you failed at phrasing sentences, not the other way around.  



> Yes it is a very good drug. Like bretylium. No, wait a minute...



You said it was good like Bretylium, which is obvious sarcasm considering you think Bretylium isn't good, which means you think Nitrous-oxide isn't good.


That may not have been what you meant, but that's exactly how you wrote it.


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## Melbourne MICA (Mar 6, 2010)

*Wish Lists*

We added Bretylium to our arrest guidelines years ago - and just as quickly dumped it. When studied, it was clearly demonstrated it made no difference to either achieving ROSC or post arrest outcomes. It was also expensive and given how often we used it, not good value for money.

Which brings up the point about value for money. Like it or not, EMS providers have to look at budgeting as much as anything else so EMS services need to see verifiable improvements in outcomes that translate into both well used health dollars and long term cost and patient benefit. The same goes for equipment and procedures.

Safety, practicality and ease of use, storage, evidence based efficacy, ability to manage side effects in the field, security issues etc - lots of things to consider when choosing pharmacology. Personally I'd like to see more emphasis on infective illness management but the issue of "diagnosis" in the field comes into it of course as well as does early treatment really improve the patients lot in the long run? That particular facet of the scenario is an important one and I am sure EMS will have a bigger impact in this area in years to come.

Antibiotic (anti-viral?), anti inflammatory, anti-coagulation/antithrombotic, anti-arrhythmic, anticholonergic, insulin/glucose management - all areas where I think we will see EMS developments - So many of our patients survive the acute event only to perish in the ICU from ARDS, SIS, DIC etc.  

Our respective Meds standards committees have their work cut out for them me thinks.

MM

PS Oh... and there is the little issue of having to carry around all these things in a box or bag without doing your back (or your head) in. Our current drug box weighs in at around 10kg fully stocked. Lug that up five flights of steps when you know half the stuff in it is not likley to make the slightest bit of difference to the patient.


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## redcrossemt (Mar 14, 2010)

Jon said:


> I see Versed on the list... don't see Ativan. Why? At least Versed+Ativan? Ativan for agitation/sedation, and Versed for sedation for cardioversion.
> 
> Why Pepcid?
> 
> ...



Ativan (lorazepam) is a good drug, but if I had to pick one, I would choose midazolam (Versed). It has a MUCH shorter duration, and can be used for sedation, anxiety, agitation, or anything else you would use Ativan for.

Pepcid (famotidine) is an H2-receptor antagonist that has shown some promise in anaphylaxis with concurrent use of an H1 blocker (diphenhydramine/promethazine). Most hospitals (at least around here) treating severe anaphylaxis will give H1 and H2 blockers post-epi, as well as a steroid - usually prednisone here.

Regarding D10, I guess we could carry all three, but honestly I'm fine mixing it if we only have one dose. Carry D10 for adults may add substantially to the weight and volume of our kit.


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## Melclin (Mar 14, 2010)

redcrossemt said:


> Regarding D10, I guess we could carry all three, but honestly I'm fine mixing it if we only have one dose. Carry D10 for adults may add substantially to the weight and volume of our kit.



If you would normally carry, D50, D25 and D10 then only carrying D10 would reduce the weight/volume of the kit. 

If you are only carrying D50 and mixing it, then you need to carrying something to mix with it as well as the D50.

A 250 ml bag of D10 is really not any more heavey than an amp of D50 and its more flexible - it can be shoved anywhere in the kit, and you need carry nothing else. We only carry one in our bags, with more in the ambulance.


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## emtjack02 (Mar 19, 2010)

Great discussions...
I would have to disagree with abx treatment prior to blood cultures unless transport times are crazy (like 3 hours).  For septic shock we use Primaxin or merem(sp) + vanco + zithromax(if pneumonia).
Etomidate is a great idea for head trauma but I dont recall seeing any mention of lidocaine.  There is mention of paralytics only for crash airways in rosens emergency medicine.  

my $0.02


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## Smash (Mar 20, 2010)

emtjack02 said:


> Great discussions...
> I would have to disagree with abx treatment prior to blood cultures unless transport times are crazy (like 3 hours).  For septic shock we use Primaxin or merem(sp) + vanco + zithromax(if pneumonia).



I assume 'abx' is antibiotics? You state that you don't agree with pre-hospital antibiotics, but then give a list of antibiotics you use.  I'm confused; do you agree or disagree with the use of antibiotics in pre-hospital care?  If you do disagree can you explain further as there is reasonable evidence that any delay in administering antibiotics in some types of sepsis (meningococcal for example) causes significantly worse outcomes.


> Etomidate is a great idea for head trauma but I dont recall seeing any mention of lidocaine.


I'm not sure why there would be, I wasn't aware that anyone still thought that lidocaine was useful in managing ICP prior to RSI. 



> There is mention of paralytics only for crash airways in rosens emergency medicine.
> 
> my $0.02



Sorry, it may be my sleep deprivation, but I don't know what you mean by this.


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## emtjack02 (Mar 20, 2010)

Im sorry...the abx listed are the ones in our hospitals sepsis protocol. 
I have not done any recent lit searches but there are still airway management/ER text advocating lidocaine as an adjunct for RSI in the head trauma pt.  
I mentioned the paralytics w/o sedation for crash airway because there was talk about not using a sedative and how inhuman that would be.  I agree that I would not want to intubated w/o sedation but I was merely trying to point out that some of the Emergency Medicine bodies out there support only giving a paralytic if the airway is immediately compromised.


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## RALS504 (Mar 21, 2010)

Awesome thread!!
I would like all of the other meds suggested & to add:
-Regular insulin IV for hyperglycemia & crush injurues
-Lopressor (Toprol) IV for AMI & HTN
-Dilaudid for extreme pain
-Decadron NEB or IV for respiratory distress
-Atrovent for respiratory
-Xopenex (levalbuterol) for resp distress in cardiac pts


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## EMTinNEPA (Mar 21, 2010)

zofran
aspirin
nitro SL + IV
cardizem
narcan
albuterol
ipatroprium
diphenhydramine
pepcid
solumedrol
oxytocin
furosemide
fentanyl
morphine
toradol
versed
haldol
etomidate
rocuronium
vecuronium
magnesium sulfate
sodium bicarbonate
calcium chloride
sodium nitrate
sodium thiosulfate
glucagon
D50
acetaminophen
thiamine
labetalol
succinylcholine
D25
epinephrine 1:10,000 and 1:1,000
ibuprofen
lidocaine
amiodarone
captopril
lopressor
insulin


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## Melclin (Mar 24, 2010)

RALS504 said:


> Awesome thread!!
> I would like all of the other meds suggested & to add:
> -Regular insulin IV for hyperglycemia & crush injurues
> -Lopressor (Toprol) IV for AMI & HTN
> ...



Why dilaudid? In addition Fentanyl, Morphine, Parecoxib, Ketamine, Inhalation analgesic? What does dilaudid do that fent or morph can't in the prehospital context?



EMTinNEPA said:


> zofran
> aspirin
> nitro SL + IV
> cardizem
> ...


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## triemal04 (Mar 25, 2010)

Melclin said:


> sodium nitrate - *vasodilator? What are its indications?*
> sodium thiosulfate *For cyanide poisoning?*


That's about the only use for sodium nitrite and sodium thiosulfate you're going to see prehospital...don't know if there is another use for them really.  Though for best results amyl nitrate needs to be added into the mix.  Unfortunately, both those drugs can cause severe problems with the pt; sodium nitrite forms methemoglobin in the blood which helps to unbind the cyanide from the cytochromes (I believe; haven't' looked at this for awhile) and up ATP production while the thiosulfate helps to speed up the metabolization of cyanide and it's conversion to thiocyanite which can be excreted from the body.  Of course, using sodium nitrite when carboxyhemoglobin is present (like after smoke inhalation, the most common time you'll see cyanide poisoning) will make things worse and further compromise the ability to transport/process O2.  And sodium nitrite has a nasty habit of causing (severe) hypotension and acidosis.  Using them is better than the alternative, but they aren't exactly benign drugs.

Hence why the Lilly Kit's are mostly being phased out and replaced by the Cyanokit which is essentially a B12-precursor.  Don't ask me how that works because I can't remember.


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## audreyj (Apr 6, 2010)

Where I live our transport times are crazy short, about 15 mins tops.  Most of these drugs that are listed would have very little benefit to us.  Our average door to balloon time for cardiac pts is 60 mins, the record being 27.  In the case of cardiac arrest IF we get a pulse and favorable rhythm back chances of us having the time to titrate a dopamine drip or a lidocaine drip is slim to none.  We grab our arrests and haul tail doing most of the code en route.  

That being said our new protocols dropped valium from our drug boxes as well as any drugs down the ET tube.  We carry a very limited supply of drugs and for that I'm grateful, in the event of having to choose a drug what if the one I choose has no effect on my patient?  

The list of meds that we carry are (in no particular order):
Albuterol
Atropine
Adenosine
Benadryl
Dopamine
Lidocaine (drip and injection)
D50
Glucagon
Glucose Paste
Epi 1:1000
Epi 1:10,000
Tetracaine
Narcan
Morphine
Valium *going away May 1*
Versed
Nitro tabs *spray going away May 1*
Nitro paste
Sodium Bicarb
ASA
Ammonia Inhalants

Our only approved IV fluid is .9, I want to say that is the complete list but don't quote me on it.  

I wish we had options for Fentanyl and Zofran.  When we intubate we give versed.  We also don't carry antibiotics.

A drug box wish list is only appropriate if your transport time determines it could be helpful.  If my transport times were longer, sure some of the drugs listed would be helpful to have.  Carrying drugs just to carry them is absurd.  More cost to the provider, more room for error, and more room for liability issues to arise.  I'm happy with the drugs we have, our system is great about taking out choices and going with the best choice overall.


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## MrBrown (Apr 7, 2010)

audreyj said:


> We grab our arrests and haul tail doing most of the code en route.



Then you need to stop.  Cardiac arrests should be worked where they fell down and more and more no RSOC = no transport.  All you are doing is relocating a corpse and creating exponentially unjustified risk.


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## Smash (Apr 7, 2010)

audreyj said:


> We carry a very limited supply of drugs and for that I'm grateful, in the event of having to choose a drug what if the one I choose has no effect on my patient?



Sorry, what?  That statement makes no sense at all.  Having a limited selection of drugs is the exact opposite of what you would want if your first choice didn't work.  Also, you would only give someone a drug that you know will have a very good likelihood of providing benefit.  For example, I won't give benadryl to a patient with symptomatic supra-ventricular tachycardia, but I will give adenosine.



> Ammonia Inhalants


Really?  Why?

[/QUOTE]When we intubate we give versed. [/QUOTE]

I assume you don't intubate head injured patients with trismus then?



> I'm happy with the drugs we have, our system is great about taking out choices and going with the best choice overall.



Hmmm...  So what is the best choice overall for pre-hospital pain relief?  Morphine?  Or are we worried about the potential for hypotension in patients with tenuous perfusion, or the prevalence of allergic or adverse reactions to morphine?
Fentanyl?  Or do we think it might be more appropriate in some cases to give a longer acting opiate, for example in extremity fractures or neck of femur fractures when we know it is going to be some time before the patient recieves any further analgesia in hospital?
Ketamine?  Great for traumatic pain, particularly fractures or multi-trauma, but then are we prepared to manage the potential for emergence phenomena?  Of course it can also be used as an induction agent for RSI in some settings, so does this add to it's attractiveness?
Toradol?  Good for moderate pain, particularly for musculoskeletal pain, but doesn't have the speed of onset that we may need.

I could go on and on, and for most drugs/conditions, not just pain.  The thing is that the "best" choice may not exist, which is why options are good.  The reason most services get the drugs they get is becuase of plenty of things, efficacy not necessarily being the most important.  Usually it is all those other thingss you are worried about:  How much does it cost?  How dumb are our paramedics?  How many people will die and therefore how much will we get sued for if we give them this drug without bothering to educate them in the use of it?

How well does it work? is usually way down the bottom of the list.

Oh, and I agree with MrBrown, transporting active codes is just plain wrong.


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## audreyj (Apr 7, 2010)

MrBrown said:


> Then you need to stop.  Cardiac arrests should be worked where they fell down and more and more no RSOC = no transport.  All you are doing is relocating a corpse and creating exponentially unjustified risk.



We have to transport them unless they show signs of being down for a long time.  We can only call a death in the field if rigor mortis has set in, gross dependent levidity, decapitation, mummification or putrefication.  If one of those is not present we must work the code and transport them, also depending on who we get on the radio they can tell us to work and transport the patient even if one of those conditions is present.  In the codes we transport we do establish lines and airways before moving them to the ambulance but we carry only a limited drug supply in our jump bags.



> Quote:
> Ammonia Inhalants
> Really? Why?



In the event of syncope, required by the state health department.  I've never heard of it being used however.  Just like the CPR shields we're required to carry, we have ambu bags in our jump bags and will use those before a CPR shield.

Our standing orders are reviewed every 2 years and changes made, and if there is an addendum to the orders within that 2 years changes are made, but that's rare.  Our choices for intubation, TCP, and cardioversion were versed and valium when sedation needed to be done, valium was proven not to work as well as versed in our system, so you eliminate the choice.  

And, like I said, our transport times are short, if we had longer transport times perhaps our drug boxes would contain different meds.  This is what has shown to be beneficial for us and our system.

For symptomatic SVT, our orders are for adenosine.


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## MrBrown (Apr 7, 2010)

What sort of success are you having with simply using midazolam to intubate?

This was allowed here in the past but withdrawn due a host of issues around the adequacy of sedation only intubation.  

Personally I think it's really dodge and shouldn't be used.


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## redcrossemt (Apr 7, 2010)

Agree about the arrests... it's wrong! Ask your medical director to support calling the arrests in the field. Do you have extra meds in your ambulance you don't have in your bag? Well, start with what you've got and send someone to the truck to get the full drug box or whatever. Maybe I'm missing something though.

Regarding having a smaller choice of meds due to short transport times... Most of my transport times are relatively short, but that doesn't mean that certain things should be done on-scene instead of waiting 10-15-20-25 minutes to get to the ER. And then's there the wait to see a doc, have someone pull the drugs, etc. 

I would prefer to be a medic with options who, because of that, must remain knowledgeable and up to date, instead of a medic who is happy having a few drugs because short transport times makes that okay.


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