# 75yo Male - post LOC wrist #



## Melclin (Apr 21, 2010)

I've noticed that there is a tendency not to post scenarios unless they are supposed to be particularly difficult, strange etc and I don't like it, cos it doesn't help us youngins learn and we all know how a good convo can start over a seemingly simple case. So I thought I might post some real cases, but not necessarily not overly difficult ones; lets remember our manners and include everyone in the process (EMTs with 15 mins of class time welcome). Will continue this idea depending on how useful it appears to be.

Dispatch: Priority 2, 75 year old MALE: Possible fracture, non dangerous body area. TIME - 15:32

O/A: Met at the door of an expensive looking house by a older man in obvious pain and is glad that "the doctor could come at such short notice". Complains that he was walking to the toilet, fell and broke his wrist. You all take a seat in his living room. He also complains that he feels quite sick because of the pain. 

I assume you'll ask for the following.

Allergies - nil. 
PHx- AMI x 2 (2004,2007). CABG x4 (2007). Hypertension (but his doc says his bp has been great lately) and he's been fighting off a nasty chest infection lately.
Meds- Diformin, aspirin, atacand. 

Event history - Complains that he was walking to the toilet, felt dizzy and then he woke up on the ground, with a "badly broken wrist" and called the "the doctors" straight away on account of the pain. 

Pulse- 190 (weak & regular) BP- 95/75 RR-22 SpO2:95 on room air. Skin is cool pale and dry.  

Wrist is obviously swollen and deformed but there is no haemorrhage or damage to the skin.

Everything else you'll have to ask for.


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## mycrofft (Apr 21, 2010)

*The drug names are unfamiliar.*

Many brands in other countries are rebranded here, or simply unavailable.

I would be assessing this man's orientation as I splinted his wrist for comfort (good distal circ/sense/ROM?Versus other side?) and maybe do a postural BP before we load-ed and go-ded.

Pneumonia in the elderly more easily brings on CNS signs than it (also) does in younger folk. Temperature?


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## NYBLS (Apr 21, 2010)

What was his BP last doctors appt? 
Was he spinning or was the world around him spinning?
Pulse seems a little too tachy, what is his usual pulse rate?
Does he seem anxious or nervous?
Does he feel dizzy currently?
Chest pain, abdominal pain, SOB, excessive thurst, numbness/tingling?

Start with a BG, rule out C-Spine, pupils, lungs.

Immobilize arm, apply ice as needed (assuming were BLS here).

Transport and finish physical exam enroute.


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## NYBLS (Apr 21, 2010)

Also, what position was he in when the pressure was taken? Consider taking an orthostatic pressure/H.R.


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## mississippimedic (Apr 21, 2010)

EKG needed.         HR, LOC, weak pulse, cool pale skin.  Probably time for chemical or electrical cardioversion.


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## Melclin (Apr 21, 2010)

mycrofft said:


> Many brands in other countries are rebranded here, or simply unavailable.
> 
> I would be assessing this man's orientation as I splinted his wrist for comfort (good distal circ/sense/ROM?Versus other side?) and maybe do a postural BP before we load-ed and go-ded.
> 
> Pneumonia in the elderly more easily brings on CNS signs than it (also) does in younger folk. Temperature?



Diformin is a type of metaformin, first line treatment for type 2 diabetes. Atacand is a angiotensin II antagonist - for Hypertension, I forget its proper name.

He is happy to nurse his own wrist and gets quite upset when you try to do otherwise. good distal circ, sensation, range of movement is pretty much nil due to pain. Wrist is obviously deformed. 

A postural BP wasn't done, and I'm not sure of how I should make it up given the wrest of the scenario..:wacko:

Temp is 38.1 (100.58). 



> What was his BP last doctors appt? *Doesn't remember*
> Was he spinning or was the world around him spinning? *He wasn't spinning himself, he felt dizzy and fell over. That's all you get from him*
> Pulse seems a little too tachy, what is his usual pulse rate? *No idea.*
> Does he seem anxious or nervous? *He seems a little anxious or perhaps agitated with your questions, and just wants to see the doctor*
> ...



ECG shows SVT @ 200


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## Aidey (Apr 21, 2010)

"Sir, I'm concerned because your heart is beating too fast. Have you ever had this happen before?"

and "I know your wrist is what is bothering you, but right now I really want to figure out what is going on with your heart. Its possible that your fast heart beat is what made you feel dizzy and fall."


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## Melclin (Apr 22, 2010)

Aidey said:


> "Sir, I'm concerned because your heart is beating too fast. Have you ever had this happen before?"
> 
> and "I know your wrist is what is bothering you, but right now I really want to figure out what is going on with your heart. Its possible that your fast heart beat is what made you feel dizzy and fall."



"No body has ever said that before", "Possibly I suppose. You tell me, you're the doctor, I have no idea what made me fall, I pay my taxes and I expect to get better care than this"


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## Aidey (Apr 22, 2010)

oops...forgot the versed before the cardioversion....

KIDDING! Really guys, kidding, I promise. 

That is usually my cue to ask the patient what it is they expect me to be doing/what I need to do to make them happy. When they say something like whip out the mobile x-ray and apply a cast I will start correcting their expectations. If it is something more realistic I will do my best to oblige. 

In his case prep for transport, IV, O2 via cannula. Attempt to cardiovert via vagal manuvers, which are likely to be unsuccessful because I doubt the pt is going to comply. After that it's keep a close eye on him and how stable he remains. He is just a tad too stable for me right now to shock him. He's really currently not unstable.


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## Melclin (Apr 22, 2010)

Aidey said:


> That is usually my cue to ask the patient what it is they expect me to be doing/what I need to do to make them happy. When they say something like whip out the mobile x-ray and apply a cast I will start correcting their expectations. If it is something more realistic I will do my best to oblige.
> 
> *I like your approach.*
> 
> In his case prep for transport, IV, O2 via cannula. Attempt to cardiovert via vagal manuvers, which are likely to be unsuccessful because I doubt the pt is going to comply. After that it's keep a close eye on him and how stable he remains. He is just a tad too stable for me right now to shock him. He's really currently not unstable.



I agree with not shocking him. Any other options? 

Have the BLS chaps considered back up? I know you don't have a monitor but does a weak pulse at 190, a bp of 95/75 and cool, pale skin warrant any concern?


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## mycrofft (Apr 22, 2010)

*No one was addressing that.*

Amazing he's still talking with that crummy a set of vitals.


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## 8jimi8 (Apr 22, 2010)

blood glucose,
ECG
Move to the stretcher
Vitals q5
IVs on scene,
Start transport
start a 250cc bolus
splint the arm, but no sling (occlusions)
Attempt a vagal maneuvers -
Monitor LOC and vitals for deterioration.

How's my pressure and rate after that bolus?


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## MrBrown (Apr 22, 2010)

Never fear, Brown is here! (No really, run, do it now, just run)

Pop in an 18 and run 250 of fluid 
Oxygen, two litres on an NC
Splint wrist 
Maybe a toot on the green whistle (methoxyflurane) if indicated.
12 lead 
Valsalva
Some midaz and cardiovert if he drops out anymore


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## Veneficus (Apr 22, 2010)

Did I miss a post?

Vagaling a pt with a HR of 190 but no indication of the rhythm? What if he is in Vtach?

Maybe check for rubs, gallops, and other abnormal heart sounds?


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## MrBrown (Apr 22, 2010)

Veneficus said:
			
		

> Did I miss a post?
> 
> Vagaling a pt with a HR of 190 but no indication of the rhythm?...
> 
> ...



10 char


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## Veneficus (Apr 22, 2010)

thanks, didn't see that in all the words.


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## 8jimi8 (Apr 22, 2010)

lol i'm usually reluctant to reply to scenarios.

i feel like i know alot, but i seriously need some more ride time.  haven't been able to volunteer in a while


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## Melclin (Apr 22, 2010)

mycrofft said:


> Amazing he's still talking with that crummy a set of vitals.


Its an interesting thing that no one has measured conscious state, but given our recent discussion of the popularity of the GCS in America it makes sense. I don't know that I can speak to its true efficacy in assessing perfusion, but I've always been taught that conscious state in these sorts of cardiac scenarios is important because when you have a cardiac condition causing a drop in CO such that it affects conscious state, then you have a problem.



8jimi8 said:


> blood glucose,
> ECG
> Move to the stretcher
> Vitals q5
> ...



Yep, results of most of those in the previous post. RE his blood sugar, didn't really think it was involved with his presentation but it was a tad low and we gave him a few lolies to nibble in the mean time. BSL up to 8 something, 15 or so mins later, no change in presentation.

Whats the logic behind the bolus? A small bolus may be appropriate in some contexts, but think about the reason why this bloke's perfusion is rubbish. Is it because he's volume depleted? Or is it because he's cardiac out put is rubbish? *Vene*, can you enlighten us as to the appropriateness of fluid in SVT? 



MrBrown said:


> Never fear, Brown is here! (No really, run, do it now, just run)
> 
> Pop in an 18 and run 250 of fluid
> Oxygen, two litres on an NC
> ...



Finally some pain relief!



Veneficus said:


> Maybe check for rubs, gallops, and other abnormal heart sounds?



Wasn't checked, but from my limited knowledge of such things, I'd say not.



8jimi8 said:


> lol i'm usually reluctant to reply to scenarios.
> 
> i feel like i know alot, but i seriously need some more ride time.  haven't been able to volunteer in a while



Reply all you want, I was hoping that people who don't usually reply will get involved. They're not medical mysteries, just everyday scenarios, albeit with one or two things going on worth talking about. I need the learning experience as much as anyone.


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## exodus (Apr 22, 2010)

Effectiveness of air intake?
How are his lungs?
Does he remember falling?
How are eyes?
He says he remembers waking up, I'd like a Trauma Resources for the +LOC.
He's still stable as far as the BP is concerned, I'd like to watch the monitor for any changes.
How has he felt over the past few days, has he felt dizzy at all, sick at all?


Zofran 4mg SIVP for the nausea. Pain already taken care of in above posts.


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## Melclin (Apr 22, 2010)

exodus said:


> Effectiveness of air intake?
> *Normal tidal volume and air intake. *
> 
> How are his lungs?
> ...



10 char


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## exodus (Apr 22, 2010)

Pain relief 2mg morphine sivp titrate to 10mg prn.

Trauma resource basically means going to a Level1 trauma center and getting immediately looked at by the surgeons. If he fell hard enough to black out, then there's a good chance there's something wrong in the brain now, some kind of trauma.

I'd like to try and explain to him, that if he fell and then just remembers waking up that there's a possibility he may have injured his brain or his neck, and that moving around as in walking, can injure it even more, which may lead to paralysis or death. And would like to take cervical precautions (C-Collar/Backboard). If he's adamant in refusing it, I obviously can't force him to do it, but he seems agreeable to going to the ER at this point, so I'll keep him as relaxed as I can.

Any family around, is this man normally this anxious?


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## MrBrown (Apr 23, 2010)

exodus said:


> Pain relief 2mg morphine sivp titrate to 10mg prn.



Man, it's hard to hear you way back there in 1990!



exodus said:


> Trauma resource basically means going to a Level1 trauma center and getting immediately looked at by the surgeons. If he fell hard enough to black out, then there's a good chance there's something wrong in the brain now, some kind of trauma.



Ah ... but did the cardiac problem cause him to black out and fall or did he black because he fell?



exodus said:


> I'd like to try and explain to him, that if he fell and then just remembers waking up that there's a possibility he may have injured his brain or his neck, and that moving around as in walking, can injure it even more, which may lead to paralysis or death.  And would like to take cervical precautions (C-Collar/Backboard).



I know you American's love your backboards and will fight to the death any chance to get rid of them but do you really think its indicated here?

Are you going to try and get this patient who is obviously a bit agitated and not the happiest with the ambo's onto a board? He's gonna pack a fit and squirm around and complain like no tommorow.  Should there be any cervical injury it's going to cause more movement than letting him adopot a position of comfort.

Besides that I don't think its clinically indiciated in this case provided he has no pain on active movement, numbness/tingling/altered sensation etc.


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## Veneficus (Apr 23, 2010)

Melclin said:


> *Vene*, can you enlighten us as to the appropriateness of fluid in SVT?



A small bolus of saline or ringers ( ~500cc) is not unheard of in a stable SVT patient to attempt to increase prefill. It would not be my first choice of therapy for the same reasons stated above. (fix the pump not the volume) There exists the possibility of volume depletion from the fx and inability to compensate from the ACE inhibitor, but even in the elderly a closed distal extremity fx shouldn't create major blood loss. But keep an eye out for increased swelling or pain that may indicate it.

Additionally his cardiac history and prolonged ACE inhibitor, makes him a risk for renal failure to start with and if he is battling an infection he is also at risk for a glomulonephritis from group A Streptococci from his respiratory infection. (current low grade systemic fever) Definitely ask about the color of his urine, dark, light, or any blood and frequency?

With his history I was surprised to not see a Beta blocker or loop diuretic in his med list. So I would ask to see his current medications to see if they were in there. If they were not and it was not a scenario oversight, I would suspect him to be in a very late stage heart failure from his lack of Beta blockade and near, if not at, renal failure from his lack of diuretic.



Melclin said:


> weak pulse at 190, a bp of 95/75 and cool, pale skin



While seemingly unstable by number and skin, with his mental status and presentation he seems more on the borderline to me.

His cool pale skin is also normally seen in late stage HF.

He seems stable enough to run a 12 lead and find out a more accurate nature of his SVT, which could be treated appropriately depending on if you had a sinus, Afib w/ RVR, or something else less common and more insidious. In the event I was happy with SVT, I’d try to vagal and chemically convert with  6,12,12 of adenosine prior to attempting an electrical cardioversion. If he made it this long, he has the extra minute or two pharm therapy would take prior to synch. cardioversion. (I would definitely perform the electrical cardioversion if the adenosine failed due to his advanced age, poor heart history, and current presentation)

His wrist is nothing I would bother a major trauma center with. He doesn’t need a critical care surgeon or even stat ortho consult. Splint it, some versed for the pain, which will also help if you choose to cardiovert. Some Ketamine would also be on the menu as it would not hemodynamically compromise him and would work nice with the benzo.

For sure he is getting transported to a heart center. His Fx can be managed with a plaster splint found in any ED with an emergency physician (an EM is more than capable to reducing and splinting a distal extremity fx, I would argue even a US paramedic is) with a consult for ortho surg up to 2 weeks later to rule out his potential scaphoid fx (in addition to a ulna/radius) which would show up as bone healing, it cannot be dx with the initial xray but would be treated prophylactically with the splinting technique used for his ulna/radius as a scaphoid fx carries a significant risk of avascular necrosis which is considerably debilitating. 

Soup to Nuts:
Show up, 
history and physical
2L o2 by nasal cannula, 
Monitor and 12 lead
2 Ivs, one as proximal as possible first.
Partner splints the arm, gives versed and ketamine IV
attempt vagal maneuver
Adenosine until max dose or conversion if the 12 lead doesn’t contraindicate it or suggest something better.
Synchonized cardioversion if it doesn’t work.
Transport to cardiac center.

Xray, plaster splint for the arm, outpatient ortho appointment in a few days (who will decide my splint looks great and leave it instead of casting because I do good work  ) take some blood and sputum cultures, run standard chem 8, CKMB, and troponin. Call cardio for their consult.

If nothing terribly wrong admit to telemetry so cards can have their way with him while his culture results stew and see if a specific antibiotic can be found to treat his respiratory infection and any migration it might have done. 

Remind myself that I have no intention of going into EM and this patient is not my problem


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## Veneficus (Apr 23, 2010)

MrBrown said:


> Besides that I don't think its clinically indiciated in this case provided he has no pain on active movement, numbness/tingling/altered sensation etc.



I'm with Brown on this one.


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## MrBrown (Apr 23, 2010)

Veneficus said:


> I'm with Brown on this one.



See, another example of why more people should listen to Brown B)

Man you gave this guy the works.  We can't use midaz and ketamine with each other (might be worth looking into that) nor do we carry adenosine (we did look at but I don't think the evidence of overwhelmingly in support of it).

Also I am unable to use ketamine for a busted wrist unless it's severe, unretractable pain significantly compromising treatment/extrication.  Morphine before ketamine does not have to be given here (I have seen both with and without) but it's pretty much the norm, couple mg of morphine should straighten out this guys pain (although I am unsure of how much an effect it will have on his circulatory system given the secondary vasodialative properties).


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## Veneficus (Apr 23, 2010)

MrBrown said:


> Man you gave this guy the works.  We can't use midaz and ketamine with each other (might be worth looking into that) nor do we carry adenosine (we did look at but I don't think the evidence of overwhelmingly in support of it).



the 1/2 life of adenosine is so short, it doesn't really figure into the mix. As for the versed and ketamine, if you are going to sedate and control pain, might as well do it right. Plus the versed will lower the side effects of ketamine. 

This idea of 2mg of versed or 2 mg of morphine every 10 or so minutes is BS. 

"I'm sorry Mr. Smith before I plug you in to 50+ joules I'm going to lessen the pain by giving you such a small amount of sedation you might think i am pushing nothing but water into your veins. Nevermind your wrist hurts, once I press this button you'll forget all about that."




MrBrown said:


> Also I am unable to use ketamine for a busted wrist unless it's severe, unretractable pain significantly compromising treatment/extrication.



That sucks. It's having a great tool but not being able to use it.



MrBrown said:


> Morphine before ketamine does not have to be given here (I have seen both with and without) but it's pretty much the norm, couple mg of morphine should straighten out this guys pain (although I am unsure of how much an effect it will have on his circulatory system given the secondary vasodialative properties).



Morphine and fluid to control BP decrease vs. ketamine is 6 of 1 or 1/2 dozen of the other. You could do it either way. Fentanyl would be better if you subscribe to the renal comprimise because it is excreted via the fecal route instead of renal. 

If the patient is agitated to start with, he is not going to be happy moving at the speed of healthcare, which is often unbearably slow, and being told he is going to be treated to an overnight stay.(at least, if not a couple of days to get his meds straightened out and some tests run) so a little more on the sedated side will probably improve his quality of life a little over the next day or two.


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## MrBrown (Apr 23, 2010)

Veneficus said:


> the 1/2 life of adenosine is so short, it doesn't really figure into the mix. As for the versed and ketamine, if you are going to sedate and control pain, might as well do it right. Plus the versed will lower the side effects of ketamine.



We do not treat arrythmias unless they are significantly compromising (ie you look really sick and the ambo's arse is sucked up more than Shamwow or something) so I think the treatment of choice will remain cardioversion and we won't be getting adenosine anytime soon.

I should clarify that ketamine is not the norm for a broken wrist because it was introduced for severe pain that is not (or is unlikely to be) responsive to morphine partic musculoskeletal and burn pain.

I always have the discretion to use it because it is what I think is best for my patient however I may have some explaining to do should the hospital take exception to me spacing old man Smith off the planet on ketamine for a busted wrist that 2-3mg would probably adequately control or if it came up at random audit.



Veneficus said:


> "I'm sorry Mr. Smith before I plug you in to 50+ joules I'm going to lessen the pain by giving you such a small amount of sedation you might think i am pushing nothing but water into your veins. Nevermind your wrist hurts, once I press this button you'll forget all about that."



As of November last year it is now allowed to give a very small dose of midazolam (like 3mg) prior to cardioversion although for the last five years or so ketamine has been allowed for pacing ... ironic?

Again, if I think it's in the best interest of my patient to ketamie him off the planet before I zap him then I can however again should the hospital take exception to it (they might take more exception to my not doing it!) or it comes up at random audit I might have a bit of explaining to do.

Cardioversion here is reserved for people who are really, really sick so I think the thinking of the Medical Advisors is that the balance of benefit of analgesia vs need to cardiovert swings in favour of the latter.


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## Melclin (Apr 24, 2010)

exodus said:


> Pain relief 2mg morphine sivp titrate to 10mg prn.
> 
> Trauma resource basically means going to a Level1 trauma center and getting immediately looked at by the surgeons. If he fell hard enough to black out, then there's a good chance there's something wrong in the brain now, some kind of trauma.
> 
> ...



I realise you're restricted by protocol, but wow, 2mg-->10mg? Have you spoken with your med director about that? 





MrBrown said:


> Man, it's hard to hear you way back there in 1990!
> 
> 
> 
> ...



I agree. To be honest when this scenario was put to me, I didn't even occur to me to immobilize him. He's up, walking around, nill pain on palp, not complaining of any deficits, I can't see a collar doing any better than lying still on the stretcher as you say.



Veneficus said:


> Additionally his cardiac history and prolonged ACE inhibitor, makes him a risk for renal failure to start with and if he is battling an infection he is also at risk for a glomulonephritis from group A Streptococci from his respiratory infection. (current low grade systemic fever) Definitely ask about the color of his urine, dark, light, or any blood and frequency?
> 
> *Atacand is an Angiotensin II receptor antagonist. Does that make any difference?  *
> 
> ...






MrBrown said:


> As of November last year it is now allowed to give a very small dose of midazolam (like 3mg) prior to cardioversion although for the last five years or so ketamine has been allowed for pacing ... ironic?
> 
> Again, if I think it's in the best interest of my patient to ketamie him off the planet before I zap him then I can however again should the hospital take exception to it (they might take more exception to my not doing it!) or it comes up at random audit I might have a bit of explaining to do.
> 
> Cardioversion here is reserved for people who are really, really sick so I think the thinking of the Medical Advisors is that the balance of benefit of analgesia vs need to cardiovert swings in favour of the latter.



Funny how different areas with similar philosophies in general can have such different views on specific treatments. 

-Midaz in any form of pain control is not on and we are warned to be very careful should we HAVE to use an opioid and midaz (various drug combos for sedation for intubation and RSI are exceptions obviously). Which I think is a shame.

-On the other hand, the cardioversion options are quite liberal compared to yours (Intensive Care only of course). We have verapamil for BP >100 and Metaraminol to get it to 100 if it isn't already, as I understand it. For synch cardioverts the deal appears to be 25mcg of Fentanyl + 2.5mg boluses of midazolam every two minutes "until the pt does not respond to verbal stimuli but does respond to pain", 75 and 150 joules. Yet we don't have pacing at all. 

-The service trusts basics to make those pain in the arse IN fent calcs but not to give it IV, in exactly the same ratios as morphine, which everyone is familiar with. 

-Ketamine is still at the trial stage. I heard a rumour that they are having trouble recruiting willing participants on account of various industrial disputes :wacko:

MY treatment for this pt was 8L by simple face mask (because I get into an argument with instructors about "nasal cannulas not being enough oxygen" every time I try to use them <_< ) 300mg ASA, 3ml methoxyflurane, 100mcg IN fent + another 50mcg 5 mins later, request MICA backup/transport to cardiac centre.

Cheers for the info Vene.


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## Veneficus (Apr 24, 2010)

Atacand is an Angiotensin II receptor antagonist. Does that make any difference? 

It lowers the renal failure possibility, but I would still test for it because of the potential heart failure after 2 MIs and the CABG and infection.

Not in poor perfusion 2ndry to SVT? 

probably that as well, but i like to cover the differential.


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## exodus (Apr 24, 2010)

Melclin said:


> I realise you're restricted by protocol, but wow, 2mg-->10mg? Have you spoken with your med director about that?




Start at 2mg, titrate up to 10 mg as needed. If more than 10 is needed, BHO.


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## MrBrown (Apr 24, 2010)

Melclin said:


> I realise you're restricted by protocol, but wow, 2mg-->10mg? Have you spoken with your med director about that?



It would appear most places in the US are very restrictive about pain control and it looks like something out of about 1990 here.

Los Angeles County: up to 20mg of morphine (source)
Lee County: up to 0.1mg/kg of morphine (source)
Dallas/Ft Worth (BioTel): up to 200mcg fent or 20mg morphine (source)
Miami (from 2001): up to 5mg or 10mg of morphine (source)
New York City ALS: up to 5mg or 10mg or morphine (source)

Nobody in the protocols I viewed is using combination analgesia e.g. an opiate and a benzo or any form of advanced analgesia e.g. ketamine or even entonox for EMT-B's .... infact Wake County, SC one of the more progressive agencies considers nox to be a Paramedic level drug!

It's actually really horrendously shockingly sad and I feel sorry for your patients.



Melclin said:


> -Midaz in any form of pain control is not on and we are warned to be very careful should we HAVE to use an opioid and midaz (various drug combos for sedation for intubation and RSI are exceptions obviously). Which I think is a shame.



We've had combo morphine and low dose midaz for about ten years and it works pretty well from all accounts however I've only seen it once before we got ketamine rolled out for all Intensive Care Paramedics.



Melclin said:


> For synch cardioverts the deal appears to be 25mcg of Fentanyl + 2.5mg boluses of midazolam every two minutes "until the pt does not respond to verbal stimuli but does respond to pain", 75 and 150 joules. Yet we don't have pacing at all.



We can give morphine and ketamine for pacing but not cardioversion how weird is that?

As I said before the maximum dose of midazolam for cardioversion is 3mg however I think if you stepped outside the guideline and had to use more it would quickly get looked at.

For example some people were using bigger doses of ketamine than was in the 2007 guideline and it got changed in the 2009 update.



Melclin said:


> -The service trusts basics to make those pain in the arse IN fent calcs but not to give it IV, in exactly the same ratios as morphine, which everyone is familiar with.



I think people need to get over the fear of the IV route in general and we've talked a little about this before I know.  With all the upskilling that is going on in this part of the world I think it's time to let go of the old timey notion that IV is bad especially with expenaded education.



Melclin said:


> -Ketamine is still at the trial stage. I heard a rumour that they are having trouble recruiting willing participants on account of various industrial disputes :wacko:



Shame, its wonderful stuff!


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## Veneficus (Apr 24, 2010)

MrBrown said:


> It would appear most places in the US are very restrictive about pain control and it looks like something out of about 1990 here.
> 
> Los Angeles County: up to 20mg of morphine (source)
> Lee County: up to 0.1mg/kg of morphine (source)
> ...



Pain control in the US is generally conservative (even in hospital) until you get anesthesia, PM&R, or End of life docs involved.

It sort of figures that if the doc is afraid to aggresively manage pain, he/she will pass that limitation on to the medics. (and you know what the education is) So asking them to differentiate ion channels from metabotropic channels when giving drug combos, determining potential effects, theraputic ranges, time, and managing them may be asking a lot to the guy who spent 12 weeks in school in Huston. Protocols must be written for the least common denominator, not the all stars.




MrBrown said:


> Nobody in the protocols I viewed is using combination analgesia e.g. an opiate and a benzo or any form of advanced analgesia e.g. ketamine or even entonox for EMT-B's .... infact Wake County, SC one of the more progressive agencies considers nox to be a Paramedic level drug!



Combo therapy is often not used by paramedics either. I have convinced some progressive ER docs to do it, but usually an opioid/benzo combo is done by the specialists listed above. I don't agree with the conservative approach. The major barrier is comfort level. Here we are required to do palliative care time our second year. You combo all those people it seems. (But keep them awake/capable enough to talk to their family) So personally i am comfortable with combo therapy from constant exposure. Not all of the US med schools even offer palliative care as an elective and watching anesthesia combo people many see as a wizard performing magic on a patient they don't want to be conscious. 



MrBrown said:


> It's actually really horrendously shockingly sad and I feel sorry for your patients.



But people keep telling me I do good work  (I know you meant the EMT-Bs)



MrBrown said:


> We've had combo morphine and low dose midaz for about ten years and it works pretty well from all accounts however I've only seen it once before we got ketamine rolled out for all Intensive Care Paramedics.



Everyone should use combo, it really works great in all of my experience. Though I confess the people (usually a nurse) who has to monitor those people think it is quite a headache. I don't believe in withholding pain control for convienence of a provider. 



MrBrown said:


> We can give morphine and ketamine for pacing but not cardioversion how weird is that?



Well if you can't do a combo with a benzo, the single benzo is a better choice than a single pain med. Especially the amnestic effects.



MrBrown said:


> As I said before the maximum dose of midazolam for cardioversion is 3mg however I think if you stepped outside the guideline and had to use more it would quickly get looked at.




sounds reasonable to me, from the perspective of if you need a lot of sedation it is probably not emergent enough to warrent the cardioversion, but if properly managed there is no legit reason to short a patient on pain control. 



MrBrown said:


> For example some people were using bigger doses of ketamine than was in the 2007 guideline and it got changed in the 2009 update.



As with any protocol, if people are constantly outside of it, the problem is lack of provider knowledge or a poorly written protocol that doesn't reflect need or reality.



MrBrown said:


> I think people need to get over the fear of the IV route in general and we've talked a little about this before I know.  With all the upskilling that is going on in this part of the world I think it's time to let go of the old timey notion that IV is bad especially with expenaded education.
> 
> 
> 
> Shame, its wonderful stuff!



Fear makes people do weird stuff.


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## MrBrown (Apr 24, 2010)

Veneficus said:


> So asking them to differentiate ion channels from metabotropic channels when giving drug combos, determining potential effects, theraputic ranges, time, and managing them may be asking a lot to the guy who spent 12 weeks in school in Houston. Protocols must be written for the least common denominator, not the all stars.



Should we just give the Houston Fire Department the Supreme Failure Award already?



Veneficus said:


> But people keep telling me I do good work  (I know you meant the EMT-Bs)



Yeah and we know those sort of "I make a difference types" are what keeps EMS in the United States at the forefront of prehopsital medicine!



Veneficus said:


> Everyone should use combo, it really works great in all of my experience. Though I confess the people (usually a nurse) who has to monitor those people think it is quite a headache. I don't believe in withholding pain control for convienence of a provider.



I have only seen combo morphine and midaz used once on a guy who had bilateral crushed femurs in a car wreck.  It worked a treat.



Veneficus said:


> Well if you can't do a combo with a benzo, the single benzo is a better choice than a single pain med. Especially the amnestic effects.



The amnestic effect is I think what we're after here, benzos themselves don't have any analgesic properties and I've always seen midaz referred to 
something that means the patient "wont remember".



Veneficus said:


> sounds reasonable to me, from the perspective of if you need a lot of sedation it is probably not emergent enough to warrent the cardioversion, but if properly managed there is no legit reason to short a patient on pain control.



I think the rationale behind a small dose of midazolam is sort-of hey look if they are that awake they can say bad words to you about the pain they don't need it.  Our Paramedics (one step below Intensive Care) can cardiovert but are not able to give midaz ... at the end of the day if a patient is that crook I think a little pain is better than a cardiac arrest.



Veneficus said:


> As with any protocol, if people are constantly outside of it, the problem is lack of provider knowledge or a poorly written protocol that doesn't reflect need or reality.



I know they did change the ketamine guideline as people were using more ketamine than had been included in the 2007 publication.  I've seen excellent effect on it's own and in combination with morphine.

I find ketamine strange and somewhat fascinating in that some people appear really smashed while others are in this weird sort of half-and-half state where they have horribly shattered limbs or nasty burns and they are talking to you as if nothing is wrong.

Perhaps a better way of putting it is that it appears to have profound analgesic effect with no CNS depression so the patient doesnt get really wasted like they would with morphine or fentanyl.

Might be why it's primary mechanisim of action is not listed as CNS depression eh? 

Now I did ask my anaesthesologist if I he could use ketamine when I had my wisdom teeth out, he said no, I was dissapointed and started questioning him about it, then he gave me drugs and I don't remember anything after that for several hours


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## 8jimi8 (Apr 24, 2010)

Veneficus said:


> Though I confess the people (usually a nurse) who has to monitor those people think it is quite a headache. I don't believe in withholding pain control for convienence of a provider.




I don't either, but if a patient has pain that is intractable to a single drug line, your patient needs to be in the ICU, or IMC.  M/S nurses don't have the resources to monitor a patient that closely and have a reasonable chance for safe monitoring.
  All nurses, also do not get as much training at that depth of pharmacology, as you mentioned...




Veneficus said:


> you know what the education is) So asking them to differentiate ion channels from metabotropic channels when giving drug combos, determining potential effects, theraputic ranges, time, and managing them may be asking a lot


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## VentMedic (Apr 24, 2010)

8jimi8 said:


> I don't either, but if a patient has pain that is intractable to a single drug line, your patient needs to be in the ICU, or IMC. M/S nurses don't have the resources to monitor a patient that closely and have a reasonable chance for safe monitoring.
> All nurses, also do not get as much training at that depth of pharmacology, as you mentioned...


 
Our med surg RNs generally average 10 patients each. Even if an RN is floating from the ICU to fill in and has more indepth knowledge and experience with various meds, it is still not feasible with the design of the floor and that many patients. At times there may only be 3 RNs for 40 patients and 2 CNAs if they are lucky.This also is acute care not LTC.


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## MrBrown (Apr 24, 2010)

Do you guys not have monitored beds in ED?


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## VentMedic (Apr 24, 2010)

MrBrown said:


> Do you guys not have monitored beds in ED?


 
Yes and the patient can be worked with ICU protocols before moving to the ICU.  However, as mentioned in some threads, if it is a Paramedic who is working sorta like an RN in the ED, that won't work and the assignments will have to be switched to get an RN to that patient. Generally it is just easier to move the patient to the unit instead of waiting for everybody to report off on their other patients.


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## Veneficus (Apr 24, 2010)

8jimi8 said:


> I don't either, but if a patient has pain that is intractable to a single drug line, your patient needs to be in the ICU, or IMC.  M/S nurses don't have the resources to monitor a patient that closely and have a reasonable chance for safe monitoring.
> All nurses, also do not get as much training at that depth of pharmacology, as you mentioned...



We are discussing managing pain by multiple mechanisms. Not even to the level of conciious sedation.

The complexity.

The benzo will increase GABA affinity creating a hyperpolarized state. So while not directly analgesic the inhibitory action of GABA will prevent CNS neural transmission particularly in the limbic system. (via CL- channels) Anxiety also increases the subjective pain people "feel." A benzo works very well for anxiety. The benzo also has no direct effect on the autonomic nervous system. (benefit described later)

The opioid receptors are located both in the CNS and peripherally. They work by inhibiting the Ca+ influx that mediates the release of glutamate transmission, preventing the presynaptic ending from releasing the transmitter. In addition post synaptic K+ channels open and efflux creates hyperpolarization. 

By adding the 2 together, you are reducing pain and anxiety (the later increasing the subjectivity of felt pain) by different mechanisms. The benefits are better sedation and pain control than could be achieved by one agent alone, so you have to use lower doses of both than you would with only one. If you are dealing with "remembered pain" or increases subjectivity it is not going to respond to opioids at all. So you literally could wind up with large doses trying to reduce pain that cannot be affected by them. Seems counter productive to me to use a high dose of a medication that you know isn't going to work before hand prior to trying something else? 

Furthermore, in severe or long term pain not using copious opioids will reduce the amount of downregulated receptors so your opioids will be effective longer and in smaller doses.

Moreover, the benzo not acting on autonomic system means you will get less cardiovascular depression than you would with a high dose/affinity opioid. seems beneficial in a hemodynamically compromised patient.

As for monitoring, you can increase the possibility of respiratory depression, but a pulse oximeter is not exactly advanced monitoring and is actually less monitoring than a heart monitor, with constant cycling blood pressure. So you actually reduce the intensity of monitoring needed. Isn't that safer? As for the "sleepiness" of the sedation, we don't put every sleeping patient on a heart monitor or any other intensive monitoring. Consider the level of alcohol intoxication reached before a pt. is put in a monitored bed. Also consider the effort to not send such a patient to the ICU. 

I am not talking about intractable pain. That is a different animal for different reasons.  

I was not trying to pick on nurses this time, I was pointing out that many US EMS providers have no idea about the mechanisms of pharm. 

seperately, for some reason everytime benzos and sedation is mentioned, it seems to send the nurses i have encountered into a panic. Clearly there is a perpetuated culture of fear of sedation, but what started it I have no idea. I figure somebody somewhere had a bad experience and overreacted and it hasn't been dispelled yet.Exactly the same behavior that EMS exhibits with spineboards.


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## 8jimi8 (Apr 24, 2010)

Veneficus said:


> I was not trying to pick on nurses this time, I was pointing out that many US EMS providers have no idea about the mechanisms of pharm.
> 
> seperately, for some reason everytime benzos and sedation is mentioned, it seems to send the nurses i have encountered into a panic. Clearly there is a perpetuated culture of fear of sedation, but what started it I have no idea. I figure somebody somewhere had a bad experience and overreacted and it hasn't been dispelled yet.Exactly the same behavior that EMS exhibits with spineboards.




I posit that the fear of sedation comes from experience with over-sedation.  I hear my peers talking about that fear quite often.


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## Shishkabob (Apr 24, 2010)

8jimi8 said:


> I posit that the fear of sedation comes from experience with over-sedation.  I hear my peers talking about that fear quite often.



Carry flumazenil for Benzos and Narcan for narcs and you should be fine.

Sedation when it's called for beats no sedation because of fear.



Now... just to get EMS agencies to carry flumazenil like they do Narcan...


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## 8jimi8 (Apr 24, 2010)

its not about reversal agents, its about the possibility of somebody dying under your nose.

Umm... excuse me... did you that 39 was DEAD?


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## Shishkabob (Apr 24, 2010)

8jimi8 said:


> its not about reversal agents, its about the possibility of somebody dying under your nose.
> 
> Umm... excuse me... did you that 39 was DEAD?



Pay closer attention


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## Veneficus (Apr 24, 2010)

Linuss said:


> Carry flumazenil for Benzos and Narcan for narcs and you should be fine.
> 
> Sedation when it's called for beats no sedation because of fear.
> 
> ...



I don't think a reversal agent is the answer to all the problems. First, if you are over sedating, then you need to get that under control.

A reversal agent is not always the best idea either even n the emergent setting. In EMS much is discssed on the topic of not "waking up" heroin addicts with narcan. But consider also not eliminating your sedation and pain control routes either. For example:

You have a burn patient with >40% BSI of partial thickness burn. He complains pain is 100/10 (as you would expect) so you dose him with some opioid of your favorite flavor. So it tanks his BP, respiratry drive, and mental status. If you reverse this with narcan you are going to eliminate opioid pain medication for the duration of the narcan. Not good at all. 

There are many more examples of the above. Especially reversal agents post surg.

Flumazenil is also not as benign narcan. Narcan binds to opioid receptors which have highest specificity to pain stimuli. Flumazenil is going to decrease the post synaptic uptake of GABA, which is the major inhbitory neurotransmitter of the CNS. (stops you from firing on all cylinders at once) when you take that away you can have everything from hallucinations to seizures. 

If you do induce a seizure with it, you may be forced to put the pt in a barbiturate coma to stop it, which incidentally attaches to a different part of the same receptor as a benzo and flumazenil, so you can really create some problems with benzo antagonists.

So lets take an example of an infant in febrile seizure. (PALS would be proud) The parents give the kid some rectal valium, you find the kid still seizing and add your benzo to it, decide it is too much and then reverse it back to seizure which you now cannot control. So rather than just controling ventilation till the benzo wears off, you now create a big problem for the child, and turn an ER visit into an PICU stay.  

Depending on the strength of the opioid or benzo you may have to set up a maintenence dose of the reveral agent which may fall beneath theraputic range long before the medication you are reversing.

In the hospital a nurse cannot just walk around with reversal agents in the pocket incase of accidental OD over a period of hours.

I assure you that I am not shy about using pharm therapy, but there is a difference between aggresive and irresponsible.


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## Shishkabob (Apr 24, 2010)

Oh agreed, it's better to avoid the over sedation to begin with, but there are patients who have more than expected reactions to medications for no apparent reason.  But I'm in a firm belief that if you carry an agonist on the rig, you should be carrying the antagonist as well... don't do something that you can't fix.

I'm also not for waking up the patients that don't need it.  If you can control the respiratory drive complications with .4mg, why push the whole 2?  Risk has to be weighed with benefit, just like everything else we do.


I've been told horror stories of medics pushing narcan on patients that seem to be in narcotic induced coma, but end up having a cancer patient who was in said induced state because of the severe pain... than you're screwed.




But alas, I'm a new medic and I know I'll have quite a while before I know when to use what.  *sigh*


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## Smash (Apr 24, 2010)

Naloxone is carried to reverse opiod overdose in the field.  If it is being used to reverse Paramedic induced overdose, something has gone horribly, horribly wrong on a whole lot of levels.

Even if a patient does have a high degree of sensitivity to a benzo, care is always just supportive; airway, breathing, circulation, drive to hospital.  Flumazenil is not a nice drug at all (as veneficus pointed out), and generally not even the ICUs here like messing with BZD receptors.  Look after them until they wake up and all is well.



> You have a burn patient with >40% BSI of partial thickness burn. He complains pain is 100/10 (as you would expect) so you dose him with some opioid of your favorite flavor. So it tanks his BP, respiratry drive, and mental status.



Morphine, 2mg every 10 minutes to a maximum of 10mg?  Should be fine with the BP and respiratory drive! 

Pain relief is one of the most useful, most important and most humane things we can do for our patients, and combination therapy is usally the best way of achieving this.  Some people might go well with 5-10mg of morphine for their broken limb, others will need, and should get, significantly more.
We know that acute pain has detrimental effects on the entire person, both physiologically and psychologically, and that the effects can be long lasting and profound (like chronic pain syndromes), yet we continue to essentially tell our patients to harden the **** up and put up with the pain, because we can't be bothered getting decent education, so Drs don't trust us with drugs (and who can blame them really?)


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## Melclin (Apr 24, 2010)

Smash said:


> If it is being used to reverse Paramedic induced overdose, something has gone horribly, horribly wrong on a whole lot of levels.



A thousand time yes. Even then, I still feel that in a lot of cases where naloxone has been used, a bit of supportive care and close monitoring would have been far more appropriate.



Smash said:


> We know that acute pain has detrimental effects on the entire person, both physiologically and psychologically, and that the effects can be long lasting and profound (like chronic pain syndromes), yet we continue to essentially tell our patients to harden the **** up and put up with the pain, because we can't be bothered getting decent education, so Drs don't trust us with drugs (and who can blame them really?)



But, Smash, I had a broken clavicle for ten hours before I could drive myself to the hospital, and this blokes just got a guts ache, bloody sheila. Little bit of pain never hurt anyone, its character building.  <_<




Veneficus said:


> I don't think a reversal agent is the answer to all the problems. First, if you are over sedating, then you need to get that under control.
> 
> A reversal agent is not always the best idea either even n the emergent setting. In EMS much is discssed on the topic of not "waking up" heroin addicts with narcan. But consider also not eliminating your sedation and pain control routes either. For example:
> 
> You have a burn patient with >40% BSI of partial thickness burn. He complains pain is 100/10 (as you would expect) so you dose him with some opioid of your favorite flavor. So it tanks his BP, respiratry drive, and mental status. If you reverse this with narcan you are going to eliminate opioid pain medication for the duration of the narcan. Not good at all.



You are welcome to an equal portion of the thousand yeses I dealt Smash regarding reversal agents. 

Despite the options for pain relief that our service has now, you still seem to see and hear of cases everyday where ambos will just bung in 3 mls of methoxyflurane and turn their brain off. Our pain guru at uni tries ever so hard to convince us to use adequate analgesia with well reasoned and evidence based arguments, and still people are super conservative, even in scenarios - like the patients pain will disappear once the you have satisfied the instructors need for you to "identify pain and initiate pain management". I'm seeing a nasty trend in some students who are presumably struggling with the volume of material to reduce ideas down to simple recipes: "If constricted pupils, Narcan 2mg", "If pain, penthrane 3 mls". "Drop in consciousness after paramedic opiate admin, narcan 2 mg". Sometimes I can't blame docs for lacking confidence in EMS.


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## MrBrown (Apr 24, 2010)

I would ask anybody who thinks some methoxyflurane or like 2mg of morphine is adequate analgesia if they have ever been in pain.  Like not ow I stubbed my toe or got a fat lip when the Mrs sucker punched me for hitting on her sister but severe, irretractable pain that is all consuming and makes you wish you could hurry up and die.

One night Brown ended up with torted testes and let me tell you it was not a fun experience limping into ED doubled over screaming in agony pulling my basketball sized gonad behind me.  Bloody surgical registrar gave me two panadol because the anaesthesiologist was in theatre.  First of all why is a surgical registrar covering the emergency department and I don't care if the anaesthesiologist at the dinner show, gimme something stronger I said!

Hence why I personally believe in not-so much dishing out morphine to everybody who goes "it hurts" but really taking an agressive approach to analgesia.  You take away pain and the patient is going to be more comfortable, its less physiologically taxing on the patient, thier family calms down, and the whole thing just works ten million percent better.

Oh and stay the hell away from flumazanil that stuff is nasty.


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## Veneficus (Apr 25, 2010)

Smash said:


> Morphine, 2mg every 10 minutes to a maximum of 10mg?  Should be fine with the BP and respiratory drive! ?



But not for your BP and respiratory drive when the patient starts stabbing you with the needle to get the rest of it from you. 

With a large surface burn patient, if you need to call somebody after 10mg, you are going to be on the phone a lot. My record in the field was 50mg/IV (because that is all I had on the truck) during a 25 minute transport, and it might as well have been water I was pushing into him. It was a bit uncomfortable when he asked me to give him something that would kill him because I couldn't help with the pain. 

When I got the the ED the doc asked me why I didn't just pour versed into him till he was out and tube him? (we didn't have RSI)

Now why didn't I think of that?

(because I was new and listened to horror stories of over medicating people and how I would lose my job, get sued, all that crap, and I didn't know sometimes such a teatment was actually indicated and humane.)


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## MrBrown (Apr 25, 2010)

Veneficus said:


> When I got the the ED the doc asked me why I didn't just pour versed into him till he was out and tube him? (we didn't have RSI)



How much midazolam is generally accepted as being required to knock somebody out you know, your average 80kg male?

For RSI we can give either 0.1mg/mg up to max 5mg midaz (which seems pretty piss poor if you ask me) or 1.5mg/kg ketamime, which seems slightly more appealing.


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## Veneficus (Apr 25, 2010)

MrBrown said:


> How much midazolam is generally accepted as being required to knock somebody out you know, your average 80kg male?
> 
> For RSI we can give either 0.1mg/mg up to max 5mg midaz (which seems pretty piss poor if you ask me) or 1.5mg/kg ketamime, which seems slightly more appealing.



0.1mg/kg is the textbook starting dose. The max listed is 0.5mg/kg. In my experience to sedate a patient to pass a tube without any other agent in the mix is varies between 10-30mg (most around 14-16) depending on their size and how agitated they are to start with.

In peds a max dose of 20mg prior is usually considered "safe." 

But I have not seen anything with absolute dosing guidlines outside of agency specific protocol.


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## Smash (Apr 25, 2010)

MrBrown said:


> How much midazolam is generally accepted as being required to knock somebody out you know, your average 80kg male?
> 
> For RSI we can give either 0.1mg/mg up to max 5mg midaz (which seems pretty piss poor if you ask me) or 1.5mg/kg ketamime, which seems slightly more appealing.



5mg does seem a little light for some cases. 0.1mg/kg to a max of 10mg here, less depending on other parameters like bp. Given in concert with 100mcg of fentanyl.  Ketamine is interesting for induction, certainly not without controversy, but I like that you have options. I'm curious about the restriction from using versed and ketamine together as versed is very commonly used to attenuate the potential for emergence phenomona with ketamine (more so with procedural sedation)

Vene, I don't think I've ever given that much morphine, but only because I have other options. As for how much we carry: Morphine 100mg, fentanyl 1500mcgs, versed 120mg. Haven't got ketamine on all the rigs yet (the wheels turn slowly) but maybe one day...  Still, got enough to knock out any random charging bull elephant we may come across.


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## MrBrown (Apr 25, 2010)

Veneficus said:


> 0.1mg/kg is the textbook starting dose. The max listed is 0.5mg/kg. In my experience to sedate a patient to pass a tube without any other agent in the mix is varies between 10-30mg (most around 14-16) depending on their size and how agitated they are to start with.



I should clarify that we use suxamethonium too *and* that midazolam is for people who have a neurogenic cause for coma with GCS equal to or less than ten.  

Everybody else gets 1.5mg/kg of ketamine.

Because we use sux as well I'm going to place a bet on the midaz or ketamine being primary used for amnesia rather than neuromuscular blunting.

Perhaps that information was important? :unsure:

Now I have never personally had midaz so you give me 5mg and I will tell you if I can remember anything! (at 70kgs I can't have 0.1mg/kg under our RSI guideline because it's 5mg max) 

I find anaesthesia rather fascinating and am aware that dosing of other common inducation agents like propofol and etomidate are much higher so 5mg of midaz looks a bit wimpy in comparison and I sort of have this self induced fear that it's not enough to knock the patient sufficently out so they don't remember anything.


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## Aidey (Apr 25, 2010)

Veneficus said:


> When I got the the ED the doc asked me why I didn't just pour versed into him till he was out and tube him? (we didn't have RSI)
> 
> Now why didn't I think of that?
> 
> (because I was new and listened to horror stories of over medicating people and how I would lose my job, get sued, all that crap, and I didn't know sometimes such a teatment was actually indicated and humane.)



^^^ In the area where I first started as a paramedic we didn't have RSI, and I worked an industrial job with a very high chance of bad burns and that was exactly what our doc told us to do. 

The way he said it was "you're not RSIing, you're overmedicating and then treating the side effects". 

I personally am a big fan of mixing opiods and benzos. In my experience it provides better pain management at lower doses of each.


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## MrBrown (Apr 25, 2010)

Oops had a mental fart and forgot we're using fentanyl too.  

Maybe I should just post up our recipe? 

BTW can you conjure up an asthmatic who needs intubating having a GCS of 10 coz I sure can't?



> *6.3 RAPID SEQUENCE INTUBATION (RSI)*
> • Indicated for patients with a GCS <10 with airway or ventilatory compromise.
> 
> • *Absolute contraindications:*
> ...


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## Veneficus (Apr 25, 2010)

Smash said:


> Vene, I don't think I've ever given that much morphine, but only because I have other options. As for how much we carry: Morphine 100mg, fentanyl 1500mcgs, versed 120mg. Haven't got ketamine on all the rigs yet (the wheels turn slowly) but maybe one day...  Still, got enough to knock out any random charging bull elephant we may come across.



We had 50mg morphine, 60mg versed, and I forget how much toradol.(because I hardly ever gave it)

At the time fent was unheard of on an ambulance in the US. If my memory serves me correctly the Aussies were just starting their studies on it prehospital.

In all fairness we had 2 grams of mag sulfate that would put somebody down and I even got permission to to it once in the US. (one of my impossible feats. ie: it will never be done again in that location) In a jam you can use the CNS depressive properties of mag but outside of far Eastern Euope, Africa, and Asia, make sure you have permission from somebody higher up the food chain than yourself and there will probably be a policy never to do that again afterword.

Most certainly don't give it to a trauma patient.


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## Veneficus (Apr 25, 2010)

MrBrown said:


> Oops had a mental fart and forgot we're using fentanyl too.
> 
> Maybe I should just post up our recipe?
> 
> BTW can you conjure up an asthmatic who needs intubating having a GCS of 10 coz I sure can't?




Sure, history of right sided heart failure and COPD with reactive asthma and they wait a few hours to call while they try to control it themselves.

The systems over in the UK, NZ, and AU seem just super compared to the US. Would have been nice to work there for a while.


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## Aidey (Apr 26, 2010)

MrBrown said:


> How much midazolam is generally accepted as being required to knock somebody out you know, your average 80kg male?



I recently had surgery and I was given versed before they intubated me. I weigh 60 kg or so and they gave me 2mg. The last thing I remember was them pushing the med, and then me asking the RN how much they were giving me. 

I also had 1mg Ativan on board about an hour previous, so that may have contributed, but I guess I am a light weight when it comes to sedation.


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## MrBrown (Apr 26, 2010)

We're using fent, sux and vec too so I spoze the midaz or ketamine is not to knock them out enough to blunt the airway reflex but rather so they wont remember.


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## Smash (Apr 26, 2010)

MrBrown said:


> We're using fent, sux and vec too so I spoze the midaz or ketamine is not to knock them out enough to blunt the airway reflex but rather so they wont remember.



Fentanyl is to blunt sympathetic response to laryngoscopy and will help a little with sedation. Versed is to sedate, and sux is to provide muscle relaxation to allow passing of the ETT, and also eliminates airway reflexes that sill cause a spike in ICP. Vec will maintain paralysis and may or may not be indicated for particular cases. 

Trying to obtund airway reflexes with benzos alone is crazy and dangerous. In order to do that you would require epic amounts of benzo, and then you are going to have destroyed the blood pressure. Not flash if you have say a head injured patient who is really quite attachd to their cerebral perfusion pressure.


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## MrBrown (Apr 26, 2010)

Smash said:


> Trying to obtund airway reflexes with benzos alone is crazy and dangerous. In order to do that you would require epic amounts of benzo, and then you are going to have destroyed the blood pressure. Not flash if you have say a head injured patient who is really quite attachd to their cerebral perfusion pressure.



We used to allow this in the past (giving people elephant approved dosages of midazolam) but it was a bit of a bugger for the reasons you mention and the mortality rate was found to increase (suprised?).

So now we have proper RSI with fent/midaz/ketamine/sux/vec.


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## Smash (Apr 26, 2010)

MrBrown said:


> We used to allow this in the past (giving people elephant approved dosages of midazolam) but it was a bit of a bugger for the reasons you mention and the mortality rate was found to increase (suprised?).
> 
> So now we have proper RSI with fent/midaz/ketamine/sux/vec.




Oh god, it makes me feel nauseated.  I see in one of the protocols that was posted earlier in this thread that this sort of things still goes on.  Just crazy.  Take a fit young, healthy male with a broken brain and trismus, obliterate any trace of BP they had with benzos, then brutalize a fully functioning larynx (the most innervated structure in the body) with a cold steel blade causing ICP to go through the roof, and then probably not get the tube in anyway.

I just threw up in my mouth a little.

Still, baby steps


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