# IV Solu-Medrol



## cannonball88 (Mar 4, 2016)

There's a viewpoint to many in the EMS community that IV Solu-Medrol in the field is generally not recommended in allergic reactions, COPD, etc. because it takes 45 minutes to take effect.

Could anyone who has used SM in the field share what they can about length of time to take effect, it's effectivity, etc?


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## STXmedic (Mar 4, 2016)

Unless you have a very long transport time, you're not going to see its effects. That doesn't mean you shouldn't give it, though. 

Assuming a 45min onset, why decide to not give it, transport them 30min to the hospital, only for the hospital to administer it (probably 15-30 after they arrive at best), then still require 45min to begin taking effect. They've shown better outcomes for reactive airway diseases with early administration for steroids. PO Prednisone is just as effective with a similar onset, too.


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## chaz90 (Mar 4, 2016)

http://www.ncbi.nlm.nih.gov/m/pubmed/14582090/

Interesting study on this very topic. Anti-inflammatory effects of corticosteroids may be more effective if administered before the inflammation and corresponding symptoms become "severe." Earlier interventions to prevent ICU admission or intubation certainly have value.


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## Tigger (Mar 4, 2016)

I have also heard that it potentiates the effects of beta agonists. I'm not sure how proven this is, or what the timeframe is. Ideas?


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## ERDoc (Mar 5, 2016)

I did my residency research project on solu-medrol administration by EMS and how it affected ER length of stay.  It was a retrospective chart review and unfortunately there were only 4 pts in the available charts that got solu-medrol from EMS so it wasn't a very meaningful study.  There was a significant difference in LOS but because of the small size it was not statistically significant.  After I graduated, my university applied for a grant to do a prspective study but didn't get the grant.


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## TransportJockey (Mar 5, 2016)

We give it at my curreny service just for yhe reasoning @STXmedic states.  Short transport times but the earlier it's on board, the better.
I have also used it at other services I've worked at because we actually had long enough transports to see it have an effect


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## Doczilla (Mar 6, 2016)

There's tons of things that we do in the field that have shoddy scientific backing, but at least in the spectrum of allergy/anaphylaxis, they should most definitely get solu medrol. 

Following the epi/benadryl, inhibiting mast cell formation (and thus preventing additional histamine release) Is pretty helpful. You could say in fact, that you "see" the effects by not seeing the reaction come back. 

For the COPDers, if you work in a system where the hospitals make you rot on the wall waiting to offload cause they're at triple capacity, I would say you see the benifits there as well.


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## dumbenoughtostay (Mar 8, 2016)

It is not often that I reply to forums, but I do follow along with some of these discussions.

Here is my two cents on this subject.  The premise that we should not give a medication or treatment because we won't see the effect in the field is flawed and short-sighted.  This sort of thinking seems to be common with EMS providers I know.  It seems to me that we are not taught to take a long term view of our patient's outcomes.  Therein lies the problem.  

Solu-medrol or some other steroid should be given if indicated.  The amount of time we spend with the patient is immaterial.  Think about it this way- what would be an appropriate transport time to consider giving it.  Forty-five minutes, seventy-five?  Where is the cut-off?

We have to keep in mind that we have the patient one-on-one.  We have the opportunity to provide various treatments earlier than when they would receive it from the ED.  The staff in most EDs is overwhelmed.  They need all the help they can get.  There are often long delays in emergency departments due to various reasons.  We can help with the load, and it will hopefully benefit the patient.

Look here- granted small retrospective study:  ncbi.nlm.nih.gov/pubmed/14582090

The forum won't let me post the link.  You will have to cut and paste. 

Just my thoughts.


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## k9Dog (Mar 14, 2016)

I think it's great. Just cause we don't see the result doesn't mean the patient won't benefit. Should we not give aspirin or lasix either because it takes awhile?


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## johnrsemt (Mar 14, 2016)

Should we not alert the Cath labs for better patient outcome because it won't affect how WE treat the patient and we won't see the cath done in the ambulance?  Or Stroke alert

We are trying to get Solu-medrol here, but we have min of 45-90 minute transports so we will see a difference, but I agree we need to be able to give it to the patient even if it is only a 5 minute transport.   It is going back to the being professional:  and part of being professional is doing what is best for the patient in the long term, not just the time we are with them.
Waiting till the patient gets to the hospital, it may well be over an hour before they get the medication that will help them.  Where I used to work we would take patients from the ECF to the ED,  then back a few hours later and reading the ED chart on the way back a couple of my patients didn't get anything from the ED for up to 3 hours after we took them in (including more pain meds for trauma).


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## Jon (Mar 21, 2016)

I had my -P-school medical director explain this to me when I was in school... It still rings true, and I still follow his advice.

When you walk through the doors of the ED, it's going to take the better part of 20-30 minutes for the staff to perform any meaningful interventions on that patient (unless they are slow, and/or the patient is cramping or a trauma).

The ED needs to put your patient in the computer. Then the RN needs to triage them. Then they put the case in the "to be seen" by the doc pile... And the doc needs to get to it. Once the doc sees the patient, they order treatment (like, PO or IV steroids or pain meds) and then the RN needs to get the order, pull the meds, and administer them - that can all easily take over 30 minutes in a semi-busy ED.

So... If the choice is, sit in the ambulance bay for a minute before going in to push another dose of pain meds, or give steroids - we should do it. It's what is right for the patient, and will reduce their discomfort and suffering, and quite possibly lead to them getting better faster.


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## Akulahawk (Mar 21, 2016)

At the hospital I'm at currently, if a patient needs Solumedrol, we can get rolling on that stuff pretty quickly if necessary. While the patient does need to be put in the computer and the RN needs to do triage, a patient that's in need of at least somewhat aggressive airway management, we can often administer Solumedrol before triage is complete as the Doc has seen the patient by then and has given verbal orders to us for it. Often, for these patients, we've already got RT giving a breathing treatment, initial assessment/vitals done, IV established (if not already done), and IV Solumedrol pushed within 10 minutes of arrival. We're a small ER and have pretty much everything close at hand and no Pixys/Omnicel to contend with... which often requires a patient to be put into the system and orders to be "written" to get anything out of it.


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## EMS2PA (Mar 22, 2016)

cannonball88 said:


> There's a viewpoint to many in the EMS community that IV Solu-Medrol in the field is generally not recommended in allergic reactions, COPD, etc. because it takes 45 minutes to take effect.
> 
> Could anyone who has used SM in the field share what they can about length of time to take effect, it's effectivity, etc?



I'd argue that the fact that it takes 45 minutes to take effect is all the more reason it should be given in the field. 
What if you get to this patient at the beginning of their allergic reaction, and because you gave the Solu-Medrol, you prevented a worsening allergic reaction or rebound anaphylaxis?
What if your patient was a patient in status asthmaticus (requiring multiple SVN treatments), and because you got that solution-medrol on board you were able to save intubation?
In the ED, we like to get steroids on board ASAP because of the time it does take to take effect. But, it does help improve outcomes.


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## XXLMedic37 (Mar 22, 2016)

I've given Solu-Medrol in the field. And yes while it does take a significant amount of time for the patient to feel the full effects of it, that doesn't mean that (1) We shouldn't give it (2) The patient may very well benefit from it.


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## 1EMTP (Mar 25, 2016)

I have used Solu-Medrol in the field, but unfortunately we do not carry it anymore.


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## Tigger (Mar 25, 2016)

Hmm I guess I thought corticosteroids were a common EMS medication. Apparently not.


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## XXLMedic37 (Mar 26, 2016)

Unfortunately not every system uses corticosteroids. It wasn't until I went to work in Texas that I used corticosteroids. Now I'm in Georgia and we are using corticosteroids as well.


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## SeeNoMore (Mar 26, 2016)

I've never not carried steroids , just goes to show how varied EMS is


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## Carlos Danger (Mar 26, 2016)

We had them in my first job as a paramedic in 1998, and I think I always had SM since.


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## Brandon O (Mar 26, 2016)

Can be important for adrenal insufficiency.


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## EMS2PA (Mar 27, 2016)

Brandon O said:


> Can be important for adrenal insufficiency.



Yes, but typically I'm not giving Solu-Medrol for adrenal insufficiency, I'm using decadron or hydrocortisone. 
And from an EMS standpoint, why would you be treating adrenal insufficiency?


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## Carlos Danger (Mar 27, 2016)

EMS2PA said:


> Yes, but typically I'm not giving Solu-Medrol for adrenal insufficiency, I'm using decadron or hydrocortisone.
> *And from an EMS standpoint, why would you be treating adrenal insufficiency*?



EMS sometimes transports pretty sick folks.

And not to speak for Brandon, but I think his comment was directed more towards the general idea of carrying steroids vs. specifically using methylprednisolone for a relative adrenal insufficiency. As in a stress dose.

BTW I'm not aware of any EMS systems that give stress doses or any evidence for it being done prehospital, but there are probably lots of things routinely done in EMS that make less sense.


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## EMS2PA (Mar 27, 2016)

Remi said:


> EMS sometimes transports pretty sick folks.
> 
> And not to speak for Brandon, but I think his comment was directed more towards the general idea of carrying steroids vs. specifically using methylprednisolone for a relative adrenal insufficiency. As in a stress dose.
> 
> BTW I'm not aware of any EMS systems that give stress doses or any evidence for it being done prehospital, but there are probably lots of things routinely done in EMS that make less sense.




I'm not saying EMS doesn't transport sick people. But from a 911 standpoint, adrenal insufficiency isn't going to be treated in the field. And from an IFT standpoint, I'd assume (yes, I know what happens when you assume), that it would have been given in the hospital already. 
Tbh, even in the ED, I've only treated 2 adrenal insufficiency patients in 8 years. And the endocrinologists have told me in the past that the Solu-Medrol isn't their preferred medication, decadron or hydrocortisone is.


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## Carlos Danger (Mar 27, 2016)

EMS2PA said:


> I'm not saying EMS doesn't transport sick people. But from a 911 standpoint, adrenal insufficiency isn't going to be treated in the field. And from an IFT standpoint, I'd assume (yes, I know what happens when you assume), that it would have been given in the hospital already.
> Tbh, even in the ED, I've only treated 2 adrenal insufficiency patients in 8 years. And the endocrinologists have told me in the past that the Solu-Medrol isn't their preferred medication, decadron or hydrocortisone is.



Again, I *think* Brandon was referring more to corticosteroids in _genera_l being potentially useful in the field; not necessarily saying that it should be standard practice to give methylprednisolone prehospital when adrenal insufficiency is suspected.

And I'm not saying that I think it should be common practice, either. But I'm also not sure it's the worst idea in the world to try giving a stress dose to a hypodynamic patient with a history of Addison's disease, or to someone who looks like they've been really sick for a few days and is nearing cardiovascular collapse.


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## chaz90 (Mar 27, 2016)

Yup. I've given Solu-Medrol for precisely the above situation. Patient was on vacation, known to have Addison's, hypotensive, and hardly responsive. We had a 40 minute or so transport, so I ran the idea by the medical control doc and he was all for it. Worked out just fine.


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## Brandon O (Mar 27, 2016)

As Remi said, I wasn't referring to specific corticosteroid choices. But there is evidence that early stress dosing (i.e. prehospital vs ED time is relevant) makes a difference to outcomes. Massachusetts started carrying methylpred for that reason and I believe other regions have done the same.

The opinion on the street seemed to be "we'll never use this" since the protocol was to give it for "known adrenal insufficiency," but that's not so wild -- you just have to hear about it in their PMH. People just didn't understand the importance.


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## Brandon O (Mar 27, 2016)

And FWIW I agree Solumedrol isn't usually the drug of choice so not sure why that's what they settled on. Maybe logistical reasons.


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## Tigger (Mar 27, 2016)

We have some agencies here carrying solu-cortef for that, but I think much of that came from a community push.


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## Akulahawk (Mar 27, 2016)

Brandon O said:


> And FWIW I agree Solumedrol isn't usually the drug of choice so not sure why that's what they settled on. Maybe logistical reasons.


It probably is for logistical reasons... the SM we have in our ED isn't mixed until it's used so it can be stored for quite a while. IIRC once it's mixed we have maybe a day to use it.


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## CTMD (Apr 3, 2016)

I've noticed that Clark County in Nevada carries Solu-Cortef but it is not in their allergic reaction or respiratory protocols. Are they not allowed to give it for respiratory issues/allergic reactions? Can anyone from Vegas way in on this?


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## BassoonEMT (Apr 17, 2016)

CTMD said:


> I've noticed that Clark County in Nevada carries Solu-Cortef but it is not in their allergic reaction or respiratory protocols. Are they not allowed to give it for respiratory issues/allergic reactions? Can anyone from Vegas way in on this?




Don't know about out there, but by me some placed carry it as the preferred treatment for adrenal insufficiency. But solu-medrol is also acceptable, just not preferred. That's the only protocol it's written in.


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## 18G (Apr 24, 2016)

EMS is the point of first medical contact. Our job is to treat the patient as a whole and to deliver whatever care is appropriate while we are with them. I believe in getting medications onboard sooner than later when they are indicated and can help change a patient's trajectory. Solu-Medrol is one of these type of medications. I totally agree with what John said which is patients do not receive immediate treatment upon rolling into the ED. It is often a good 20-30mins before meds get administered. One study found that it took an average of 70mins for an EMS arrived patient to receive their first dose of pain medication. So, if you're sitting in the ambulance bay at the ED,  take an extra minute while you're still 1:1 with the patient and administer the medication.

I agree with the Solu-Medrol for Addisons crisis. While not the preferred steroid, it does work.


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