38yo Shortness of Breath

[redcrossemt]

ST elevation of 3mm in leads V5 and V6.

Would also want to look at the posterior leads...

 

[MrBrown]

MelClin, how is it that you can gain IV access, give fluids to cardiogenic shock, bypass hospital for cathlab, yet have to give IN or inhaled analgesia? That's wierd!

Because IV analgesia may not be in the base level scope of practice in Victoria

 

[Melclin]

What do you mean by plenty? ...

I just skimmed over that and took its to mean he was too young for it to be an AMI. My mistake. I agree with you, its young, and you would be interested in factors that had accelerated the process.

MelClin, how is it that you can gain IV access, give fluids to cardiogenic shock, bypass hospital for cathlab, yet have to give IN or inhaled analgesia? That's wierd!

Because IV analgesia may not be in the base level scope of practice in Victoria

We can give IV analgesia in the form of morphine (as I said, I really didn't want to give the guy morphine because of the BP). We just are not supposed to give fentanyl via the IV route. I'm sure you could call the clinician and explain your problem and if you sounded like you had things under control then you'd be allowed too.

Its just that some of the older basic level paramedics are still around from the days when our basics weren't that different from your American basics. So every time they throw something new into the mix for basics, despite the fact that the majority of us are university educated and very competent, they still have to consider how the worst of us might stuff things up. A very frustrating fact indeed. It will be nice when we can say, "You really don't have to worry about giving us new drug X, we all did pharmacology at uni, we all had drug calcs as a massive part of our curriculum - drug X will be fine, most of us know lots about it anyway, because a lot of recent research has called for its use in the pre-hospital setting - and naturally we're all up to date on recent research". *Sigh* ...one day.

 

[Smash]

Ah, ok that makes sense.

It's funny though, as I was fairly sure that according to CPG A0407, page 63 of Ambulance Victoria CPGs version 4, last updated 11/01/05 that IV fluid for cardiogenic shock was an Intensive Scare skill

Mind you, that is the problem with printed protocol they go out of date (fashion?) fairly easily, necessitating local variances which my sources may not have informed me about. h34r:

 

[Melclin]

You're quite possibly right. Our book learnin' at uni is not specific to Victorian protocols so we tend to learn a lot more than we might necessarily be allowed to practice. I'll read the new guidelines see what the new word is on the matter (the ones on the internet are fairly old if those are the ones you're refering too).

EDIT: the guideline lists it as a MICA skill, specific to cardiogenic shock. However, we'd simply have to 'suspect' that a pt was volume depleted so administer fluids. Which reminds me of how a lot of APO pts are 'asked if they have chest pain *winking*' because we can't give morphine to calm an APO pt down for CPAP (thats a MICA skill) but we can give it for most kinds of pain so..... I wonder if a certain RRT lass will turn up to rip me a new one about this.

 

[Smash]

Maybe, one never knows...

The CRUSADE trial looked at morphine in chest pain patients and concluded that thos who recieved morphine and conlcuded that they were more likely to die. It was however a retrospective registry examination, and it certainly raised more questions than it necessarily answered. Obviously the biggest question is: Did they recieve morphine because they were more unwell, therefore more likely to die anyway, or did the morphine cause them to die? It;s a big question.

Nonetheless respiratory depression is something to be avoided obviously in these patients, so I would at least be cautious with morphine.

Then again, I'm just a 'B' with no letters after my name, so heck, I don't know.

Quote for the day:

"The spread of secondary and latterly of tertiary education has produced a large population of people, often with well developed literary and scholarly tastes, who have been educated far beyond their capacity to undertake analytical thought." - Peter Medawar

 

[MrBrown]

The CRUSADE trial looked at morphine in chest pain patients and concluded that thos who recieved morphine and conlcuded that they were more likely to die. It was however a retrospective registry examination, and it certainly raised more questions than it necessarily answered. Obviously the biggest question is: Did they recieve morphine because they were more unwell, therefore more likely to die anyway, or did the morphine cause them to die? It;s a big question.

That study was mentioned in our latest clinical newsletter; problem is that methodology is pretty backwards and open to lots of interpretation; I forget the name but we learnt in research methods that you can have a situation just like this and say "well morphine caused them to die" because you have a) they got morph and b) they died, when in fact the two may be unrelated.

I wonder how many people who don't realise the methodology is flawed will read [about] it and change thier practice, consider changing it or hit up thier medical directors for it to be changed.

 

[Smash]

That study was mentioned in our latest clinical newsletter; problem is that methodology is pretty backwards and open to lots of interpretation; I forget the name but we learnt in research methods that you can have a situation just like this and say "well morphine caused them to die" because you have a) they got morph and b) they died, when in fact the two may be unrelated.

I wonder how many people who don't realise the methodology is flawed will read [about] it and change thier practice, consider changing it or hit up thier medical directors for it to be changed.

Far be it from me to discuss methodolgy of research papers, I'll only get a few strawmen built and thrown my way along with a fair old smattering of lies and abuse. Nonetheless, us brave few should soldier on, so once more into the breach dear friends, once more / or close the wall up with our English dead...

You've hit the nail on the head; there is no way demonstrate a causative link between the two from the CRUSADE trial. At very best it raises the possibility that more research may need to be conducted into the effects of morphine in patients with chest pain (and cardigenic shock).

However I would still be careful with morphine in the cardiogenic shock patient. I would probably tend towards fentanyl anyway as there is a lesser likelihood of causing further hypotension with it.

 

[MrBrown]

Probably one of the reasons we are getting fent

 

[Melclin]

I like that quote; its familiar, which makes sense given the person who said it (describes some of my lecturers pretty well). Taken in combination with your signature, I think we may have much in common.

On the topic of morphine, it would make sense that a drug that can cause adverse haemodynamic changes might cause troubles in the ACS context. I'll add that to the list of reasons why I love fent. In any case I'm off to bed, 50mg of promethazine is getting the better of me.

 

[MrBrown]

Bloody hell mate, 25mg IV (which stings something FIERCE) and wow my GCS was what ... like 8 or 9? ... seriously I was pretty smashed they said the other patients were asking what I was on, and that they wanted some ... hell if I remember

Mind you your 50mg was probably PO

 

[usalsfyre]

MAP is 66, so I'm going to hesitate jumping on pressors right away. ASA, O2, IV, fentanyl for pain control due to the labile pressure, and small/careful fluid boluses (100-200ml at a time) until the lungs get wet or B/P gets to a comfortable level. Posterior 12 lead, and consider transdermal/IV NTG depending on outcome of further 12 lead and/or fluid boluses.

 

[Melclin]

Mind you your 50mg was probably PO

Yep.

Probably a fact more suited to the promethazine thred, but its also a local anesthetic. A fact that I discovered first when I accidentally bit down on a tablet once and my entire mouth burnt for a moment then went completely numb for about 30 mins .