75yo Male - post LOC wrist #

[exodus]

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?

 

[MrBrown]

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

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

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?

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.

 

[Veneficus]

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.

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

 

[Veneficus]

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.

 

[MrBrown]

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).

 

[Veneficus]

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."

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.

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.

 

[MrBrown]

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.

"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.

 

[Melclin]

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?

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

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



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



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.

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.

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?

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.

Couldn't answer those questions with any degree of certainty. It was apparently a real scenario that was put to me at uni. The sessional may have left off some details, or I may have missed it.


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

Not in poor perfusion 2ndry to SVT?

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

What are you planning on going into if you don't mind my asking?

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.

 

[Veneficus]

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.

 

[exodus]

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.

 

[MrBrown]

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.

-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.

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.

-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.

-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!

 

[Veneficus]

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)!

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.

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.

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)

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.

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.

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.

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.

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.

 

[MrBrown]

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?

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!

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.

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".

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.

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

 

[8jimi8]

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...

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

 

[VentMedic]

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.

 

[MrBrown]

Do you guys not have monitored beds in ED?

 

[VentMedic]

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.

 

[Veneficus]

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.

 

[8jimi8]

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.

 

[Shishkabob]

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...