a few newbie questions from ALS standards

[Aileana]

I've been reading through my ALS standards, and have a few (probably very newbie) questions I've been wondering about. I'll try not to drown you in all of my questions at once, but I'll post a few at a time.

-For anaphylaxis patients, since the throat is so swollen, is intubation possible?
-why, for hypothermic patients, is IV access to be started, but nothing is to be administered?
-how do you properly give SC injections without causing swelling under the skin?
-when is glucogon given, as opposed to glucose?
-how long must one wait after 2 failed intubation attempts to attempt again?
-can epinephrine and atrophine be given together for PEA/asystole?

Any assistance on this would be appreciated. thanks in advance!

 

[bstone]

I've been reading through my ALS standards, and have a few (probably very newbie) questions I've been wondering about. I'll try not to drown you in all of my questions at once, but I'll post a few at a time.

-For anaphylaxis patients, since the throat is so swollen, is intubation possible?

If they are unresponsive with no gag reflex, then you can try. Establishing that airway may save them (along with Epi, etc)

-why, for hypothermic patients, is IV access to be started, but nothing is to be administered?

Dunno.

-how do you properly give SC injections without causing swelling under the skin?

Not sure I understand. SC is so near the top of the skin that it almost always causes some minor swelling.

-when is glucogon given, as opposed to glucose?

Glucogon acts on the liver whereas glucose is straight dextrose. If memory serves, Glucogon can be given IM and it useful if you cannot establish IV access.

-how long must one wait after 2 failed intubation attempts to attempt again?

My protocols say 2 minutes between failed ET attempts.

-can epinephrine and atrophine be given together for PEA/asystole?

My protocols say 1mg of each 1 minute apart from each other while doing CPR.

Any assistance on this would be appreciated. thanks in advance!

No prob! Hope others chime in with their protocols.

 

[Aileana]

If they are unresponsive with no gag reflex, then you can try. Establishing that airway may save them (along with Epi, etc)

If they're conscious, but the airway is compromised by the swelling, would attempting to intubate assist, or would it increase anxiety, and aggravate(sp?) the swelling?

Not sure I understand. SC is so near the top of the skin that it almost always causes some minor swelling.

Sorry, I should have worded the question better . I meant to ask what one can do to prevent abscesses and discomfort when giving SC injections.

Glucogon acts on the liver whereas glucose is straight dextrose. If memory serves, Glucogon can be given IM and it useful if you cannot establish IV access.

If IV access is possible, which of these is preferred to administer?

Thanks so much for your help!

 

[bstone]

If they're conscious, but the airway is compromised by the swelling, would attempting to intubate assist, or would it increase anxiety, and aggravate(sp?) the swelling?

I don't think we ever do conscious intubation. I know medics can sometimes do RSI (based on if their protocols allow). I think shoving a tube down the throat of a person who is dying of a severe allergy response would only serve to agitate them more.

Sorry, I should have worded the question better . I meant to ask what one can do to prevent abscesses and discomfort when giving SC injections.

Umm...not completely sure. Do it right? Heh.

If IV access is possible, which of these is preferred to administer?

IV access with the D5W is the ideal. Once you use the glucagon it uses up all the stores in the liver so you can't really use it twice.

Thanks so much for your help!

Welcome!

 

[Ridryder911]

I've been reading through my ALS standards, and have a few (probably very newbie) questions I've been wondering about. I'll try not to drown you in all of my questions at once, but I'll post a few at a time.

-For anaphylaxis patients, since the throat is so swollen, is intubation possible?

Sometimes, sometimes it is not. One of the few times I had to perform an emergency crich was on a anaphylaxis. The tongue does immediately swell as well as the posterior throat. This condition in anpaphylaxis is called angioneurotic edema, one of the true emergencies. I also suggest inhaled & IV steroids to reduce swelling.

-why, for hypothermic patients, is IV access to be started, but nothing is to be administered?

I don't suggest that. Any increase in stimulation may cause V-fib. Unless one has (appropriately) heated fluids or is able to administer resuscitated medications if needed, then there is no need to attempt to establish. There is a reason I stated "attempted".

-how do you properly give SC injections without causing swelling under the skin?

Sub-q is in the fat area, NOT to be confused with intradermal (such as TB skin test). This is one of the most mis-performed skills by Paramedics. The amount that is given should not exceed(>1ml) & cause swelling, if you do have to administer more than that volume (? medication) then multiple injections should be performed, at different sites (abd, post upper arm, thigh). Abscesses are caused by improper injections and due to diabetics poor healing process. Remember- ONE DOES NOT ASPIRATE on sub-q. The needle should be short and only reach sub-q if the skin is properly pinched or gathered up. If you see swelling it was done improperly.

-when is glucagon given, as opposed to glucose?

Usually Glucagon is administered as an alternative to IV Glucose, when one cannot establish an IV line, Glucagon is usually administered sub-q. It can be administered IV route, but then why not administer Glucose?
Remember, Glucagon has other indications than hypoglycemia. As well, current research is describing maybe D50w is not such a good thing. Rather, D25 or even D10w is just as effective. .

-how long must one wait after 2 failed intubation attempts to attempt again?

This is an usual standard to point out, that you have attempted and it is time to allow someone else to attempt and perform. We are all humans, and all of us have good days and bad days. As well, some are more experienced than others. Usually, after two attempts it has been noted that providers have become frustrated and rushed. It is better to have another set of eyes. This rule is suggested, however; not written down in stone, except for SOP.

-can epinephrine and atropine be given together for PEA/asystole?

Yes, but it is much better to alternate. Remember, Atropine is only given to PEA when the ventricular rate is bradycardic. As well, allow time to flush the line after each medication and allow at the least of 3 minutes with good CPR for circulation before administering the additional dosage. AHA has even stressed that it is NOT so much the medication, as resucititation that causes the saves.

Any assistance on this would be appreciated. thanks in advance![/QUOTE]

Good questions, and your welcome. I suggest reviewing through AHA ACLS, AMLS textbooks, and many good EMS texts.. (not all are good).

R/r 911

 

[Aileana]

Sometimes, sometimes it is not. One of the few times I had to perform an emergency crich was on a anaphylaxis. The tongue does immediately swell as well as the posterior throat. This condition in anpaphylaxis is called angioneurotic edema, one of the true emergencies. I also suggest inhaled & IV steroids to reduce swelling.

Which steroids would be given in this case?

What would you recommend in terms of practice to perform better Sub-Q injections? What is the treatment for abscesses? Also, I've seen some conflicting information on massaging the injection site after administering. Is massaging the injection site an appropriate portion of treatment?

Good questions, and your welcome. I suggest reviewing through AHA ACLS, AMLS textbooks, and many good EMS texts.. (not all are good).
R/r 911

where would I get my hands on these textbooks, and which would you recommend? Sorry I'm responding to your answers with more questions, just trying to understand ALS a bit better
Thanks again!

-Aileana

 

[Ridryder911]

Which steroids would be given in this case?

What would you recommend in terms of practice to perform better Sub-Q injections? What is the treatment for abscesses? Also, I've seen some conflicting information on massaging the injection site after administering. Is massaging the injection site an appropriate portion of treatment?

Steroid therapy is controversial. The most initial treatment of course is H2 blockers to stop the MAST cell production of antihistamine response. As well, as possible administration of Epinephrine. My medical control and myself have
seen + results of steroid therapy (however it does take time to absorb). Steroid therapy such as Solu-Medrol IV, or some physicians may prefer Decadron sub-q, IM, or even some have used it in nebulized form.. (not common practice). Again, it depends on aggressiveness of the physician or practitioner.

Sub-q should be given in the most fatty areas. Usually the back of the forearms, abdominal area (that is divided up for rotations) lateral side of the thighs, again any fatty area. Sub-q sites should be rotated to abscesses may be reduced. It is common due to the irritation of the medication and because of poor circulatory status. I do not suggest "massaging" any SQ, since it is usually a stronger concentration (remember sub-q is slow acting) and can cause irritation to the area as well may enhance absorption, in which we we do not want in this case.

Treatments vary, but usually warm compresses to the area will reduce the swelling. Monitor for symptoms of cellulitis and inflammation. Sometimes antibiotics such as Keflex, has to be administerd. Again, usually there is an underlying cause for the abscesses.

where would I get my hands on these textbooks, and which would you recommend? Sorry I'm responding to your answers with more questions, just trying to understand ALS a bit better
Thanks again!

-Aileana

Usually general Paramedic texts do not address such treatments, or not in detail like they should. Critical care paramedic texts, sometimes adress these topics. Most RN or even practical nursing texts do and do so more in-depth. Remember, medicine is medicine.

Google and you will find more information. Be careful which sites, choose respectable and creditable ones.

R/r 911

 

[Aileana]

thanks so much! Any idea where I could buy/download CCP texts?

 

[Onceamedic]

. Remember- ONE DOES NOT ASPIRATE on sub-q. R/r 911

hmmm.. we are being taught to aspirate on both sub-q and IM -
Sub-Q - small gauge needle, 1/2" - 5/8" long, tent the skin, insert at a 45 degree angle, aspirate and inject.

As I understand it, aspiration is to ensure that you haven't hit a vessel. It is possible to hit a vessel sub-Q, so why wouldn't I aspirate ?

 

[Ridryder911]

Yes, it is possible to inject into a vein. I was taught as well to aspirate, some are now teaching not to, that one is aspirating fat tissue. For safety sake, I should clarify to aspirate, if that is in one's protocol.

Again, there is difference in opinion. Some argue, there is very little venous in the sub-q area, where others describe that there is a risk. It all depends upon your local policy. This is why I hate transferring or working various hospitals, there is many small minute differences, however; one must know or in the case of "Murphy's law" event, your screwed.

R/r911

Here is a link for Bledsoe's: May I also suggest Critical Care Nusing Made Easy (excellent book) and AMLS text.
http://www.amazon.com/Critical-Care-Paramedic-Bryan-Bledsoe/dp/013119271X