Good Call wanted to share

[tah06090]

Thought id share this call from last shift. Dispatched to assist a nearby town BLS unit they requested ALS to there scene. Call was for a 48 yo female CP with radiation to arm/neck. U/a 48 yo female no hx no meds quit smoking 6months ago. She was very weak, SOB, pale, diaphoretic. She stated it all began while reading the news paper sudden onset 10/10 cp crushing radiating to both arms neck jaw and face with severe Nausea. Nearest Hospitol was 45 min was a long ride lol. did standard stemi care on the way absolutely could not control this ladies pain. Surprisingly she was hypertensive the whole time. Her right sided EKG had ST elevation in v4 as well.

 

[ExpatMedic0]

Nice one!

 

[fast65]

Nice, what were you using for pain control?

 

[tah06090]

gave ASA, Zofran 4mg, NTG x3 and 10mg morphine

 

[tah06090]

Surprisingly after all that her pressure on arrival was 130s/80s initially we had 170s systolic

 

[blindsideflank]

10 mg over 40 mins.. What was the dosing schedule there?

 

[tah06090]

We have very crappy protocols...........

 

[EpiEMS]

gave ASA, Zofran 4mg, NTG x3 and 10mg morphine

Btw what are your standing order morphine limits?

 

[tah06090]

for ischemic cp protocol says i start at 2mg every 5-15min based on BP 100 systolic

 

[tah06090]

Btw what are your standing order morphine limits?

For CP note above and traumatic injury up to 10 then need to call in. We carry Fent but online order only and we usually get denied.

 

[fast65]

Hmmmm, 10 mg over 40 minutes isn't very much, but I understand your protocols don't allow it.

 

[EpiEMS]

Hmmmm, 10 mg over 40 minutes isn't very much, but I understand your protocols don't allow it.

My reaction as well. I would've expected a , but protocols are protocols, I realize.

Makes me curious what standing orders are for morphine administration...I sense a poll coming...

 

[zzyzx]

Looks like a STEMI mimic to me. I would have just AMA'ed her.

 

[fast65]

My reaction as well. I would've expected a , but protocols are protocols, I realize.

Makes me curious what standing orders are for morphine administration...I sense a poll coming...

I'm allowed 2-5 mg PRN up to 15 mg before it becomes a category B procedure in which I have to give a copy of the chart to medical director. However, I can still give more after I hit that 15 mg mark.

 

[tah06090]

We only carry 20mg of morphine and 100 mcg of fent

 

[fast65]

We only carry 20mg of morphine and 100 mcg of fent

Really? What's your typical transport time?

 

[abckidsmom]

We only carry 20mg of morphine and 100 mcg of fent

We have 2 drug boxes on our trucks, with 20 mg morphine and 200 mcg fent in each.

Average 45 min transport, that's not usually adequate.

 

[usalsfyre]

NTG x3

Good job, but in the future you might want to think twice about this in RVI.

 

[fast65]

We have 2 drug boxes on our trucks, with 20 mg morphine and 200 mcg fent in each.

Average 45 min transport, that's not usually adequate.

Yup, we carry 30 mg morphine and 500 mcg fentanyl on our rigs.

Good job, but in the future you might want to think twice about this in RVI.

I'm curious, what's your opinion on giving NTG in an RVI if you provide a fluid bolus first to increase preload?

 

[chaz90]

I'm fine with a NTG trial in cases of RVI as long as the BP is initially high enough and I have an IV. Most evidence I read about it doesn't seem to recommend a complete contraindication for NTG, but definitely to use caution during administration. As it so rarely occurs alone though without also involving the inferior wall, I'd expect many patients with RVI to already be hypotensive and bradycardic.

Also, we only carry 400 mcg Fentanyl.