Guideline Updates

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Dodges Pucks
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Our system is in the midst of the yearly guideline update. Thought I'd share some interesting changes for the sake of discussion.

Of most note, epi and amiodarone/lidocaine were removed from the cardiac arrest guideline for patients 19 years and older. For most "garden variety" cardiac arrests, electricity if indicated and an iGel with passive O2. After four shocks we are supposed to cease efforts. Two cycles of PEA/asystole also means stop, so a presenting PEA arrest gets one round of compressions and some oxygen and that's it. This all came to be during COVID but is staying indefinitely. I await some additional info as to what evidence is being used here.

We are no longer using atropine for bradycardia. If the patient is sick enough to require intervention, either pace or epi push dose to bridge to infusion (or both).

Lidocaine and amiodarone were removed for wide complex tach with a pulse. If the patient requires intervention, sedate (if appropriate) and cardiovert.

Droperidol has returned for both agitation and nausea/vomiting.

I am hoping we will try to start carrying cyanokits, at least on the batt chief ride.

TXA topically for nosebleeds. Wish we could start using it for actual hemorrhage but our medical director is "not looking for a fight."

We still won't be doing RSI here which I have mixed thoughts on.
 

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Our system is in the midst of the yearly guideline update. Thought I'd share some interesting changes for the sake of discussion.

Of most note, epi and amiodarone/lidocaine were removed from the cardiac arrest guideline for patients 19 years and older. For most "garden variety" cardiac arrests, electricity if indicated and an iGel with passive O2. After four shocks we are supposed to cease efforts. Two cycles of PEA/asystole also means stop, so a presenting PEA arrest gets one round of compressions and some oxygen and that's it. This all came to be during COVID but is staying indefinitely. I await some additional info as to what evidence is being used here.

We are no longer using atropine for bradycardia. If the patient is sick enough to require intervention, either pace or epi push dose to bridge to infusion (or both).

Lidocaine and amiodarone were removed for wide complex tach with a pulse. If the patient requires intervention, sedate (if appropriate) and cardiovert.

Droperidol has returned for both agitation and nausea/vomiting.

I am hoping we will try to start carrying cyanokits, at least on the batt chief ride.

TXA topically for nosebleeds. Wish we could start using it for actual hemorrhage but our medical director is "not looking for a fight."

We still won't be doing RSI here which I have mixed thoughts on.
These things usually do have evidence to support them, unclear how valid the 'evidence is. I say that with regard to the pacing over atropine. I suspect it is to simplify things, ie less stuff to carry, inventory, restock etc...\

It's just that IME with so many that epi in symptomatic brady cardia doesn't reliably raise the HR because so many people are taking beta blockers. I think you need a higher dose to get the HR up. The blood pressure definitely comes up well with epi which is good for CPP and maybe that way raising the HR. By the time you get the HR up you may have more pressure than you want/need.

I'll still take raising the HR with native conduction over pacing because of the efficiency of contraction/better SV than external pacing but if the cardiac output is so low that it takes forever for the AS04 to get around, I can see the point I guess.

More than one way to skin a cat....
 

Peak

ED/Prehospital Registered Nurse
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Our system is in the midst of the yearly guideline update. Thought I'd share some interesting changes for the sake of discussion.

Of most note, epi and amiodarone/lidocaine were removed from the cardiac arrest guideline for patients 19 years and older. For most "garden variety" cardiac arrests, electricity if indicated and an iGel with passive O2. After four shocks we are supposed to cease efforts. Two cycles of PEA/asystole also means stop, so a presenting PEA arrest gets one round of compressions and some oxygen and that's it. This all came to be during COVID but is staying indefinitely. I await some additional info as to what evidence is being used here.

We are no longer using atropine for bradycardia. If the patient is sick enough to require intervention, either pace or epi push dose to bridge to infusion (or both).

Lidocaine and amiodarone were removed for wide complex tach with a pulse. If the patient requires intervention, sedate (if appropriate) and cardiovert.

Droperidol has returned for both agitation and nausea/vomiting.

I am hoping we will try to start carrying cyanokits, at least on the batt chief ride.

TXA topically for nosebleeds. Wish we could start using it for actual hemorrhage but our medical director is "not looking for a fight."

We still won't be doing RSI here which I have mixed thoughts on.
So they want you to convert out an irritable heart with electricity but nothing else? What about the patient who arrested after vomiting and diarrhea who has a K of 1.6, there is no way that will convert and stay out without a membrane stabilizer.

Same for the just shocking a stable wide complex, if you are not addressing the underlying etiology then what is the likelihood the patient converts and stays in a narrow rhythm?

I’m not a fan of antipsychotics in patients without a well established medical history, there is a reason that drug comes with a boxed warning. Patients who are taking antipsychotics at baseline or are using street drugs are going to be at a pretty significant risk for arrhythmia.

I have similar concerns for nausea. Patients who present with nausea and vomiting are at risk for electrolyte loss and giving a qt prolonging agent can be dangerous, especially without a rhythm strip and basic chemistry. I also have some concern for the ethics of giving antipsychotics to patients for nausea (especially early generations that are very sedating) if more typical therapies have not been attempted.

TXA is a great topical agent. I think that people forget that there is a pretty big risk associated with patients over 65 or have other risk factors (smoking, oral birth control, et cetera) of developing thrombus with IV administration; risk of increased thrombus can be seen in all ages. It isn’t a great outcome to treat a mild to moderate traumatic hemorrhage only to have an iatrogenic stroke or massive PE. We do use TXA topically a lot on our oral bleeders (mostly onc patients or those with oral surgeries) with great results. Pledgets soaked in neo or afrin also can be considered in the nose, and I have found lido with epi to work well on gauze one the gums (although not as effective as TXA).

Not to sound like a jerk, but if they won’t trust you to appropriately use atropine in bradycardia why would they give you RSI?
 
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Dodges Pucks
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So they want you to convert out an irritable heart with electricity but nothing else? What about the patient who arrested after vomiting and diarrhea who has a K of 1.6, there is no way that will convert and stay out without a membrane stabilizer.

Same for the just shocking a stable wide complex, if you are not addressing the underlying etiology then what is the likelihood the patient converts and stays in a narrow rhythm?
I have zero idea how they expect us to get anything back with the way things are written aside from patients that arrest in front of us. They claim that patients who receive more than four shocks have an almost asystole type survival rate. I suppose it decreases remarkably but just shocking and not doing anything else seems like it isn't going to work very well either. Also we aren't to transport these so there goes any hope of treating electrical storm induced arrests which while rare, might be survivable with the right, non-prehospital therapist.

I’m not a fan of antipsychotics in patients without a well established medical history, there is a reason that drug comes with a boxed warning. Patients who are taking antipsychotics at baseline or are using street drugs are going to be at a pretty significant risk for arrhythmia.

I have similar concerns for nausea. Patients who present with nausea and vomiting are at risk for electrolyte loss and giving a qt prolonging agent can be dangerous, especially without a rhythm strip and basic chemistry. I also have some concern for the ethics of giving antipsychotics to patients for nausea (especially early generations that are very sedating) if more typical therapies have not been attempted.
I have zero interest in using droperidol as a first line treatment for patients that are a clear risk to me or themselves, just as I did when we carried Haldol. Versed and Ketamine will still be the go to aside from very specific situations or in which the patient can participate in the care plan and thinks that this will assist. As for nausea, last year I asked to get a second line choice for when Zofran fails and this is what we got. Can't say I have much experience here, my understanding is that metoclopramide is less sedating so I had asked for that initially. I would hope folks are smart enough to have these patients on the monitor, which is also included in the guideline.

TXA is a great topical agent. I think that people forget that there is a pretty big risk associated with patients over 65 or have other risk factors (smoking, oral birth control, et cetera) of developing thrombus with IV administration; risk of increased thrombus can be seen in all ages. It isn’t a great outcome to treat a mild to moderate traumatic hemorrhage only to have an iatrogenic stroke or massive PE. We do use TXA topically a lot on our oral bleeders (mostly onc patients or those with oral surgeries) with great results. Pledgets soaked in neo or afrin also can be considered in the nose, and I have found lido with epi to work well on gauze one the gums (although not as effective as TXA).
It is really not hard to teach paramedics to give these medications appropriately. These concerns are all valid, but it should not be used prehospitally for moderate hemorrhage. We give it at a part time job with zero issue per UCHealth's trauma people. I understand that it is not a panacea but in an extended transport environment it may have some benefit for both postpartum and trauma causes. I dunno, maybe may help is not a enough of a reason to carry it. Our MD wants to carry it but is not perhaps involved as we would like so I don't really see this going anywhere.

Not to sound like a jerk, but if they won’t trust you to appropriately use atropine in bradycardia why would they give you RSI?
I don't think it is a trust thing with any of these medications, or at least that was not communicated. QA has not identified any sort of misuse to my knowledge. I think a lot of this is in the name of "streamlining" things which I have mixed thoughts on. As for RSI, at medical direction's request we pulled data off the last three years of calls and felt RSI would probably be used 12-15 times per year and that was deemed not enough. For better or for worse RSI is the standard in the region and I don't enjoy getting berated when I come in with a patient who needs an airway and the doctor wants to know why there isn't one. The procedure is done successfully throughout the region with low complications. I understand the evidence does not point to much benefit to its use, but yet when both hospitals are pushing it for EMS, it leaves us in a tough place.
 
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Dodges Pucks
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It's just that IME with so many that epi in symptomatic brady cardia doesn't reliably raise the HR because so many people are taking beta blockers. I think you need a higher dose to get the HR up. The blood pressure definitely comes up well with epi which is good for CPP and maybe that way raising the HR. By the time you get the HR up you may have more pressure than you want/need.
Do you find that glucagon is effective in these patients?
 
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Dodges Pucks
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Not talking about BB overdoses...Just underlying blood levels in someone that also has bradycardia from another reason.
I mean giving glucagon as an adjunct therapy when epinephrine isn't working well (for whatever patient presentation) and the patient is known to be on a beta blocker.
 

Peak

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I have zero interest in using droperidol as a first line treatment for patients that are a clear risk to me or themselves, just as I did when we carried Haldol. Versed and Ketamine will still be the go to aside from very specific situations or in which the patient can participate in the care plan and thinks that this will assist. As for nausea, last year I asked to get a second line choice for when Zofran fails and this is what we got. Can't say I have much experience here, my understanding is that metoclopramide is less sedating so I had asked for that initially. I would hope folks are smart enough to have these patients on the monitor, which is also included in the guideline.


It is really not hard to teach paramedics to give these medications appropriately. These concerns are all valid, but it should not be used prehospitally for moderate hemorrhage. We give it at a part time job with zero issue per UCHealth's trauma people. I understand that it is not a panacea but in an extended transport environment it may have some benefit for both postpartum and trauma causes. I dunno, maybe may help is not a enough of a reason to carry it. Our MD wants to carry it but is not perhaps involved as we would like so I don't really see this going anywhere.
Reglan is not typically considered to be sedating. It does have a pretty significant risk of akathesia and feeling of panic if pushed quickly. It can also cause some tardive dyskinesia, Parkinsonism symptoms, and tick like presentations especially with prolonged clinical use.

While phenergan is considered sedating is is much less so than many other medications that are considered antipsychotics, especially if a small dose (6.25 mg in adults) as a slow IVP or 10 minute infusion.

Kytril is a great option for those who zofran is not effective. Unfortunately it has a reputation of being very expensive, although it really isn’t really more expensive than zofran when it came on the market.

I do find that a small dose of Ativan (0.25-0.5 mg in adults) works quite well for nausea without a large sedating effect (especially if the patient isn’t taking a sedating antiemetic or on narcotics).

Without becoming grossly unprofessional I would look strongly at the data coming out of places like UCLA, Cook county, DMC, Barnes/Jewish, shock trauma in Baltimore, and NY Pres. These are hospitals that see large volumes of multi-system trauma patients.

TXA really shouldn’t be given in postpartum hemorrhage, its use is controversial and only if other interventions have failed. While it was shown in the literature to reduce the mortality from bleeding, the study patients had the same overall mortality in the treatment and control arms. These patients are at massive risk for stroke and PE. The first line treatment should be aggressive fundal massage while supporting the vagina to prevent prolapse. Mothers can also be encouraged to breastfeed or perform nipple massage as this releases oxytocin.

These patients should be getting first IV Pit, PR cytotec, IM methergin and hemobate. While theses drugs do have side effect profiles they act by increasing the uterine tone which will decrease bleeding in most women enough to allow them to heal or go to OR. Women who have bleeding for which increasing tone is not indicated (uterine rupture, placental abruption, and so on) TXA is unlikely to provide enough therapy and these patients require emergency cesarian and bleeding control typically meaning a hysterectomy. These patients will likely require mass transfusion and a gram of TXA isn’t likely to change that.

Rapid transport to a high risk OB center with a high acuity NICU is mandatory. I would encourage you ask the attending or charge the next time you take a patient into the ED where their crash OB trays are, I think you’ll be disappointed with their answers. Just recently we were sent a lady that we had to crash section because the level 1 didn’t have the capability.
 

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I mean giving glucagon as an adjunct therapy when epinephrine isn't working well (for whatever patient presentation) and the patient is known to be on a beta blocker.
Oh...So I'd say that would be a pretty 'dirty' way to raise the HR given other way more clean, reliable drugs and interventions. So, no...I've never, nor would I, give glucagon for refractory bradycardia outside a BB overdose.
 
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Dodges Pucks
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Oh...So I'd say that would be a pretty 'dirty' way to raise the HR given other way more clean, reliable drugs and interventions. So, no...I've never, nor would I, give glucagon for refractory bradycardia outside a BB overdose.
We are supposed to be giving it for refractory anaphylaxis patients who are on beta blocker therapy, I figure it would also possibly be of assistance if an epinephrine drip was not working very well in BB patients.

I think pacing is probably the more reliable intervention here though a few studies have shown some pretty poor mechanical capture acquisition rates.
 

Peak

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We are supposed to be giving it for refractory anaphylaxis patients who are on beta blocker therapy, I figure it would also possibly be of assistance if an epinephrine drip was not working very well in BB patients.

I think pacing is probably the more reliable intervention here though a few studies have shown some pretty poor mechanical capture acquisition rates.
Do you ever give stress dose steroids?
 
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Dodges Pucks
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Do you ever give stress dose steroids?
I have not personally. We can treat a severe adrenal crisis patient with 10mg of dex but I have not encountered such a patient.
 

Peak

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I have not personally. We can treat a severe adrenal crisis patient with 10mg of dex but I have not encountered such a patient.
A large number of our patients will have some degree of adrenal fatigue either from chronic illness or obesity. I’ve found that a stress does often benefits the efficacy of vasoactives. If you are getting a poor response to pressors a dose of calcium is often very beneficial, a lot of patients are subclinically hypocalcemic and 20 mg/kg or a gram of CaCl can substantially improve pressure, just make sure not to slam it if they are at risk of profound hypokalemia as the stone heart is irreversible (although I’ve yet to see a documented case outside of the OR or CVICU).

Do y’all carry solucortef or solumedrol? Dex can work in a pinch but it isn’t as potent to the crisis patient.
 
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Dodges Pucks
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A large number of our patients will have some degree of adrenal fatigue either from chronic illness or obesity. I’ve found that a stress does often benefits the efficacy of vasoactives. If you are getting a poor response to pressors a dose of calcium is often very beneficial, a lot of patients are subclinically hypocalcemic and 20 mg/kg or a gram of CaCl can substantially improve pressure, just make sure not to slam it if they are at risk of profound hypokalemia as the stone heart is irreversible (although I’ve yet to see a documented case outside of the OR or CVICU).

Do y’all carry solucortef or solumedrol? Dex can work in a pinch but it isn’t as potent to the crisis patient.
I think it would be the quite call-in to pull either of those off but is certainly something to remember. Much better to think of why the usual therapies aren't working rather than just turning them up...

There is an option to carry solumedrol but only one of my jobs carries both and even then that physician adviser does not want to see solumedrol on the ambulances because "dex works better and can be given in more ways." Perhaps the latter is true.
 

Peak

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I think it would be the quite call-in to pull either of those off but is certainly something to remember. Much better to think of why the usual therapies aren't working rather than just turning them up...

There is an option to carry solumedrol but only one of my jobs carries both and even then that physician adviser does not want to see solumedrol on the ambulances because "dex works better and can be given in more ways." Perhaps the latter is true.
I would say that dex is easier to dose, but there are a lot of studies that show that orapred or methylred are just as effective in treating things like croup and anaphylaxis. The down side is that the shorter duration of action means more frequent dosing, but for a critical admission that will end up in intensive care that shouldn’tbe a decision maker.

The increased efficacy often means we are converting patients back to solumedrol or solucortef in the unit.
 

Peak

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@Tigger Did you ever hear about that kid that didn’t get stress dosed at one of the schools? I think it was like 7 or 8 years ago?
 

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Dodges Pucks
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@Tigger Did you ever hear about that kid that didn’t get stress dosed at one of the schools? I think it was like 7 or 8 years ago?
I do remember this, I think there were two various serious incidents in southern Colorado. It was right when I started in this area.
Are you guys actually able to get droperidol? We haven't seen it for years.
We are carrying it, McKesson is selling it from "American Regent."
 

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