How liberal are you with antiemetics?

[redcrossemt]

Quite liberal.

We have standing orders for 4mg IV or IM. The protocol suggests calling for orders of a repeat dose of 4 more if it doesn't help.

For kids under 12 y/o it is also post-radio, but suggests 0.1mg/kg IV or IM.

 

[FLEMTP]

A while back we had a thread with several medics advocated withholding antiemetics from drunk patients to "teach them a lesson". I figured we could expand that conversation a little. How liberal or conservative are you when it comes to antiemetics? Do you give them preemptively (pt. hasn't vomited yet but feeling queasy)? Do you give them before backboarding patients that are intoxicated and queasy (think airway compromise once you've got them strapped to your cot and alone in the back). What does your service carry?

Personally, I give Zofran out very frequently. If someone is nauseated, they're getting Zofran (usually). I give it preemptively to make my patients more comfortable, prevent airway issues, and make life easier for my partner who would have to clean up the vomit in the truck. Keeps my uniform clean, too. Our protocol is ondanestron 4mg IV/IM.

We carry phenergan 25 mg carpujets. I give it out like candy. If someone says they are nauseated, they get it. I dont like people throwing up, and the trucks we have (freightliner chassis & the newer ones are F450 extended cabs but the box is the same dimentions) cause motion sickness...

well.. thinking about it.. its either the trucks.. or the partner I work with lol...

the only exception is if someone is already pretty sedated by something else.. alcohol, benzodiazapines, etc im more cautious giving it. I dont wanna sedate them right into the ICU

 

[8jimi8]

We carry phenergan 25 mg carpujets. I give it out like candy. If someone says they are nauseated, they get it. I dont like people throwing up, and the trucks we have (freightliner chassis & the newer ones are F450 extended cabs but the box is the same dimentions) cause motion sickness...

well.. thinking about it.. its either the trucks.. or the partner I work with lol...

the only exception is if someone is already pretty sedated by something else.. alcohol, benzodiazapines, etc im more cautious giving it. I dont wanna sedate them right into the ICU

So how much are you pushing of the 25mg?

 

[redcrossemt]

the only exception is if someone is already pretty sedated by something else.. alcohol, benzodiazapines, etc im more cautious giving it. I dont wanna sedate them right into the ICU

Good point! There are relative contraindications, as with any medication, so I'm not sure "candy" is a good analogy. And, that's why I like ondansetron... Much less sedating, if at all. Our only absolute contraindication is prior allergic (or other poor) reaction to 5-HT3 antagonists (the "trons" or similar).

 

[FLEMTP]

So how much are you pushing of the 25mg?

We don't really have a "protocol" persay.. because we don't use protocols. We have medical guidelines, but we can step outside of those as we please (without having to call a doc) as long as it is medically justified and/or appropriate and its not something insane that we haven't had the appropriate training for ( like performing a thoracostomy)

So... my answer to you is:

12.5mg initially.. and if it is a long transport... and they vomit after they've had the meds on board for about 30 minutes or so.. then i'll consider giving another 12.5.

For people that have drug elimination issues, (ie: liver & kidney problems or elderly) i knock it down to 6.25

No matter what the dosing is, I like to dilute it out and give it nice and slow. It can cause some venous irritation when given too fast.

 

[8jimi8]

In the hospital we give 6.25, I have once given 12.5, but it was an out of range order that my charge questioned. The doc explained that we used to give 25 all the time and that she would be fine

 

[the_negro_puppy]

What about nausea + vomiting due to suspected food poisioning.

Withold anti-emetics due to vomiting being bodies way of removing toxins?

 

[8jimi8]

What about nausea + vomiting due to suspected food poisioning.

Withold anti-emetics due to vomiting being bodies way of removing toxins?

it seems like you answered your own question, no?

if suspected food poisoning, then don't give anti-emetics. Maybe i'm wrong?

 

[MrBrown]

We have ondansetron PO for Technician while Paramedic and above have it IV.

It is indicated for severe nausea and/or vomiting, one wafer or 4mg IV.

How do we feel about prophylactic anti emetics before using opiate analgesia? It's common practice here and the Clinicial Management Group absolutely hate it (as there is no evidence of benefit) but nertz to them.

Absence of evidence does not mean evidence of absence!

 

[8jimi8]

We have ondansetron PO for Technician while Paramedic and above have it IV.

It is indicated for severe nausea and/or vomiting, one wafer or 4mg IV.

How do we feel about prophylactic anti emetics before using opiate analgesia? It's common practice here and the Clinicial Management Group absolutely hate it (as there is no evidence of benefit) but nertz to them.

Absence of evidence does not mean evidence of absence!

again, i have to ask WHY DO YOU GIVE SOMETHING ENTERAL TO SOMEONE WHO FEELS ABOUT TO VOMIT??????

someone explain this to me, Vene?

IM i can understand, IV i can understand. Brown: there is no evidence that opiates cause nausea as a side effect?? is that what you mean to say?

as far as pain control, i like phenergan + opioids, synergism of analgesia + prophylaxis/relief on the nausea

 

[Melclin]

We're a bit behind the times with the anti-emetics here.

We have metoclopramide (IV/IM) and Prochlorperazine (IM). Neither can be given to children (<15 by our definition) but some feel uncomfortable giving it to anybody under about 22 unless its an issue of prophylaxis in spinal immobilization. Metoclopramide gets handed out at the drop of a hat, prochlorperazine seems rarely used, mostly because I think it exists in the minds of most ambos as the drug u use when u can't use metoclop, and you NEED an anti-emetics...which is not often.

So we have two anti-emetics that have a range of common, crappy side affects and are questionable efficacy wise not to mention we have nothing for children :wacko:


We really need ondansetron.

 

[Smash]

How do we feel about prophylactic anti emetics before using opiate analgesia? It's common practice here and the Clinicial Management Group absolutely hate it (as there is no evidence of benefit) but nertz to them.

I would have to side with your medical group on this, it does not strike me as a particularly smart way of treating patients. The number of people who experience nausea as a result of morphine is very low (<5%). All drugs (including ondansetron) have potential side effects or interactions with other drugs, so unless there is a reason to give them (and chances are there won't be), why add more pharmacology to the patient?

A much larger percentage of patients have allergic or anaphylactic reactions to antibiotics. If then (for arguments sake) you were to administer antibiotics to someone, would you give them prophylactic epinephrine, phenergan and dexamethasone?

There is also a reasonable body of evidence that shows that anti-emetic prophylaxis is ineffective at preventing nausea or vomiting post morphine administration (including at least one placebo controlled RCT that I am aware of) so personally I would wait to see what my patient needs before giving them more drugs.

 

[redcrossemt]

again, i have to ask WHY DO YOU GIVE SOMETHING ENTERAL TO SOMEONE WHO FEELS ABOUT TO VOMIT??????

Are people actually doing swallow-whole PO? Or are you who say PO referring to the rapidly disintegrating tablets? Technically I believe it's still PO, but for nausea do you really need to start an IV or stick everyone if they aren't vomiting yet?

 

[LucidResq]

it seems like you answered your own question, no?

if suspected food poisoning, then don't give anti-emetics. Maybe i'm wrong?

I ended up in the ER on Friday for moderate-severe abd pain and N/V. Probably due to bad shrimp (or prairie dog ghosts but that's another story), but I went in because I was getting pretty dehydrated (hadn't kept anything down, including water/fluids for over 12 hours) and the pain was severe enough to keep me from sleeping it off.

Among other things I got IV Zofran almost immediately and was sent home with prochlorperazine. And thank God. I'd rather wait for that stuff to come out the other end.... I had already gotten most, if not all, of it up already anyways.

Even in a case where someone may have had some bad food and is just queasy but hasn't vomited yet, I think that vomiting it up probably wouldn't make a big difference especially if we're talking food that's actually contaminated. I might be wrong though...

I believe with many foodborne illnesses, dehydration is usually the biggest threat... unless we're talking enterohemorrhagic E.Coli which does all kinds of crazy hemolytic stuff too. :wacko: But I digress...

 

[redcrossemt]

I wanted to and forgot to mention the food poisoning thing earlier...

I similarly to Lucid have been sick before - in my case with a long bout of salmonella poisoning traced to a local restaurant. I'm fairly sure that vomiting didn't help me kick it. I would guess that the bacteria involved in most true food poisoning cases are colonizing the GI tract but not specifically only the stomach where vomit would be coming from. Even if bacteria were only in the stomach, I think antiemetics would be preferred over getting rid of some of the bacteria that will quickly recolonize.

Zofran ODTs were my best friend during my salmonella spell. And back to my earlier point, the dissolving tablets do work effectively and quickly, all without IV access or a shot. Now don't get me wrong, if the patient is dehydrated or needs an IV for another reason please give me the ondansetron IV. Otherwise though, I'll take the ODT.

 

[alphatrauma]

A while back we had a thread with several medics advocated withholding antiemetics from drunk patients to "teach them a lesson". Personally, I give Zofran out very frequently. If someone is nauseated, they're getting Zofran (usually). I give it preemptively to make my patients more comfortable, prevent airway issues, and make life easier for my partner who would have to clean up the vomit in the truck. Keeps my uniform clean, too.

I do not (nor does my Medical Director) advocate giving EtOH or drug intoxicated, actively vomiting, patients anti-emetics in the field. I would ask anyone who does to lay out their rationale, as it pertains to medical risk/benefit/positive patient outcomes... not the cleanliness of their rig or uniform.

Hopefully you are forming a differential diagnosis prior to administration.

Even in a case where someone may have had some bad food and is just queasy but hasn't vomited yet, I think that vomiting it up probably wouldn't make a big difference especially if we're talking food that's actually contaminated. I might be wrong though...

I believe with many foodborne illnesses, dehydration is usually the biggest threat...

Which can usually be corrected with IV hydration

I don't wanna have to clean up the mess

Worse reason ever for giving a medication (well, maybe 2nd worse)

No matter what the dosing is, I like to dilute it out and give it nice and slow. It can cause some venous irritation when given too fast.

Sad thing is, I've seen providers slamming Zofran like it was Adenocard.

again, i have to ask WHY DO YOU GIVE SOMETHING ENTERAL TO SOMEONE WHO FEELS ABOUT TO VOMIT??????

x2




I spent a couple years working with primary care physicians in an urgent care setting, and it never ceased to amaze me how people refuse to let their body do it's job. Instant gratification is the order of the day, as busy schedules do not provide the convenience for rest and time to recuperate. And we wonder why it takes so long to get better. Don't get me started on the overuse/misuse of antibiotics.

Back on track... Ask yourself, why is your intoxicated patient vomiting? Alcohol is a POISON (as far as the body is concerned), when the body's ability to metabolize it has been exceeded - toxicity. Will someone PLEASE explain to me how suppressing the the vomit reflex is a good thing in this particular patient. Yes there are exceptions (varicies/caustic substances/bleeding), but these are not the bulk of those presenting. As far as airway is concerned... fowlers/semi-fowlers anyone? I think there may be a suction canister somewhere on the truck.

There are MANY excellent uses for Odanestron/Zofran, but making the poster child for this application an intoxicated patient, is pure lunacy. I will go on record as saying that withholding treatment from a patient who needs it is unacceptable... but so is the other extreme - delivering care/treatment that is unwarranted for the sake of convenience.

 

[1badassEMT-I]

I would use it if I could push it.......I can give fentanyl and morephine that can make you sick as hell but I cant give zofran to ease the effects of them. GO figure.... Got to love WV protocols.

 

[1badassEMT-I]

I do not (nor does my Medical Director) advocate giving EtOH or drug intoxicated, actively vomiting, patients anti-emetics in the field. I would ask anyone who does to lay out their rationale, as it pertains to medical risk/benefit/positive patient outcomes... not the cleanliness of their rig or uniform.

Hopefully you are forming a differential diagnosis prior to administration.




Which can usually be corrected with IV hydration



Worse reason ever for giving a medication (well, maybe 2nd worse)



Sad thing is, I've seen providers slamming Zofran like it was Adenocard.



x2




I spent a couple years working with primary care physicians in an urgent care setting, and it never ceased to amaze me how people refuse to let their body do it's job. Instant gratification is the order of the day, as busy schedules do not provide the convenience for rest and time to recuperate. And we wonder why it takes so long to get better. Don't get me started on the overuse/misuse of antibiotics.

Back on track... Ask yourself, why is your intoxicated patient vomiting? Alcohol is a POISON (as far as the body is concerned), when the body's ability to metabolize it has been exceeded - toxicity. Will someone PLEASE explain to me how suppressing the the vomit reflex is a good thing in this particular patient. Yes there are exceptions (varicies/caustic substances/bleeding), but these are not the bulk of those presenting. As far as airway is concerned... fowlers/semi-fowlers anyone? I think there may be a suction canister somewhere on the truck.

There are MANY excellent uses for Odanestron/Zofran, but making the poster child for this application an intoxicated patient, is pure lunacy. I will go on record as saying that withholding treatment from a patient who needs it is unacceptable... but so is the other extreme - delivering care/treatment that is unwarranted for the sake of convenience.

Well said!

 

[MrBrown]

I would use it if I could push it.......I can give fentanyl and morephine...

Should I really trust you to administer something that you can't spell properly?

... but then again, should you trust me in that orange jumpsuit with "DOCTOR" written on it? ....

Seriously tho.

 

[1badassEMT-I]

Should I really trust you to administer something that you can't spell properly?

... but then again, should you trust me in that orange jumpsuit with "DOCTOR" written on it? ....

Seriously tho.

It is early here I am still drinking coffee to wake up ...... OK I will take the E out of morphine....