Ideal Drug Box

[redcrossemt]

I see Versed on the list... don't see Ativan. Why? At least Versed+Ativan? Ativan for agitation/sedation, and Versed for sedation for cardioversion.

Why Pepcid?

Why D5W, LR, and NSS. What population gets what?

And why D10? I've got D10 for infants... D50 for adults.

Ativan (lorazepam) is a good drug, but if I had to pick one, I would choose midazolam (Versed). It has a MUCH shorter duration, and can be used for sedation, anxiety, agitation, or anything else you would use Ativan for.

Pepcid (famotidine) is an H2-receptor antagonist that has shown some promise in anaphylaxis with concurrent use of an H1 blocker (diphenhydramine/promethazine). Most hospitals (at least around here) treating severe anaphylaxis will give H1 and H2 blockers post-epi, as well as a steroid - usually prednisone here.

Regarding D10, I guess we could carry all three, but honestly I'm fine mixing it if we only have one dose. Carry D10 for adults may add substantially to the weight and volume of our kit.

 

[Melclin]

Regarding D10, I guess we could carry all three, but honestly I'm fine mixing it if we only have one dose. Carry D10 for adults may add substantially to the weight and volume of our kit.

If you would normally carry, D50, D25 and D10 then only carrying D10 would reduce the weight/volume of the kit.

If you are only carrying D50 and mixing it, then you need to carrying something to mix with it as well as the D50.

A 250 ml bag of D10 is really not any more heavey than an amp of D50 and its more flexible - it can be shoved anywhere in the kit, and you need carry nothing else. We only carry one in our bags, with more in the ambulance.

 

[emtjack02]

Great discussions...
I would have to disagree with abx treatment prior to blood cultures unless transport times are crazy (like 3 hours). For septic shock we use Primaxin or merem(sp) + vanco + zithromax(if pneumonia).
Etomidate is a great idea for head trauma but I dont recall seeing any mention of lidocaine. There is mention of paralytics only for crash airways in rosens emergency medicine.

my $0.02

 

[Smash]

Great discussions...
I would have to disagree with abx treatment prior to blood cultures unless transport times are crazy (like 3 hours). For septic shock we use Primaxin or merem(sp) + vanco + zithromax(if pneumonia).

I assume 'abx' is antibiotics? You state that you don't agree with pre-hospital antibiotics, but then give a list of antibiotics you use. I'm confused; do you agree or disagree with the use of antibiotics in pre-hospital care? If you do disagree can you explain further as there is reasonable evidence that any delay in administering antibiotics in some types of sepsis (meningococcal for example) causes significantly worse outcomes.

Etomidate is a great idea for head trauma but I dont recall seeing any mention of lidocaine.

I'm not sure why there would be, I wasn't aware that anyone still thought that lidocaine was useful in managing ICP prior to RSI.

There is mention of paralytics only for crash airways in rosens emergency medicine.

my $0.02

Sorry, it may be my sleep deprivation, but I don't know what you mean by this.

 

[emtjack02]

Im sorry...the abx listed are the ones in our hospitals sepsis protocol.
I have not done any recent lit searches but there are still airway management/ER text advocating lidocaine as an adjunct for RSI in the head trauma pt.
I mentioned the paralytics w/o sedation for crash airway because there was talk about not using a sedative and how inhuman that would be. I agree that I would not want to intubated w/o sedation but I was merely trying to point out that some of the Emergency Medicine bodies out there support only giving a paralytic if the airway is immediately compromised.

 

[RALS504]

Awesome thread!!
I would like all of the other meds suggested & to add:
-Regular insulin IV for hyperglycemia & crush injurues
-Lopressor (Toprol) IV for AMI & HTN
-Dilaudid for extreme pain
-Decadron NEB or IV for respiratory distress
-Atrovent for respiratory
-Xopenex (levalbuterol) for resp distress in cardiac pts

 

[EMTinNEPA]

zofran
aspirin
nitro SL + IV
cardizem
narcan
albuterol
ipatroprium
diphenhydramine
pepcid
solumedrol
oxytocin
furosemide
fentanyl
morphine
toradol
versed
haldol
etomidate
rocuronium
vecuronium
magnesium sulfate
sodium bicarbonate
calcium chloride
sodium nitrate
sodium thiosulfate
glucagon
D50
acetaminophen
thiamine
labetalol
succinylcholine
D25
epinephrine 1:10,000 and 1:1,000
ibuprofen
lidocaine
amiodarone
captopril
lopressor
insulin

 

[Melclin]

Awesome thread!!
I would like all of the other meds suggested & to add:
-Regular insulin IV for hyperglycemia & crush injurues
-Lopressor (Toprol) IV for AMI & HTN
-Dilaudid for extreme pain
-Decadron NEB or IV for respiratory distress
-Atrovent for respiratory
-Xopenex (levalbuterol) for resp distress in cardiac pts

Why dilaudid? In addition Fentanyl, Morphine, Parecoxib, Ketamine, Inhalation analgesic? What does dilaudid do that fent or morph can't in the prehospital context?

zofran
aspirin
nitro SL + IV
cardizem
narcan
albuterol
ipatroprium
diphenhydramine
pepcid
solumedrol
oxytocin
furosemide
fentanyl
morphine
toradol
versed
haldol
etomidate
rocuronium
vecuronium
magnesium sulfate
sodium bicarbonate
calcium chloride
sodium nitrate - vasodilator? What are its indications?
sodium thiosulfate For cyanide poisoning?
glucagon
D50
acetaminophen
thiamine
labetalol
succinylcholine
D25
epinephrine 1:10,000 and 1:1,000
ibuprofen
lidocaine
amiodarone
captopril
lopressor
insulin

 

[triemal04]

sodium nitrate - vasodilator? What are its indications?
sodium thiosulfate For cyanide poisoning?

That's about the only use for sodium nitrite and sodium thiosulfate you're going to see prehospital...don't know if there is another use for them really. Though for best results amyl nitrate needs to be added into the mix. Unfortunately, both those drugs can cause severe problems with the pt; sodium nitrite forms methemoglobin in the blood which helps to unbind the cyanide from the cytochromes (I believe; haven't' looked at this for awhile) and up ATP production while the thiosulfate helps to speed up the metabolization of cyanide and it's conversion to thiocyanite which can be excreted from the body. Of course, using sodium nitrite when carboxyhemoglobin is present (like after smoke inhalation, the most common time you'll see cyanide poisoning) will make things worse and further compromise the ability to transport/process O2. And sodium nitrite has a nasty habit of causing (severe) hypotension and acidosis. Using them is better than the alternative, but they aren't exactly benign drugs.

Hence why the Lilly Kit's are mostly being phased out and replaced by the Cyanokit which is essentially a B12-precursor. Don't ask me how that works because I can't remember.

 

[audreyj]

Where I live our transport times are crazy short, about 15 mins tops. Most of these drugs that are listed would have very little benefit to us. Our average door to balloon time for cardiac pts is 60 mins, the record being 27. In the case of cardiac arrest IF we get a pulse and favorable rhythm back chances of us having the time to titrate a dopamine drip or a lidocaine drip is slim to none. We grab our arrests and haul tail doing most of the code en route.

That being said our new protocols dropped valium from our drug boxes as well as any drugs down the ET tube. We carry a very limited supply of drugs and for that I'm grateful, in the event of having to choose a drug what if the one I choose has no effect on my patient?

The list of meds that we carry are (in no particular order):
Albuterol
Atropine
Adenosine
Benadryl
Dopamine
Lidocaine (drip and injection)
D50
Glucagon
Glucose Paste
Epi 1:1000
Epi 1:10,000
Tetracaine
Narcan
Morphine
Valium *going away May 1*
Versed
Nitro tabs *spray going away May 1*
Nitro paste
Sodium Bicarb
ASA
Ammonia Inhalants

Our only approved IV fluid is .9, I want to say that is the complete list but don't quote me on it.

I wish we had options for Fentanyl and Zofran. When we intubate we give versed. We also don't carry antibiotics.

A drug box wish list is only appropriate if your transport time determines it could be helpful. If my transport times were longer, sure some of the drugs listed would be helpful to have. Carrying drugs just to carry them is absurd. More cost to the provider, more room for error, and more room for liability issues to arise. I'm happy with the drugs we have, our system is great about taking out choices and going with the best choice overall.

 

[MrBrown]

We grab our arrests and haul tail doing most of the code en route.

Then you need to stop. Cardiac arrests should be worked where they fell down and more and more no RSOC = no transport. All you are doing is relocating a corpse and creating exponentially unjustified risk.

 

[Smash]

We carry a very limited supply of drugs and for that I'm grateful, in the event of having to choose a drug what if the one I choose has no effect on my patient?

Sorry, what? That statement makes no sense at all. Having a limited selection of drugs is the exact opposite of what you would want if your first choice didn't work. Also, you would only give someone a drug that you know will have a very good likelihood of providing benefit. For example, I won't give benadryl to a patient with symptomatic supra-ventricular tachycardia, but I will give adenosine.

Ammonia Inhalants

Really? Why?

[/QUOTE]When we intubate we give versed. [/QUOTE]

I assume you don't intubate head injured patients with trismus then?

I'm happy with the drugs we have, our system is great about taking out choices and going with the best choice overall.

Hmmm... So what is the best choice overall for pre-hospital pain relief? Morphine? Or are we worried about the potential for hypotension in patients with tenuous perfusion, or the prevalence of allergic or adverse reactions to morphine?
Fentanyl? Or do we think it might be more appropriate in some cases to give a longer acting opiate, for example in extremity fractures or neck of femur fractures when we know it is going to be some time before the patient recieves any further analgesia in hospital?
Ketamine? Great for traumatic pain, particularly fractures or multi-trauma, but then are we prepared to manage the potential for emergence phenomena? Of course it can also be used as an induction agent for RSI in some settings, so does this add to it's attractiveness?
Toradol? Good for moderate pain, particularly for musculoskeletal pain, but doesn't have the speed of onset that we may need.

I could go on and on, and for most drugs/conditions, not just pain. The thing is that the "best" choice may not exist, which is why options are good. The reason most services get the drugs they get is becuase of plenty of things, efficacy not necessarily being the most important. Usually it is all those other thingss you are worried about: How much does it cost? How dumb are our paramedics? How many people will die and therefore how much will we get sued for if we give them this drug without bothering to educate them in the use of it?

How well does it work? is usually way down the bottom of the list.

Oh, and I agree with MrBrown, transporting active codes is just plain wrong.

 

[audreyj]

Then you need to stop. Cardiac arrests should be worked where they fell down and more and more no RSOC = no transport. All you are doing is relocating a corpse and creating exponentially unjustified risk.

We have to transport them unless they show signs of being down for a long time. We can only call a death in the field if rigor mortis has set in, gross dependent levidity, decapitation, mummification or putrefication. If one of those is not present we must work the code and transport them, also depending on who we get on the radio they can tell us to work and transport the patient even if one of those conditions is present. In the codes we transport we do establish lines and airways before moving them to the ambulance but we carry only a limited drug supply in our jump bags.

Quote:
Ammonia Inhalants
Really? Why?

In the event of syncope, required by the state health department. I've never heard of it being used however. Just like the CPR shields we're required to carry, we have ambu bags in our jump bags and will use those before a CPR shield.

Our standing orders are reviewed every 2 years and changes made, and if there is an addendum to the orders within that 2 years changes are made, but that's rare. Our choices for intubation, TCP, and cardioversion were versed and valium when sedation needed to be done, valium was proven not to work as well as versed in our system, so you eliminate the choice.

And, like I said, our transport times are short, if we had longer transport times perhaps our drug boxes would contain different meds. This is what has shown to be beneficial for us and our system.

For symptomatic SVT, our orders are for adenosine.

 

[MrBrown]

What sort of success are you having with simply using midazolam to intubate?

This was allowed here in the past but withdrawn due a host of issues around the adequacy of sedation only intubation.

Personally I think it's really dodge and shouldn't be used.

 

[redcrossemt]

Agree about the arrests... it's wrong! Ask your medical director to support calling the arrests in the field. Do you have extra meds in your ambulance you don't have in your bag? Well, start with what you've got and send someone to the truck to get the full drug box or whatever. Maybe I'm missing something though.

Regarding having a smaller choice of meds due to short transport times... Most of my transport times are relatively short, but that doesn't mean that certain things should be done on-scene instead of waiting 10-15-20-25 minutes to get to the ER. And then's there the wait to see a doc, have someone pull the drugs, etc.

I would prefer to be a medic with options who, because of that, must remain knowledgeable and up to date, instead of a medic who is happy having a few drugs because short transport times makes that okay.