"Outside the norm" paramedic drugs

[medicsb]

...I heard talk and read in our clinical meeting minutes about beta blockers (either labetolol and/or metoprolol) for hypertensive crisis, CVA and AMI along with calcium channel blockers for new onset AF with RVR and with associated hypotension.

If the criteria for a CCB is actually "AF with RVR AND associated hypotension", then I'd be really worried about your medical director. Why would you give a medication that consistently reduces BP to a patient that is already hypothensive?

The beta blockers will collect a lot of dust or be over used.

 

[Handsome Robb]

If the criteria for a CCB is actually "AF with RVR AND associated hypotension", then I'd be really worried about your medical director. Why would you give a medication that consistently reduces BP to a patient that is already hypothensive?

The beta blockers will collect a lot of dust or be over used.

Maybe I'm missing something but CCB in AF with RVR is a widely accepted treatment, no? Control the rate, increase ventricular filling thus increase CO, pressure comes up...like I said I've been wrong before and I may have misread the notes.

You could argue associated hypotension would make it symptomatic and thus equal Edison medicine but if their mentation is intact I'd rather use medications first. I'm still not sold on the idea of treating AF with RVR in the prehospital field, especially with the short transport times in my system unless they are circling the drain.

 

[medicsb]

Maybe I'm missing something but CCB in AF with RVR is a widely accepted treatment, no? Control the rate, increase ventricular filling thus increase CO, pressure comes up...like I said I've been wrong before and I may have misread the notes.

You could argue associated hypotension would make it symptomatic and thus equal Edison medicine but if their mentation is intact I'd rather use medications first. I'm still not sold on the idea of treating AF with RVR in the prehospital field, especially with the short transport times in my system unless they are circling the drain.

It is a widely accepted treatment, but is typically not given to hypotensive patients. Actually, hypotension is a contraindication for diltiazem or verapamil. If you get a chance to use it, you'll see that it often doesn't "normalize" the rate until a few doses have been given, and then it is often followed with an infusion (not typically done prehospital). Anyhow, similar to beta-blockers, CCBs are negative inotropes, thus any gain in EDV could be moot if the ESV is also increased. Additionally, both CCBs have vasodilatory properties that also add to a drop in BP.

IF you recall COxSVR(or TPR) = MAP, CO = SV x HR, and SV=EDV-ESV.

The CCBs will do the following:
[(incr.LVEDV - incr.LVESV) x decr.HR] x decr.SVR = decr. MAP

If the patient is hypotensive or borderline, it may be worth giving a fluid bolus to improve the BP or to decrease the degree of change in BP. Some might advocate CaCl as a pretreatment, but I believe the evidence in support of this is nonconclusive.

 

[NomadicMedic]

... If you get a chance to use it, you'll see that it often doesn't "normalize" the rate until a few doses have been given, and then it is often followed with an infusion (not typically done prehospital)...

Is this just anecdotal? My experience has been the opposite. 20mg of Cardizem has slowed just about every case of Afib with RVR I've treated. Admittedly I've given the drug only about 10 times...

 

[STXmedic]

Second n7's. Anecdotal as well, but I've never had a single dose not normalize the rate.

Rob, I guess as with any arrhythmia causing significant hypotension, the truly unstable get some form of electricity. Here, if we want to give cardizem with a SBP <120, we have to call or use Amio instead. And they want electricity for any SBP <90.

 

[medicsb]

Is this just anecdotal? My experience has been the opposite. 20mg of Cardizem has slowed just about every case of Afib with RVR I've treated. Admittedly I've given the drug only about 10 times...

Anecdotal, yes. But, pretty much every dose I've given has decreased AV conduction (even when just 10mg - smaller dose due to borderline BP, which I forgot to mention before), usually by 20-40 beats per minute. But when the original ventricular rate was 140-180, the result isn't a "normal" rate (say, <100), but usually its enough to relieve palpitation, dyspnea, and/or chest pain/discomfort. Also, I'd say only about 1/4 of the patients got the full 20mg dose as we would use weight-based doses up to 20mg on the 1st dose. Maybe had we used 20mg across the board, I would have seen more frequent rate "normalization".
(FWIW, my "n=" isn't very big, somewhere around 20-25 over 5 years. Not small, but not big.)

 

[dahus7712]

Geodon, dilaudid, flumazenil

 

[NomadicMedic]

Geodon, dilaudid, flumazenil

Wow. I didn't think any services in Washington carried flumazenil. Where is that, and is it on standing order?

 

[Handsome Robb]

It is a widely accepted treatment, but is typically not given to hypotensive patients. Actually, hypotension is a contraindication for diltiazem or verapamil. If you get a chance to use it, you'll see that it often doesn't "normalize" the rate until a few doses have been given, and then it is often followed with an infusion (not typically done prehospital). Anyhow, similar to beta-blockers, CCBs are negative inotropes, thus any gain in EDV could be moot if the ESV is also increased. Additionally, both CCBs have vasodilatory properties that also add to a drop in BP.

IF you recall COxSVR(or TPR) = MAP, CO = SV x HR, and SV=EDV-ESV.

The CCBs will do the following:
[(incr.LVEDV - incr.LVESV) x decr.HR] x decr.SVR = decr. MAP

If the patient is hypotensive or borderline, it may be worth giving a fluid bolus to improve the BP or to decrease the degree of change in BP. Some might advocate CaCl as a pretreatment, but I believe the evidence in support of this is nonconclusive.

That makes a lot of sense, thank you for explaining it!

Per our CQI meeting we will be not carrying CCBs.

They did add Metoprolol for STEMIs with a SBP >140 and a HR >100 after NTG. As you said it seems like they will collect dust. The STEMIs I've seen, albeit not many, did not meet the criteria for it

Also we are phasing in vasopressin in arrests. Not as a replacement for dose one or two though you either use the usual 1 mg 1:10,000 epi q3-5 or Vasopressin 40 IU q20. It's one or the other not both.

 

[Veneficus]

Wow. I didn't think any services in Washington carried flumazenil. Where is that, and is it on standing order?

Nobody should be carrying flumazenil on an ambulance.

Standing order or not.

 

[NomadicMedic]

Nobody should be carrying flumazenil on an ambulance.

Standing order or not.

Agreed... That's why I asked.

 

[AWDennis]

Anti-emetics : Inapsine
Ondansetron

RSI Meds: Etomidate
Succinylcholine
Vecuronium
Midazolam

Pain Meds: Fentanyl
Nitrous Oxide

Corticosteroids: Solu-Medrol

And there are currently two studies in the county, a "ALPS" study and a "HypoResus" study

 

[dahus7712]

I work form Lifeline Ambulance up in Omak. I'm just starting as a new medic and it's totally a cowboy system up here. Ya it's in our protocols for an unconscious. Narcan and romazacon to rule out.

 

[usalsfyre]

Anti-emetics : Inapsine
Ondansetron

RSI Meds: Etomidate
Succinylcholine
Vecuronium
Midazolam

Pain Meds: Fentanyl
Nitrous Oxide

Corticosteroids: Solu-Medrol

And there are currently two studies in the county, a "ALPS" study and a "HypoResus" study

With the exception of Inapsine I'd say all of these are pretty standard...

 

[usalsfyre]

Narcan and romazacon to rule out.

:blink:

I'd be pretty well ignoring that protocol :unsure:...

 

[Smash]

:blink:

I'd be pretty well ignoring that protocol :unsure:...

Protocol? What protocol? I don't see no protocol here...

I wonder how many seriously bad days that protocol leads to, for patient and paramedic alike?!

 

[Aidey]

Protocol? What protocol? I don't see no protocol here...

I wonder how many seriously bad days that protocol leads to, for patient and paramedic alike?!

This is not the protocol you are looking for...