"Outside the norm" paramedic drugs

[NomadicMedic]

I didn't think Bretyllium was made anymore? Like the Bretyllium factory laid off all the oompa loompas... Or the Bretyllium mine collapsed ... Or something like that.

 

[medicsb]

When I left my old job a year and a half ago, we were still carrying flumazenil. Some desk jockey swore it was required by the state, but interestingly, the state regs didn't mention it. We also still had thiamine, verapamil, terbutaline, metoprolol, and labetalol. When I started, we had bumex, decadron, and alternate opiate antagonist (i forget which), but only because there had been a shortage of lasix, solu-medrol, and narcan at some point.

I think there may still be some MICUs in NJ carrying insulin for the treatment of hyperkalemia.

 

[Jon]

When I left my old job a year and a half ago, we were still carrying flumazenil. Some desk jockey swore it was required by the state, but interestingly, the state regs didn't mention it. We also still had thiamine, verapamil, terbutaline, metoprolol, and labetalol. When I started, we had bumex, decadron, and alternate opiate antagonist (i forget which), but only because there had been a shortage of lasix, solu-medrol, and narcan at some point.

I think there may still be some MICUs in NJ carrying insulin for the treatment of hyperkalemia.

I don't think half that stuff is on the PA list at all!

One of my jobs is going to decadron, because our doc likes it better in some cases, and it means we don't have to worry about a solu-medrol shortage down the road.

 

[Jon]

I don't think half that stuff is on the PA list at all!

One of my jobs is going to decadron, because our doc likes it better in some cases, and it means we don't have to worry about a solu-medrol shortage down the road.

In my neck of the woods, some services are starting to carry PO/SL Zofran. Primary reason for stocking it was for Tactical/Remote medicine (EMS strike teams and SWAT medics), but now the region is OK with it going on the trucks for "regular" patients, especially with folks having a hard time getting ahold of Zofran.

As for Narcs- Versed/Ativan, Morphine/Fentanyl - Some or all of the above, depending on the shortage of the month. Nothing really cool here. Toridol would be cool.

 

[medicsb]

I don't think half that stuff is on the PA list at all!

One of my jobs is going to decadron, because our doc likes it better in some cases, and it means we don't have to worry about a solu-medrol shortage down the road.

Yeah, NJ is weird like that. Limited standing orders (actually they've become more liberal since i left), but docs might order a ton of interventions depending where you worked. Anyhow, most of those drugs never got used. Terbutaline was occaisionally given to a bad asthmatic or COPD patient (did hear of a doc ordering it on a patient in preterm labor) and metoprolol would be given to STEMIs before the big study out of China. Now and then thiamine was given to altered mental status patients with a known EtOH abuse history. Only gave labetelol once, but I know that some other projects used it more often.

 

[stallion]

Interesting to see what everybody uses....and what some of us lack. Here's a few that we have that may be out of the norm

Prochlorperazine (Stemetil) in addition to odansetron as anti emetics

I've think there are a few services out there that carry AB's...we have ceftriaxone. We primiarly use it for meningococcal disease, however, we are also able to start end goal directed therapy (used in addition with fluids and dexamethasone) for sepsis.

We also have IV beta 2 agonists (along with nebulized).

Very jealous of the services who carry oral/liquid anti-histamines...would love to have PO Zyrtec (cetirizine)

 

[Veneficus]

Was not aware of the "moderate sedation" qualities of phenergan. It's our only anti-emetic at the sports medicine job and has worked very well the one or two times the doc has given it in the last couple of years. Well enough that the player could play in a game an hour later, so I guess the sedation properties cannot be too significant?

It is dose dependant.

at 6-50mg (usually in ems used at 12.5 or 25mg) it can be significantly depressing.

 

[Remeber343]

We have a significant elderly population where i am, we do 6.25/12.5/25mg, of course it is dependent on the severity of the patient. Also want to be a bit careful when giving it with narcs, they work well together, It can cause quite the sedation.

 

[Handsome Robb]

How about beta blockers?

We don't carry it but I know an agency near me carries atenolol.

The last time I saw it was for SBP > 220 with symptoms of HTN, I can't remember what/if there was a diastolic pressure listed as well.

We carry a pretty standard list where I work.

 

[Handsome Robb]

We don't carry it but I know an agency near me carries atenolol.

The last time I saw it was for SBP > 220 with symptoms of HTN, I can't remember what/if there was a diastolic pressure listed as well.

We carry a pretty standard list where I work.

I lied, labetolol not atenolol.

 

[Doczilla]

I also think beta blockers are underused in Ems. Not really for hypertensive crisis, but theyre great in AMI. Think about it, what if your chest pain has a total occlusion, (safe bet in any STEMI) that reflex tachycardia from the nitro might just kill them.

Choosing dexemethasone over methylprednisolone is strange, because in the context of airway burns , asthma , COPD, anaphalaxys, and other acute stuff, solu medrol works faster.

 

[WestMetroMedic]

It is my understanding that there is no statistical decrease in morbidity and mortality with beta blocker administration in the setting of acute myocardial infarction. I think there are also better things that you can do for these patients such as judicious admin of nitro via gtt at an aggressive rate. I've carried lopressor at my previous service and have it a couple of times and haven't seem any real improvements in my patients or declines and the service pulled it from the trucks shortly after I left.

Other random ones I have carried are Cardizem (not a fan)
Levophed
Labatelol
Proparicaine
Xopenex (saleswoman must have been hot enough to convince our medical director to carry this ridiculous waste of money)

My current service is very utilitarian but we do have Ketamine for profound agitation and next month, we are going to start using it as a pain adjunct. It is an amazing medication for mental health crisis patients.

 

[Veneficus]

I lied, labetolol not atenolol.

labetolol is a great drug, but I think esmolol would be better.

It can be easily titrated and similar to propofol, when you turn off the drip the effects stop very rapidly. I have never seen it used outside of the ICU though.

I have used labetolol in the EMS setting and while it works very well, I would be concerned about mixing it with other agents like morphine or versed in patients who may require them as well.

 

[Doczilla]

I'll have to look it up, but beta blockers have a big edge over nitro in total occlusions (stemi) . And again, poor decisions with nitro and total occlusions can be deadly. Some of the more cardioselective ones don't really hurt RV infarcts, too.

I've used propofol extensively on both sides. Big fan. I like ketamine better for general purpose though

 

[medicsb]

I'll have to look it up, but beta blockers have a big edge over nitro in total occlusions (stemi) . And again, poor decisions with nitro and total occlusions can be deadly. Some of the more cardioselective ones don't really hurt RV infarcts, too.

I've used propofol extensively on both sides. Big fan. I like ketamine better for general purpose though

Look up the results of COMMIT. The use of early IV beta-blockers in MI has been greatly narrowed because of this study. Their routine administration has largely been abandoned in many practices.

 

[mycrofft]

Silly question, but if the drug is within protocols I wouldn't think of it as outside the norm. If it was outside the protocols, what is it doing on a vehicle?

 

[Veneficus]

Silly question, but if the drug is within protocols I wouldn't think of it as outside the norm. If it was outside the protocols, what is it doing on a vehicle?

I think it is in reference to some services being more liberal or advanced than others in what they deem appropriate for prehospital administration.

 

[NomadicMedic]

Many of these drugs are outside of the "standard" load out that the majority of paramedic level services carry. If you read the first post, you'll note that I was curious about exceptions from the standard drugs.

 

[mycrofft]

Who sets the standards?
If it is up to each agency's medical controller, they can stock almost anything then, right?

 

[Akulahawk]

Who sets the standards?
If it is up to each agency's medical controller, they can stock almost anything then, right?

I would say that the drugs that can be stocked could be anything that is approved by the Local EMS agency and approved by the State EMSA. In California's case, all the drugs listed in this thread could be stocked, if it's approved... but with some of them... good luck getting it approved by anyone (that matters).:blink: