Protocol question

[Trashtruck]

Take long backboards out of the protocols. Treat them like the Reeves...use them for a carrying device, but don't put them in the protocols.

Does anybody use nitropaste for CHFer's?

 

[Medic Tim]

Take long backboards out of the protocols. Treat them like the Reeves...use them for a carrying device, but don't put them in the protocols.

Does anybody use nitropaste for CHFer's?

It is available for Intermediates and medics in Maine .

 

[chaz90]

RSI for medics that prove themselves proficient and competent. I know plenty of medics that have no business pushing paralytics.

Take nasotracheal intubation out. We carry the kits, are trained to do it but the ERPs here would blow a gasket if you brought a patient in with a nasal tube and QA/I wouldn't be far behind. If you don't want us doing it then don't give us the protocol, supplies and training to perform it...

I agree with the need for RSI with rigorous training and oversight.

I also think nasotracheal intubation has a place though. They shouldn't be common, but it can be used in rare cases where the orotracheal route is anticipated to be too difficult to push paralytics or where a rapid airway is necessary without vascular access.

 

[chaz90]

Take long backboards out of the protocols. Treat them like the Reeves...use them for a carrying device, but don't put them in the protocols.

Does anybody use nitropaste for CHFer's?

Delaware uses Nitropaste with CHF patients in addition to 0.8 mg SL every 5 minutes. We also use Nitropaste on ACS patients, for better or for worse.

 

[STXmedic]

Delaware uses Nitropaste with CHF patients in addition to 0.8 mg SL every 5 minutes. We also use Nitropaste on ACS patients, for better or for worse.

Same here, and throw in nitro for infusion as well.

 

[Carlos Danger]

I agree with the need for RSI with rigorous training and oversight.

RSI should not, IMO, be a standard paramedic skill. A very large percentage of paramedics (if not a significant majority) simply do not have the airway experience or judgement to do it safely, and it has not been shown to improve outcomes in most patients, anyway. In fact many studies indicate more harm than benefit.

RSI should be reserved for EMS systems that have uncommonly strong education and QI programs, and that can show that it does, in fact, improve outcomes in their system.

Heck, intubation itself is in question....

I also think nasotracheal intubation has a place though. They shouldn't be common, but it can be used in rare cases where the orotracheal route is anticipated to be too difficult to push paralytics or where a rapid airway is necessary without vascular access.

The problem is, blind NTI isn't "rapid", unless you get lucky, or perhaps if you practice it a lot. But it's not really an easy procedure, and it's impossible to practice it on real people. There's a reason why it went by the wayside quite a while ago.

I suppose there are times when an attempt isn't going to hurt anything. So I wouldn't necessarily take it out of the protocols, I guess.

Same here, and throw in nitro for infusion as well.

I wonder how many people who think they want to do nitro infusions in the field have ever set one up or titrated it?

I don't think it offers the advantages you guys think it does, and I don't think it is time effective unless you have pretty long transport times.

 

[Carlos Danger]

Airway algorithm:

• "RSI is only indicated in the patient whom, because of impending respiratory failure, you do not expect to survive transport to the closest ED; there is no such thing as 'elective intubation' in the prehospital setting"
  
  
• "Bag-mask ventilation will not be done in any case, unless the Sp02 drops below 90 and airway placement is not imminent"
  
  Protocol:
  1. Placement of high-flow NC
  2. Pre-oxygenation with NRB
  3. IO or IV placement
  4. Induction with ketamine (preferably) or etomidate (only where ketamine is contraindicated)
  5. Relaxation with succinylcholine (preferably) or rocuronium (only where succinylcholine is contraindicated)
  6. ONE look (which shall be terminated at 60 seconds, or when the Sp02 drops below 93) via VL or DL (+/- bougie) --> ETI.
  7. If unsuccessful at ETI --> supraglottic airway --> done
  8. If unsuccessful at SGA placement --> cric --> done
  
  
  Only allowing RSI to be done when it is truly necessary, and placing a "hard stop" at 1 ETI attempt would eliminate the vast majority of the problems that I have seen with prehospital RSI.
  
  The goal is to ventilate the lungs, not to place plastic between the cords.

 

[truetiger]

Out in the rural setting, hauling it the the local ED usually isn't an option in most cases of RSI, many times the doctors at these facilities are less familiar with intubation than the medics.

 

[PNW EMT]

Uhh, how long have you been out of the scene? It's been over 20 years since I've seen a PASG on a truck.

Pierce County, WA requires them on all trucks BLS and ALS. There's like one place on earth you can buy them from and when you do they always say "ah you must be from Pierce County!"

 

[medicdan]

Pierce County, WA requires them on all trucks BLS and ALS. There's like one place on earth you can buy them from and when you do they always say "ah you must be from Pierce County!"

apparently RI still requires MAST pants statewide as well... I'd love someone else to confirm. Remember, this is the state that has non-ACLS cardiacs...

 

[Handsome Robb]

Take long backboards out of the protocols. Treat them like the Reeves...use them for a carrying device, but don't put them in the protocols.

Does anybody use nitropaste for CHFer's?

Nitropaste for both CHF and ACS, no infusions. Transport times are too short generally.

 

[TheLocalMedic]

1. Get rid of Lasix. It's not a good pre-hospital drug.

2. No board unless obvious c-spine deformity/tenderness or neuro deficit.

3. Haldol + Ativan dart guns should be on every ambulance!

 

[Amberlamps916]

Lactate testing......

 

[18G]

To give atrovent without calling Medical Command.