Should I85s be allowed to help with pain managment?

[Veneficus]

The FDA does not have unreasonable restrictions on the medical uses of nitrous oxide. It is definitely not so restrictive to make it prohibitive for prehospital treatment. I'm not sure where you are receiving your information from but I assure you that is not the case in Virginia. Many states have adopted laws regarding the human consumption of nitrous for recreational use but it remains a main stay in dentists offices, especially pediatric dentists and is a viable option for prehospital use. The limitation as listed above is with the delivery device. Not the gas itself..

As I understand, unless something has changed, nitrous/oxygen cannot be mixed into 1 tank in the US, when last I saw nitrous on a EMS rig, it was in a very unwieldy case with 2 seperate tanks and a mixer.

Whether or not it is controlled isn't an issue, it is just a logistical nightmare. Between multiple tanks, mixers, off gasing, etc.

An excellent drug for sure, but I am not convinced the issues it comes with makes it a reasonable alternative.

As for your comments concerning narcan there are inherent risks with ventilating a patient for the 20 minutes needed such as gastric distention, vomiting, and aspiration. These complications are more prevalent with BLS providers...

But they are easily remidied with basic techniques and adjuncts. I do not buy the argument we need to administer a medication (in this case narcan) because people cannot proficently do their job.

I agree what you said is true.

I believe in the case of administering too much narcotic it is a viable option to slowly reverse the effects to maintain respirations. Why would I want to ventilate a patient for 20 minutes when I can titrate .2-.4 mg of narcan and return their respiratory drive to normal while maintaining the pain reducing effects of the drug.

In the prehospita environment, if you are treating for acute pain, chances are if the patient has a hypersensitive reaction which causes respiratory depression, the amount of administered drug is going to be relatively low dose.

So the chances that you can restore spontaneous respiration while managing pain are rather small.

If there is a larger dose of opioid titrated, then I must question whether or not the patient was actually in respiratory arrest and not simply impaired?

If your argument holds true for all narcotic overdoses then we should be intubating all of them and just waiting for the effects of the drug to wear off. I see your point but I'm not buying it for prehospital medicine..

My argument is not about all narcotic overdoses, it is about accidental overdose by a healthcare provider while treating acute pain.

I think it important not to try to use a one-size-fits-all approach to medicine.

Using a reversal agent on a chronic substance abuser (or even first time substance abuser) is not the same can of worms as an accidental overdose by a HCP.

 

[Craig Alan Evans]

As I understand, unless something has changed, nitrous/oxygen cannot be mixed into 1 tank in the US, when last I saw nitrous on a EMS rig, it was in a very unwieldy case with 2 seperate tanks and a mixer.

Something has changed. The
device we use is in a small bag and combines nitrous with oxygen at a 50/50 mix delivered by a demand valve which is self administered. Very easy. So easy that we routinely bring it onto athletic fields to provide instant pain management from skeletal fractures/strains/sprains while packaging the patient for transport.

Whether or not it is controlled isn't an issue, it is just a logistical nightmare. Between multiple tanks, mixers, off gasing, etc.

Off gassing is not an issue. I would have noticed.

An excellent drug for sure, but I am not convinced the issues it comes with makes it a reasonable alternative.



But they are easily remidied with basic techniques and adjuncts. I do not buy the argument we need to administer a medication (in this case narcan) because people cannot proficently do their job.

We may not need to but a back up plan is preferred.

I agree what you said is true.




In the prehospita environment, if you are treating for acute pain, chances are if the patient has a hypersensitive reaction which causes respiratory depression, the amount of administered drug is going to be relatively low dose.

So the chances that you can restore spontaneous respiration while managing pain are rather small.

I've had no issue with this technique with chronic narcotic users or methadone patients. Through SAT and ET CO2 monitoring with small doses of nalaxone a patient can be easily managed not only by their respiration rate but more accurately through their End Tidal CO2 levels.

If there is a larger dose of opioid titrated, then I must question whether or not the patient was actually in respiratory arrest and not simply impaired?




I think it important not to try to use a one-size-fits-all approach to medicine.

I agree. One size fits all is never good. This is a thinking mans business.

Using a reversal agent on a chronic substance abuser (or even first time substance abuser) is not the same can of worms as an accidental overdose by a HCP.

Agreed but the same principals remain.

 

[Craig Alan Evans]

Clearly I need a lesson on quoting and replying. Needless to say. Read through and you can see my answers between your paragraphs.

 

[jwk]

Also if I could just comment on narcan as a reasonable treatment.

If you reverse opioids you were administering for pain, then the pain comes back and the patient will probably have to suffer the 20 or so minutes until it wears off.

It is never done post surgery anywhere I have been for that very reason, best to just ventilate the pt.

Hmmm, sorry, that's somewhat off base.

We do use Narcan following surgery, although rarely. Sometimes we give too much narcotic or sometimes the surgeon is faster than we thought he would be or his procedure changed. Regardless, we want the patient breathing at the end of the case. I would never extubate an apneic patient and then electively manage their airway with a mask, knowing that they've still got a lot of narcotic on board that I have to deal with. That's poor management. However, we don't want to slam in a big dose of Narcan either - the sympathetic blast (and the pain) that follows is not good for a lot of patients. Our Narcan comes 0.4mg/cc. I dilute that up to 10cc with saline, and then give 1cc (40mcg) at a time, with doses spaced about 2 minutes apart, until the patient starts breathing. By titrating the dose, I can get them breathing and still keep them comfortable. That's not possible when giving a full 0.4mg dose or more at a time.

An interesting sidelight - in our hospital, any use of naloxone or flumazenil following anesthesia or procedural sedation generates a QI report to the pharmacy - the assumption is the patient recieved too much narcotics or benzos, so it's considered an adverse drug reaction.

 

[Craig Alan Evans]

Hmmm, sorry, that's somewhat off base.

We do use Narcan following surgery, although rarely. Sometimes we give too much narcotic or sometimes the surgeon is faster than we thought he would be or his procedure changed. Regardless, we want the patient breathing at the end of the case. I would never extubate an apneic patient and then electively manage their airway with a mask, knowing that they've still got a lot of narcotic on board that I have to deal with. That's poor management. However, we don't want to slam in a big dose of Narcan either - the sympathetic blast (and the pain) that follows is not good for a lot of patients. Our Narcan comes 0.4mg/cc. I dilute that up to 10cc with saline, and then give 1cc (40mcg) at a time, with doses spaced about 2 minutes apart, until the patient starts breathing. By titrating the dose, I can get them breathing and still keep them comfortable. That's not possible when giving a full 0.4mg dose or more at a time.

An interesting sidelight - in our hospital, any use of naloxone or flumazenil following anesthesia or procedural sedation generates a QI report to the pharmacy - the assumption is the patient recieved too much narcotics or benzos, so it's considered an adverse drug reaction.

I agree completely. Thank you for the back-up. Slowly and efficiently reducing the effects of the narcotic is much more preferred over waiting for the drug to wear off and risking airway complications. This can be accomplished safely and easily in both the prehospital an hospital settings.

 

[Veneficus]

Hmmm, sorry, that's somewhat off base.

We do use Narcan following surgery, although rarely. Sometimes we give too much narcotic or sometimes the surgeon is faster than we thought he would be or his procedure changed. Regardless, we want the patient breathing at the end of the case. I would never extubate an apneic patient and then electively manage their airway with a mask, knowing that they've still got a lot of narcotic on board that I have to deal with. That's poor management. However, we don't want to slam in a big dose of Narcan either - the sympathetic blast (and the pain) that follows is not good for a lot of patients. Our Narcan comes 0.4mg/cc. I dilute that up to 10cc with saline, and then give 1cc (40mcg) at a time, with doses spaced about 2 minutes apart, until the patient starts breathing. By titrating the dose, I can get them breathing and still keep them comfortable. That's not possible when giving a full 0.4mg dose or more at a time.

An interesting sidelight - in our hospital, any use of naloxone or flumazenil following anesthesia or procedural sedation generates a QI report to the pharmacy - the assumption is the patient recieved too much narcotics or benzos, so it's considered an adverse drug reaction.

I never suggested extubating and bagging anyone. If there is a tube in, why would anyone remove it?

I was suggesting managing the airway and bagging for a short period of time when titrating analgesia.

You are also talking about a dose so small it is never used in EMS. In my EMS experience providers often administered 2 mg narcan as a bolus, more refined providers in a titrating dose.

How often do you really snow somebody titrating analgesia and then have to wake them up moments later?

Patient breathing at the end of the case is the obvious goal, but it sounds more like an institutional decision.

Where I am usually at, the OR schedules are not so tight that a 10 or 20 mminute delay while waiting for a pt to wake up is an issue.

There is also an anesthesiologist in every OR too though... There are no assistants, nurse anestatists, etc.

I can see the reason for QI, but I think it is quite unfair to call it an adverse drug reaction.

 

[ZootownMedic]

As mentioned in another thread, good luck finding a blender .

IN fentanyl is safe, mostly effective and aside from controlled substance concerns, easy to use.

Until they develop wooden chest syndrome :rofl:

 

[Handsome Robb]

Until they develop wooden chest syndrome :rofl:

From what I have read and was told by the PharmD for the Level II's ICUs here you *generally* have to slam a huge dose for it to happen. Not to say it isn't possible, but it's also possible for us to manage in the field provided you aren't a total windowlicker of a provider.

 

[ZootownMedic]

From what I have read and was told by the PharmD for the Level II's ICUs here you *generally* have to slam a huge dose for it to happen. Not to say it isn't possible, but it's also possible for us to manage in the field provided you aren't a total windowlicker of a provider.

Yes my friend....I was like 85% joking...although I did hear of a 6 yom developing it with a normal SIVP and a standard 0.07 mg/kg dosage. It was in the PICU here in C springs and the RN that told me about was reliable.

As for EMT-I/85's pushing narcotics....I wouldn't be down with it. Here to push narcotics you have to place the patient on the monitor and capnography. I seriously doubt most 85's(or 99's for that matter) have a good enough understanding of cardiac rhythms and capnography to be able to interpret these findings effectively. Just my .02 cents

 

[EpiEMS]

As for EMT-I/85's pushing narcotics....I wouldn't be down with it. Here to push narcotics you have to place the patient on the monitor and capnography. I seriously doubt most 85's(or 99's for that matter) have a good enough understanding of cardiac rhythms and capnography to be able to interpret these findings effectively. Just my .02 cents

Why do you have to have them on the monitor and have capnography for narcotics administration? Military medics push narcotics all the time without an EKG or EtCo2, no?

 

[OzAmbo]

As for EMT-I/85's pushing narcotics....I wouldn't be down with it. Here to push narcotics you have to place the patient on the monitor and capnography. I seriously doubt most 85's(or 99's for that matter) have a good enough understanding of cardiac rhythms and capnography to be able to interpret these findings effectively. Just my .02 cents

Capnography? Seriously?

Not having a go at you personaly brother but but if your system needs that much oversight for narcotics i hope they dont let your intermediates use GTN.

Why are people scared about narcs but hand out GTN like tic tacs ill never understand

 

[Doczilla]

This is because we don't carry monitors in our aid bag.

Also, giving narcs to a traumatic amputee has an extremely low side effect profile. The amount of depression you see usually correlates to the amount of pain they are in.

 

[OzAmbo]

This is because we don't carry monitors in our aid bag.

Also, giving narcs to a traumatic amputee has an extremely low side effect profile. The amount of depression you see usually correlates to the amount of pain they are in.

I hear ya there Doc, but oin the sae vein, theres those that underanage pain for fear of cardio-respiratroy depression based on "they dont look like they are in pain" :sad:

I'm confused though by the "monitors in the aid bag" bit though, what specifically are you referring to?

Later...

 

[Veneficus]

Capnography? Seriously?

Not having a go at you personaly brother but but if your system needs that much oversight for narcotics i hope they dont let your intermediates use GTN.

Why are people scared about narcs but hand out GTN like tic tacs ill never understand

Doctors all over the world are taught to fear pain control.

Swing on over to the recent medical school discussions on cardiac toxicity of lidocaine when suturing, they pop up every few months or so.

The US makes it your doctor's fault if you become addicted to the narcs he gives you.

Capnography while administering morphine...

From the country that claims to have the best medicine in the entire world...

At least you are safe.

 

[VFlutter]

It is a policy on one of our med/surg floors that anyone on a narcotic PCA pump has be on continuous capnography (Via NC) .....too bad the nurses have no clue what the readings indicate let alone can tell you the differences between capnography and Spo2 Plethysmography.

Numerous times RRT's are called for patients breathing ~ 4 times a minute and the response from the nurse is always "but his sp02 was fine last time I checked"

 

[Veneficus]

It is a policy on one of our med/surg floors that anyone on a narcotic PCA pump has be on continuous capnography (Via NC) .....too bad the nurses have no clue what the readings indicate let alone can tell you the differences between capnography and Spo2 Plethysmography.

Numerous times RRT's are called for patients breathing ~ 4 times a minute and the response from the nurse is always "but his sp02 was fine last time I checked"

That is a failure of the hospital to provide proper training and oversight.

That is not the failure of the nurse.

 

[VFlutter]

That is a failure of the hospital to provide proper training and oversight.

That is not the failure of the nurse.

I agree, a lot of the physicians push for these types of policies to be implemented without the hospital providing adequate training.

Another great example is physicians requiring certain patients to be on telemetry monitors on non-cardiac floors on which nurses are not required to be ACLS certified. Therefore I have to call a non ACLS to let them know that their patient is in VT and they ask me what they should do (I am technically a non licensed employee) or calling an RRT for a patient in sinus arrhythmia. But that is a whole different topic.

 

[MikeCivitello]

Correct - pre-mixed 02 and N20 is not FDA approved in the US. That leaves us with 2 gas cylinders and a device/mixer with demand valve. Unfortunately there is no way around that.

The biggest issue that I have heard with the pre-mixed gas is that it can potentially separate at low temperatures and there is no way to actually know what % mixture the patient is getting (unless you had them hooked up to a gas analyzer).

The device that was most commonly known in the US will resurface again soon - sometime this fall. We are manufacturing it. I can see a lot of benefits of offering nitrous oxide and oxygen for pain management - but also see the challenges of all of the gear that you need to carry. We will actually be trying to come up with a better / more convenient packaging - and hopefully we can obtain feedback from current and former users - but that would be a discussion for another thread or forum I'm guessing.

Mike

As I understand, unless something has changed, nitrous/oxygen cannot be mixed into 1 tank in the US, when last I saw nitrous on a EMS rig, it was in a very unwieldy case with 2 seperate tanks and a mixer.

Whether or not it is controlled isn't an issue, it is just a logistical nightmare. Between multiple tanks, mixers, off gasing, etc.

An excellent drug for sure, but I am not convinced the issues it comes with makes it a reasonable alternative.

 

[JPINFV]

Question regarding the O2/N2O mixer. Why not just have a N2O bottle and a mixer that can attach to the O2 bottles already carried like a vent that bleeds in O2? After all, you're always going to have the portable tank that's strapped to the gurney and the large O2 tank on the ambulance.

 

[NYMedic828]

Disappointed in you guys...

I had to be the first to post this?


:rofl::rofl::rofl:
http://www.youtube.com/watch?v=_C2oaJYuNCU&feature=related