Treatment Question
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Morphine is not contraindicated in hypotensive patients, however a reduced dose is prudent.
What is stopping you from ensuring a good running drip and starting with say 1mg as an initial dose and going up in 0.5mg increments provided no significant decrease in blood pressure develops?
Or would you rather leave Nana in pain?
Brown recalls one old Nana who was crook, like critical problem crook, hypotensive at 90/60, septal infarct on 12 lead, in extreme pain ... you know what happened? Nana got started out 0.5mg of morphine and another 0.5mg and she was much more comfy and her BP was no worse for wear.
Maybe it's not where your from but out here you need a systolic of atleast 100. And since her Second BP was 72/(who cares that is too low anyways) and she is fluid depleted anyways not to mention that MS has vasodilatory effects I would never even think of giving this to her. But you cowboys out In NZ are doin it different. She has a fluid problem fix that first. Not to mention do I really wanna slow down her labored breathing w/ wheezes? Come on I know you guys might play MDs on TV but let's get back to the basics....low BP fix it.
But Im just a CA medic what do I know right?
But Im just a CA medic what do I know right?
The initial BP was 97/79 that is entirely an appropriate BP for a small dose of morphine, it's not an appropriate BP for GTN
No, we are not cowboys left to practice wild and untamed rogue medicine in the street and Nana's living room.
What fluid problem does Nana have? Is it intravascular? Free fluid in the abdomen? ECF expansion?
Low blood pressure does not always mean hypovolaemia!
A respiratory rate of 22/min is not really laboured although Brown conceeds somebody with a very long expiratory phase (such as a wheezy asthmatic) might also be considered laboured breathing.
If morphine and other opiod analgesics have such a negative respiratory effect then maybe they should not be given to anybody?
Do you know how many patients Brown has seen firsthand, heard about second or thirdhand that have suffered any sort of respiratory problems from having morphine administered? None.
At the end of the day, you said it not Brown ....
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Yeah...no.
What you refer to is a LOCAL PROTOCOL restriction on the administration of morphine. It is by no means an absolute contraindication. When we carried morphine on the truck here we had no B/P "floor" for administration, the word was use with caution. Morphine has "unreliable" vasodilatory effects, it's a side effect caused by histamine release, diphenhydramine as a pretreatment MAY be effective in preventing this anyway. None of this is being a "cowboy", it's understanding the medications you carry and they're end effect beyond "treating pain".
Further, while the "pump, pipe, fluid" model of shock is easy to understand it's a bit simplistic for treating shock at the paramedic level. Based on the falling (not "already low and staying there") B/P I strongly suspect acute whole blood loss i.e. acute hemorrhage. This is not a "fluid problem" you can fix without blood products and possibly surgery. "Fixing" her low B/P will likely kill her. Crystaloids for hemorrhage you can't control do NOTHING good. "Fluid" in the hospital setting vs the EMS setting may mean different things.
Finally I've found the respiratory depression component of opiates to be vastly overplayed by EM, especially in patients with any significant catecholamine drive.
I would hesitate on pain relief in this patient, but because these patients are often VERY catecholamine dependent. JWK might have better thoughts on this subject.
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BTW, one of the reasons Fentanyl has become so popular is hemodynamic stability.
Plus they've got access to Ketamine down there.
the_negro_puppy
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Ok so this is my second time typing this cause the long version was reloaded by my ipad before I sent it so it got erased any who. Short hand version, labored breathing was stated by the OP so lets take his word for it, a BP of 97/79 and a second BP of 74/42 and falling isn't concerning to you? I could see pain management if I was a hospice nurse for this pt. As the OP stated she was a ST @ 130 so not really a pump problem. Could we do anything for a bleed? nope. Can I do something to help with her falling BP? sure can, is it the best solution? nope but its better than nothing in the pre-hospital setting. Im not gunna sit around and play Doogie Howser on this pt, its a Fluid challenge,O2, and diesel. The argument here is would MS really benefit this pt? Plain and simple no, would it do more harm then good? guess well never know. There are to many factors we dont know about this pt, and there are a handful of ways this call could have been run. You've got your way I have mine in the end this pt needs one thing... a Doctor. So i guess we could agree to disagree.
Wrong. NOTHING is the perfect thing to do. Why do you feel the need to treat B/P? As long as their conscious, withhold fluid.
See previous why a fluid challenge is a bad idea. O2, ehhh, okay. Transport is appropriate.
:blink:Huh? Treating pain isn't beneficial?
Come on mate, this lady is obviously in pain so how is pain relief not indicated? Gosh Americans seem so scared of giving anybody analgesia :unsure:
It sounds like this lady might have had an abdo bleed but she might have one of eleventybillion other things wrong with her. Hypotension is highly nonspecific.
It sounds like this lady might have had an abdo bleed but she might have one of eleventybillion other things wrong with her. Hypotension is highly nonspecific.
Brown might give her a small fluid bolus .... maybe 250cc to see if we can get her BP up a wee bit.
Now, obviously if her tummy is pulsating so bad even blind Brown can see it or she has no distal pluses and screaming about her tearing back pain Brown would think it a bad idea.
The plummeting pressure with abd pain says "hemorrhage" to me. A SMALL challenge I might agree with...but I without seeing the patient I can't say.
Like I said before I'm even a little dubious on analgesia, simply because strong sympathetic drive is the only thing keeping these folks alive. The anesthetic technique often described for the patient in severe hemorrhagic shock is "succinylcholine and an apology". However this has nothing to do with B/P or the specific properties of any opiate.
If this lady was Super Crook™ i.e. pale, no radial pulse, unrecordable blood pressure, falling level of consciousness then Brown would give a small fluid bolus only and take her to the hospital with much of the fastness.
Other than that, it sounds like the patient was in pain and had some signs and symptoms which lead us to believe she has a possible intra-abdominal bleed.
Sure, she is probably going to die in surgery and make the anaesthetist fill out lots of paperwork ... but in the meantime, Brown does not think it is contraindicated to give her a tiny dose of analgesia if she is in severe pain. even if it some methoxyflurane or 0.5mg-1mg of morphine.
Other than that, it sounds like the patient was in pain and had some signs and symptoms which lead us to believe she has a possible intra-abdominal bleed.
Sure, she is probably going to die in surgery and make the anaesthetist fill out lots of paperwork ... but in the meantime, Brown does not think it is contraindicated to give her a tiny dose of analgesia if she is in severe pain. even if it some methoxyflurane or 0.5mg-1mg of morphine.
Probably not...I just get a little nutless when the pressure dips south of 70 systolic
.Probably not...I just get a little nutless when the pressure dips south of 70 systolic
As does Brown, but if Brown picked this lady up with a pressure of 97 systolic and she was in severe pain then Brown would be fine with a very small dose of morphine. If her pressure was 70 then no, obviously not.
True, I've gotten too used to Q5 minute NIBPs from the LP12. My thought process went "it trended from 97 to 72 systolic...holy blood loss Batman!" Then I went back and read that was initial vs drop-off pressure. Stupid on me, carry on...
usafmedic45
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Sorry....life got in the way of my following up with your question.
Basically the idea of "that's where COPDers live" is an outdated idea that stemmed from poor interpretation of limited data analyzed through the lens of less scientific knowledge of physiology than we have today. Jeff Whitnack (a very smart RT and a man I consider myself lucky to call a friend) has an entire Powerpoint about this. Basically, the rise in CO2 that was the origin of the "you depress ventilation if you give O2 to COPDers" stems from three things:
1. The Haldane effect (RBCs not carrying O2 can carry CO2 instead and when you start giving O2, it pushes that CO2 into the plasma where it is detected by the ABG or ETCO2 (indirectly in the latter case))
2. Release of the V/q mismatch seen in hypoxia (basically you suddenly start perfusing sections of lung that were previously not being ventilated and up comes the CO2; you actually can see the same thing happen if you have a ventilated patient with a PE who is given thrombolytics)
3. For the last factor, I can't do any better than to quote Jeff directly: "A small amount of the CO2 retainers whom are in acute failure, and whom have their PaCO2 increased further from the two mechanisms listed above, will then reduce their minute ventilation further by about 15-20%. Usually the PaO2 will have been about 40 on room air, the PaCO2 70. Given 100% O2 the PaO2 rises well above the 170 range whereby all hypoxic drive is obliterated, and the PaCO2 rises to 90 or more. But is this a result of a central drive deficiency? Or of central wisdom? When the PaO2 is 40 the patient can’t let their PaCO2 go up to 90. If they did the PaO2 would plummet to about 20 and rapid death would ensue (per the alveolar air equation). But when the hypoxic drive “gun to the head” is removed, the patient then titrates their respiratory effort such that the ventilatory effort and work is proportioned out for the long haul. It is not a drive deficiency. We may view this as patient permissive hypercapnea, may apply non-invasive ventilation, may simply realize that hypoxemia kills and hypercapnea does not, or may intubate them. Or hypoxemia may be used as a respiratory stimulant. But if this is the tactic chosen, it should be viewed as akin to giving epinephrine to an already compromised myocardium in order to maintain adequate perfusion pressure. Just as if we were to see this same patient arrive in stable condition for a clinic condition later we wouldn’t insist they needed an epi drip to maintain a sufficient cardiac output, so too should we not insist that a CO2 retainer not in crisis needs hypoxemia in order to stimulate adequate respiratory drive." SOURCE: http://home.pacbell.net/whitnack/The_Death_of_the_Hypoxic_Drive_Theory.htm
There is also a list of references on that website and if anyone is interested, I can see if Jeff will allow me to repost the full powerpoint that goes with that presentation.
If inadequately treated yes, but to simply let someone ride with a low sat out of fear of the oxygen boogie man (who doesn't exist) is an incredibly stupid thing to do. The vast majority of COPDers with adequate therapy and rehabilitation can and do achieve and maintain saturations >90. If someone has a sat that low and is not getting treated for it, then whomever is responsible for their medical care has dropped the ball and is endangering that patient.
mycrofft
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To addit to USAF:
How many patients over the years have we seen in nursing homes wearing oxygen deliverers, or transported with oxygen running, or even resuscitated inluding oxygen, and they weren't dead? How many actually reported and appeared relieved and improved?
And how many times have we seen someone* announce "That guy's got COPD, fergoshsakes get that O2 off", it is DC'ed, and the pt starts to decompensate? Nice to have some scientific muscle behind decades of observation, excellent.
* New EMT, in the ambulance, after leaving the originating facility where the pt was on O2, in most cases. :sad:
PPS: I thought I had posted a reply that sometimes nurses, especially when they are tired or stressed, will try to bully techs, and yes some are still working where someone still does Trendellenberg. As a retired RN and former EMT, I just wanted to reveal that earth shattering news flash.
How many patients over the years have we seen in nursing homes wearing oxygen deliverers, or transported with oxygen running, or even resuscitated inluding oxygen, and they weren't dead? How many actually reported and appeared relieved and improved?
And how many times have we seen someone* announce "That guy's got COPD, fergoshsakes get that O2 off", it is DC'ed, and the pt starts to decompensate? Nice to have some scientific muscle behind decades of observation, excellent.
* New EMT, in the ambulance, after leaving the originating facility where the pt was on O2, in most cases. :sad:
PPS: I thought I had posted a reply that sometimes nurses, especially when they are tired or stressed, will try to bully techs, and yes some are still working where someone still does Trendellenberg. As a retired RN and former EMT, I just wanted to reveal that earth shattering news flash.
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