Too many things I wanna say.
I wish I'd have thrown my hat into the ring earlier.
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?
Not that I think it applies to this case, but I've found that mildly hypotensive pts often come good with a bit of morphine rather than the other way around.
Hell, we put 45mg of morphine into a bloke the other night and it didn't touch his blood pressure.
I'm having a bit of trouble picturing this pt, but if her COPD is really hitting her hard, I'd be more concerned about morphine and that. But it would just mean I went gently.
Still, my partner says I could come across a runny nose and I'd still have a line in, a litre of fluid up and 10 of morph in by the time we got to the truck
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
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.
I had this condundrum the other day, male mid 30's I think, super serious asthma hx, sounded like he'd fractured a rib earlier in the night and then his asthma kicked into gear. The current attack wasn't too bad, but it also wasn't responsive to salbutamol, atrovent and prednisolone. 10/10 chest pain. So I'm thinking gently gently with the morph. Gave him 5mg in the end (ended up sticking the penthrane through the hole in the neb mask which worked a treat incidentally). Didn't touch his resps. I was talking to a CSO about it later and he reckoned as long as I stuck with small increments and kept a good eye on it, I should have just kept going until his pain was under control.
He wasn't worried about the resp depression at all and he's one smart cookie.
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.
Why does a sinus tach at 130 not mean a "pump problem" to you? Pain relief is important in many ways aside from it being humane. If we didn't use analgesics we'd just about never open the drug bag, its a big part of our job.
I can say with complete confidence that we are better at pain management in ambulance than most hospitals. If a pts pain wasn't managed well in hospital, I wouldn't take that to mean it didn't need to be managed.
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.
This doesn't scream haemorrhage to me, at least initially. It sounds more like one of the many poorly cared for oldies who are miscellaneous crook and a bit dry. I'm having a hard time picturing this pt from the narrative and the second pressure is certainly cause for concern.
Sux and an apology is considered to be inhumane by a lot of people round these parts. Even very sick pts with generally still get some level of sedation/analgesia for intubation.
Yes, by splinting and then chemically, as needed, absent contraindications.
Ruptured ovarian cysts- depends, but probably (absent any contraindications).
Burns- That's pretty obvious.
Appendicitis- Yes.
You'd splint a femur before any analgesia? :unsure:
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