What could I have done differently for this call?

chickj0434

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So we were dispatched for a 77 year old female indigestion. We get there pt is conscious and alert holding an ice pack to her chest and respirations in the 30s complaining of shortness of breath. No hx besides anxiety and high BP. Grab a set of vitals and pts sat is 84 on room air. Pt is getting herself worked up as well stressing about everything in the room but there is definitely something going on and doesn't seem like anxiety attack. Applied non rebreather 15 lpm of o2 pt sat is 95. Pt presents with cough and wheezing. We call for als for an intercept but als is unavailable. Bring pt to hospital.

When we bring our next call to hospital saw that pt is on cpap and going to isolation and icu. Didnt get to find out exactly what was going on but is there anything I should of done differently ?

Would bvm been a better route to go?
 
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Jim37F

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Respirations in the 30s is definitely tachypneic enough to suggest thinking about a BVM. Besides the rate, how was the quality of the breaths? In the 30s they're probably fairly shallow I'm presuming.

But with the NRB you said their O2 saturation improved significantly. I've seen patients whose RR was in the 30s with shallow-ish breaths improve with NRB before, how did your patient's quality of breathing change? If the mask helped the RR be less tachypneic and breaths more full, then a BVM may not have been warranted.

And for a conscious, alert patient, sticking a BVM in their face and forcing air into their lungs outside their own control can be fairly alarming, people have panic attacks over CPAP, it's quite possible a BVM could have increased their anxiety and made things worse. OR if their breathing was shallow enough, it could have been just the thing to get good air in and out and make them feel better. It's really hard to judge something like that based on a couple black and white numbers.

A more complete description of what exactly you were seeing would be helpful, otherwise with just a Rate, I can say it's definitely an intervention to consider, but not enough to say one way or the other to use/not use. But since you also said the O2 saturation improved I'd almost say don't use, but I'd like to know if the overall quality of breathing also improved.

You also mentioned wheezing, was it audible wheezing just standing next to the patient, or have to listen with the steth to hear? What about skin signs? You said their mentation was a bit off, but did that improve with the NRB and increased saturation as well?

I'd almost lean more towards CPAP over BVM (I know I know, CPAP is still ALS skill in a lot of places, and likely outside your scope here, but still...)

But that your respiratory distress patient ended up in Isolation in the midst of a pandemic caused by a respiratory virus, that would be just a tad freaky to me, hopefully you we were wearing proper PPEs (N95 and goggles)
 
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chickj0434

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Respirations in the 30s is definitely tachypneic enough to suggest thinking about a BVM. Besides the rate, how was the quality of the breaths? In the 30s they're probably fairly shallow I'm presuming.

But with the NRB you said their O2 saturation improved significantly. I've seen patients whose RR was in the 30s with shallow-ish breaths improve with NRB before, how did your patient's quality of breathing change? If the mask helped the RR be less tachypneic and breaths more full, then a BVM may not have been warranted.

And for a conscious, alert patient, sticking a BVM in their face and forcing air into their lungs outside their own control can be fairly alarming, people have panic attacks over CPAP, it's quite possible a BVM could have increased their anxiety and made things worse. OR if their breathing was shallow enough, it could have been just the thing to get good air in and out and make them feel better. It's really hard to judge something like that based on a couple black and white numbers.

A more complete description of what exactly you were seeing would be helpful, otherwise with just a Rate, I can say it's definitely an intervention to consider, but not enough to say one way or the other to use/not use. But since you also said the O2 saturation improved I'd almost say don't use, but I'd like to know if the overall quality of breathing also improved.

You also mentioned wheezing, was it audible wheezing just standing next to the patient, or have to listen with the steth to hear? What about skin signs? You said their mentation was a bit off, but did that improve with the NRB and increased saturation as well?

I'd almost lean more towards CPAP over BVM (I know I know, CPAP is still ALS skill in a lot of places, and likely outside your scope here, but still...)

But that your respiratory distress patient ended up in Isolation in the midst of a pandemic caused by a respiratory virus, that would be just a tad freaky to me, hopefully you we were wearing proper PPEs (N95 and goggles)

Thanks for the response. Because she was so anxious the idea of a bvm in my head would make her even more anxious at the time. But looking back might have been the better option. Her sat did bump up but yes her respirations were still high. Wheezing could be heard slightly just by sitting next to her.
 

DrParasite

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Did the patient die as a result of your actions? no? then I wouldn't worry about it.

as for your question about using a BVM vs a NRB, I doubt I would have used the BVM had I been in your position, at least not as my first device. She's old, her sat isn't great, she's conscious and she has a history of anxiety... and we are loading and going... you ever tried using a BVM on a person while you are moving? not easy. Plus, assisting with ventilations via a BVM is likely going to work her up even more

what were her initial lung sounds? and her current BP? skin color? mental status (other than obsessing over everything in the room)?

If I was in your position, I would have done the exact same thing, especially considering her sat went up with the NRB. You fixed her ABC issues, now let's get her to the truck and re-evaluate. if things are going well, take her to the hospital (which is exactly what you did). if he's deteriorating (looking really tired, struggling to breathe, changes in mental status), then we need to do something else, and I would switch to a BVM, and call ahead to the hospital advising you have a dying patient and will need a bed upon your arrival.
 

E tank

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Thanks for the response. Because she was so anxious the idea of a bvm in my head would make her even more anxious at the time. But looking back might have been the better option. Her sat did bump up but yes her respirations were still high. Wheezing could be heard slightly just by sitting next to her.
Her sat came up with what you did...what would've happened if you applied positive pressure and her problem was a pneumothorax?
 

johnrsemt

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A medic coworker of mine had a patient who had RR of 60-80, coughing all night at work. Took him to the hospital. wheezes in all lobes, Albuterol helped a little, but not a lot, Left lower chest pain, 6/10 worse on deep breathing. BP 130/70 (normally 90/50) HR ~100. SPO2 90%ish.
Medic gave the patient 100mcg of Fentanyl; pain dropped to 1/10. RR dropped to ~15. stayed there for about 25 minutes. Slowly the RR increased again back up to about 60 as the Fentanyl wore off and pain increased. 2nd dose of 100mcg of Fentanyl just before arriving at the hospital.

Diagnosed with Pneumonia, and 1 broken and 1 cracked rib from coughing so hard. hurt so much to try to breathe deep that the patient was breathing shallowly and rapidly to get enough air. Kept the patient at the hospital for 48 hours on a Fentanyl drip so that his RR would stay down, and he would breathe deeply.

A lot of co-workers harass the medic for the pain medication: "you could have stopped his breathing due to the pain meds". "He didn't need pain meds, he needed O2", etc. The patient did well, ED doctor thought the medic did well; the RN about **** herself when she found out what was done. Upon arrival at the ED, the doctor ordered 50mcg Fentanyl and 30mg Toradol IV every 30 minutes, and the nurse refused, "Until someone explains to me how this is going to help a breathing problem I am not giving it".
The ED doctor told the patient to explain it, which didn't make the nurse happy. But I got to explain it and then I got the medication doses until I got to go upstairs.

I love Guidelines, and not Protocols.
 

wtferick

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N95.
Non-Rebreather.
Done. Not much else BLS could have done at this point lol. Straight to rule out.
 

akflightmedic

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A medic coworker of mine had a patient who had RR of 60-80, coughing all night at work. Took him to the hospital. wheezes in all lobes, Albuterol helped a little, but not a lot, Left lower chest pain, 6/10 worse on deep breathing. BP 130/70 (normally 90/50) HR ~100. SPO2 90%ish.
Medic gave the patient 100mcg of Fentanyl; pain dropped to 1/10. RR dropped to ~15. stayed there for about 25 minutes. Slowly the RR increased again back up to about 60 as the Fentanyl wore off and pain increased. 2nd dose of 100mcg of Fentanyl just before arriving at the hospital.

Diagnosed with Pneumonia, and 1 broken and 1 cracked rib from coughing so hard. hurt so much to try to breathe deep that the patient was breathing shallowly and rapidly to get enough air. Kept the patient at the hospital for 48 hours on a Fentanyl drip so that his RR would stay down, and he would breathe deeply.

A lot of co-workers harass the medic for the pain medication: "you could have stopped his breathing due to the pain meds". "He didn't need pain meds, he needed O2", etc. The patient did well, ED doctor thought the medic did well; the RN about **** herself when she found out what was done. Upon arrival at the ED, the doctor ordered 50mcg Fentanyl and 30mg Toradol IV every 30 minutes, and the nurse refused, "Until someone explains to me how this is going to help a breathing problem I am not giving it".
The ED doctor told the patient to explain it, which didn't make the nurse happy. But I got to explain it and then I got the medication doses until I got to go upstairs.

I love Guidelines, and not Protocols.

To be fair...I am very unsure I would follow an order of "30mg toradol every 30 mins" as this seems very dangerous and high risk with minimal benefit. If you have more information on this, I am all ears.

I would also greatly question an order of 50mcg of fentanyl q30 mins. Especially with neither of these having a "stop order"....as in "give x drug q30 x 2".

If I read this right, you were the patient? As a RN, I definitely would question this order. I understand reducing pain, I do not understand the order. And a slightly better plan needs to be taking place in my ER, because if I am having to do q 30 min meds....that doc is gonna hear it! LOL...aint no one got time for that and I have other patients and other things to do!
 

Peak

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A lot of co-workers harass the medic for the pain medication: "you could have stopped his breathing due to the pain meds". "He didn't need pain meds, he needed O2", etc. The patient did well, ED doctor thought the medic did well; the RN about **** herself when she found out what was done. Upon arrival at the ED, the doctor ordered 50mcg Fentanyl and 30mg Toradol IV every 30 minutes, and the nurse refused, "Until someone explains to me how this is going to help a breathing problem I am not giving it".
The ED doctor told the patient to explain it, which didn't make the nurse happy. But I got to explain it and then I got the medication doses until I got to go upstairs.

I love Guidelines, and not Protocols.

That story is highly embellished at best.

The literature shows equal analgesia between a toradol dose of 10, 15, and 30 mg in adults when given IV. Standard dosing frequency is every 6 hours if given as repeat dosing IV. Higher and more frequent dosing are more likely to result in adverse effects.

Giving a medication order in which there is increased risk without any benefit would be negligence and/or incompetence.
 

silver

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A medic coworker of mine had a patient who had RR of 60-80, coughing all night at work. Took him to the hospital. wheezes in all lobes, Albuterol helped a little, but not a lot, Left lower chest pain, 6/10 worse on deep breathing. BP 130/70 (normally 90/50) HR ~100. SPO2 90%ish.
Medic gave the patient 100mcg of Fentanyl; pain dropped to 1/10. RR dropped to ~15. stayed there for about 25 minutes. Slowly the RR increased again back up to about 60 as the Fentanyl wore off and pain increased. 2nd dose of 100mcg of Fentanyl just before arriving at the hospital.

Diagnosed with Pneumonia, and 1 broken and 1 cracked rib from coughing so hard. hurt so much to try to breathe deep that the patient was breathing shallowly and rapidly to get enough air. Kept the patient at the hospital for 48 hours on a Fentanyl drip so that his RR would stay down, and he would breathe deeply.

A lot of co-workers harass the medic for the pain medication: "you could have stopped his breathing due to the pain meds". "He didn't need pain meds, he needed O2", etc. The patient did well, ED doctor thought the medic did well; the RN about **** herself when she found out what was done. Upon arrival at the ED, the doctor ordered 50mcg Fentanyl and 30mg Toradol IV every 30 minutes, and the nurse refused, "Until someone explains to me how this is going to help a breathing problem I am not giving it".
The ED doctor told the patient to explain it, which didn't make the nurse happy. But I got to explain it and then I got the medication doses until I got to go upstairs.

I love Guidelines, and not Protocols.
It breaks my heart to say this as I love slinging high doses of fentanyl, but it definitely is up there for one of the worst choices of pain management to order here (beyond just a one time dose to settle the patient out like in the ambulance or on arrival to the ED).
 

Carlos Danger

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That story is highly embellished at best.

The literature shows equal analgesia between a toradol dose of 10, 15, and 30 mg in adults when given IV. Standard dosing frequency is every 6 hours if given as repeat dosing IV. Higher and more frequent dosing are more likely to result in adverse effects.

Giving a medication order in which there is increased risk without any benefit would be negligence and/or incompetence.
The only thing negligent about that toradol dose is the interval. Larger doses of toradol provide a longer duration of analgesia and have more potent anti-inflammatory effects, which can have downstream benefits in terms of pain management. So given that 30mg is perfectly safe in the vast majority of people, it remains a standard dose in an adult where no contraindications exist, and I'm not sure why anyone would want to give a dose of an analgesic that they know will wear off within two hours when giving a larger dose is still safe and will last 5+ hours and will potentially allow faster tapering of opioids.

50mcg of fentanyl every FIVE minutes and 30mg of toradol every 6 hours makes a lot more sense than giving both every 30 minutes, though there are much better choices than fentanyl boluses or infusion in that scenario.
 

Peak

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The only thing negligent about that toradol dose is the interval. Larger doses of toradol provide a longer duration of analgesia and have more potent anti-inflammatory effects, which can have downstream benefits in terms of pain management. So given that 30mg is perfectly safe in the vast majority of people, it remains a standard dose in an adult where no contraindications exist, and I'm not sure why anyone would want to give a dose of an analgesic that they know will wear off within two hours when giving a larger dose is still safe and will last 5+ hours and will potentially allow faster tapering of opioids.

50mcg of fentanyl every FIVE minutes and 30mg of toradol every 6 hours makes a lot more sense than giving both every 30 minutes, though there are much better choices than fentanyl boluses or infusion in that scenario.

I have seen several cases of AKI after a single dose of toradol in patients who were previously healthy. A higher dose of toradol does increase the risk of kidney insult.
 

Carlos Danger

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I have seen several cases of AKI after a single dose of toradol in patients who were previously healthy. A higher dose of toradol does increase the risk of kidney insult.
And several times I've seen respiratory arrest after a single dose of fentanyl, and even once with ketamine. Does that mean we should stop using those drugs? I can assure you that opioids cause a lot more harm than toradol, and you will likely cut your ME's further with a larger initial dose of toradol.
 

Peak

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And several times I've seen respiratory arrest after a single dose of fentanyl, and even once with ketamine. Does that mean we should stop using those drugs? I can assure you that opioids cause a lot more harm than toradol, and you will likely cut your ME's further with a larger initial dose of toradol.

I didn’t suggest we stop using toradol, I suggested that we follow the current evidence and maintain current practice in medication administration. There is a large amount of evidence that there is a analgesic ceiling at a 10-15 mg dose IV and that higher doses do not provide more relief. I haven’t seen any evidence that giving 30mg results in a longer duration of action, I’d appreciate if you can share the literature you have to support it.
 

Carlos Danger

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I didn’t suggest we stop using toradol, I suggested that we follow the current evidence and maintain current practice in medication administration. There is a large amount of evidence that there is a analgesic ceiling at a 10-15 mg dose IV and that higher doses do not provide more relief. I haven’t seen any evidence that giving 30mg results in a longer duration of action, I’d appreciate if you can share the literature you have to support it.
Most of the "current evidence" you are talking about comes from studies done in the ED setting. They are all very narrowly-focused and involve some variation of simply comparing the pain scores of patients who receive different dosing regimens of toradol at different time intervals.

Here's the problem with those studies: while toradol can be very useful as part of an analgesic strategy, it is not a very good pain reliever by itself for anything other than mild-moderate pain (and for mild-moderate pain, there are better options, but thats another topic). So it isn't surprising that giving 3x as much (a 30mg dose) of something that doesn't work very well (a 10mg dose of toradol) produces unimpressive results.

I didn’t suggest we stop using toradol, I suggested that we follow the current evidence and maintain current practice in medication administration. There is a large amount of evidence that there is a analgesic ceiling at a 10-15 mg dose IV and that higher doses do not provide more relief. I haven’t seen any evidence that giving 30mg results in a longer duration of action, I’d appreciate if you can share the literature you have to support it.
You haven't seen any evidence? You should start with the drug insert. Page 3 or 4, depending on where the pdf breaks: "The greatest difference between large and small doses of ketorolac tromethamine by either route was in the duration of analgesia."

It's basic linear elimination pharmacokinetics. Higher plasma concentrations = longer time above the EC curve. Most drugs follow that elimination model and it explains why, all things being equal, a larger dose of almost anything will produce longer lasting effects.

NSAIDS are bit unique in the duration of their effects though, in that higher plasma concentrations = greater prostaglandins inhibition, and early reduction in prostaglandin concentration at the site of surgical injury has been shown to improve post-op pain and reduce the risk of chronic pain syndromes by preventing chemical and structural changes at the level of tissue damage and in the nervous system. This is part of the reason why things like preop celecoxib and gabapentin and intraop ketamine have shown effective in reducing post-op pain even days later. They actually prevent pain from developing at the source, rather than just temporarily interrupting the pain signals from reaching the brain, like opioids do.

I know that's a bit of a tangent whit has little application in the ED setting, where rapidly reducing patient-reported pain scores (in order to appease the Press-Ganey gods) pretty much sums up the entirety pain management.

Bottom line: there is nothing at all negligent or incompetent about 30mg doses of toradol.
 

Peak

ED/Prehospital Registered Nurse
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Most of the "current evidence" you are talking about comes from studies done in the ED setting. They are all very narrowly-focused and involve some variation of simply comparing the pain scores of patients who receive different dosing regimens of toradol at different time intervals.

Here's the problem with those studies: while toradol can be very useful as part of an analgesic strategy, it is not a very good pain reliever by itself for anything other than mild-moderate pain (and for mild-moderate pain, there are better options, but thats another topic). So it isn't surprising that giving 3x as much (a 30mg dose) of something that doesn't work very well (a 10mg dose of toradol) produces unimpressive results.


You haven't seen any evidence? You should start with the drug insert. Page 3 or 4, depending on where the pdf breaks: "The greatest difference between large and small doses of ketorolac tromethamine by either route was in the duration of analgesia."

It's basic linear elimination pharmacokinetics. Higher plasma concentrations = longer time above the EC curve. Most drugs follow that elimination model and it explains why, all things being equal, a larger dose of almost anything will produce longer lasting effects.

NSAIDS are bit unique in the duration of their effects though, in that higher plasma concentrations = greater prostaglandins inhibition, and early reduction in prostaglandin concentration at the site of surgical injury has been shown to improve post-op pain and reduce the risk of chronic pain syndromes by preventing chemical and structural changes at the level of tissue damage and in the nervous system. This is part of the reason why things like preop celecoxib and gabapentin and intraop ketamine have shown effective in reducing post-op pain even days later. They actually prevent pain from developing at the source, rather than just temporarily interrupting the pain signals from reaching the brain, like opioids do.

I know that's a bit of a tangent whit has little application in the ED setting, where rapidly reducing patient-reported pain scores (in order to appease the Press-Ganey gods) pretty much sums up the entirety pain management.

Bottom line: there is nothing at all negligent or incompetent about 30mg doses of toradol.

You know plenty well that the package inserts don’t necessarily reflect the most current practice and are based on the early and limited clinical trials and typically only updated if there are serious concerns post market.

While the package insert states the duration of analgesia being longer it justifies this by showing a longer half life of the product which we all know doesn’t necessarily reflect the clinical duration of action or reflect therapeutic ceiling. Additionally that data which was part of the original trial only included 24 participants which were used to demonstrate the plasma concentrations the drug and metabolites over time rather than in a large blinded study to assess for clinical effectiveness.

There are also plently of studies that demonstrate equal clinical effectiveness for pain management with doses of Motrin at 400 vs 800 mg in adults. A therapeutic ceiling for NSAIDs does exist, and any increased dose is well know to carry increased risk of nephrotoxic effects.
 

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