When to assist/administer medications

[conemt]

Hello,

Lately I have been trying to figure out when is the appropriate time to assist and administer medications according to the NREMT standards. I have been reading questions lately like 'after your primary assessment, you should...'
An example would be "Your patient complains of crushing chest pain, after the primary assessment, you should do what?" The answers would usually look like A. Continue onto history taking B. Administer Nitroglycerin etc etc.

I have always learned it as 'BSI, Scene Size up, GI, C/C, Primary Assessment, History Taking, Secondary Assessment, Vitals, Interventions (this is where the administration of meds should take place?), Reassessment"

What if it is a more serious injury and the patient needs his/her epinephrine? Would I still ask SAMPLE/OPQRST, take vitals, and then assist with epi?

Thanks.

 

[Jim37F]

The purpose of the primary exam is to find and treat life threatening conditions. Yes the book separates it into "Assess Airway, then Assess Breathing, then Assess Circulation...." in reality you'll be doing all three pretty much at the same time. So say you're called to the park for a difficulty breathing call and as you're making patient contact you can here the wheeze and see the hives (aka your general impression =Big Sick) you should be thinking Epi pen already to fix their non-patent airway during your primary.

On the other hand if you go to a chest pain call but the patient appears to be in no to mild distress (A&Ox4, patent airway, speaking in full sentences, pink, warm, dry skin, etc) I'd want to get a full HPI, HAM (History, Allergies, Meds) and initial set of vitals before rushing off to assist with nitro.

 

[Chewy20]

What if it is a more serious injury and the patient needs his/her epinephrine? Would I still ask SAMPLE/OPQRST, take vitals, and then assist with epi?

How would you ask someone all these questions, if they can barely breath or speak due to their allergic reaction?

You'll learn very quickly that class room scenarios are much different then a real call. You'll get the hang of it. Quit worrying.

 

[conemt]

How would you ask someone all these questions, if they can barely breath or speak due to their allergic reaction?

I know I'm going to sound really nit picky right here but I learned to resort to asking family/friends then... But I understand.


From what I learned by these two posts is that it depends on seriousness. So the way I should be thinking about this is if the patient does not receive it and they have a chance of dying, give it to them during/after the primary assessment.

 

[Chewy20]

I know I'm going to sound really nit picky right here but I learned to resort to asking family/friends then... But I understand.


From what I learned by these two posts is that it depends on seriousness. So the way I should be thinking about this is if the patient does not receive it and they have a chance of dying, give it to them during/after the primary assessment.

Lol ok then I will be nit picky as well. Why are you going to sit there and ask family questions like those before you administer a potentially life saving medication while the PT is in anaphylactic shock? What if there is no bystanders?

Do both at once if you can. But get the PT his damn meds.

 

[conemt]

Thanks Chewy. I also found the question that was giving me difficulty.

"
A 38-year-old female was bitten by fire ants while at the park with her kids. Your primary assessment reveals that she is semiconscious, has profoundly labored breathing, and has a rapid, thready pulse. She has a red rash on her entire body and her face is very swollen. You should:

Choose one answer.


A. perform a rapid secondary assessment.


B. administer 0.3 mg of epinephrine.


C. place her supine with her legs elevated 6″ to 12″.


D. assist her ventilations with 100% oxygen.

"

So in this case the answer was 'D.' And that is simply because oxygen always comes first before anything right? If D. was not there, the answer would have been B I'm guessing.

 

[Qulevrius]

Of course it was D. It's not the O2 that comes 1st, it's the ABCs. If your pt is in acute respiratory distress, you address that immediate issue 1st.

Also, when you listed your education level as EMT, was it because you're a trying to become one, or did you already take your NREMT ?

 

[johnrsemt]

We aren't supposed to help with homework, but the answer should be B; She needs O2, but she can stop breathing while you are getting her on O2. Give her Epi, to combat the Allergic reaction, then O2 to help out

 

[conemt]

We aren't supposed to help with homework,

This "homework" was done 2 months ago. The reason why I've been confused is because I just wanted to know the explanation behind WHEN to administer medication. Of course O2 comes first, that's the first thing any EMT-B masters. Maybe it was a bad example, but since we have different medications (oral glucose, narcan, epi, aspirin) I just wanted reassurance of where in the patient assessment it fits in (after ABCs? After the secondary? After SAMPLE?) Because each medications varies in emergency.

 

[conemt]

EMT, was it because you're a trying to become one, or did you already take your NREMT ?

I passed the NREMT. I just don't think my question was conveyed properly in my wording (and the example that I used) I reworded it in my previous comment

 

[SeeNoMore]

So it's always a little bit of a trick to prep for a test vs real life care. Obviously they are related, but you will rarely proceed in the very linear fashion they suggest in NREMT tests and instead will be doing multiple things at once and focusing on specific findings while attempting not to get tunnel vision. For the pt in profound respiratory distress w/ inappropriate respiratory effort , no matter what medications you consider administering you still need to start with ventilation and oxygenation. Administering meds is not necessarily a step of it's own, but will follow a primary assessment (+/- other interventions, for example a 12 lead ECG) and typically v/s. In the real world if I am with a patient with a complaint of chest pain that seems to be fitting a story for ACS I will give ASA while setting up the 12 lead ecg and doing my exam. However, nitro is reserved for after the 12 lead (w/ consideration of the findings for example a presumed right ventricular infarction).

I don't know if that helps. In summary : You need to assess your patient to get an idea of how sick they are and whether life threats are present. So as you well know this includes scene safety, c spine, ABCs etc. You give medications based on the need to treat a condition(s) and the timing should be based on your plan of care and pt condition (V/S for example or the need to expedite transport in a major trauma case w/ care performed en route)

There is room for creativity in prehospital medicine but often you are choosing a standard set of first line agents based on a good assessment and indications/contraindications.

 

[Qulevrius]

To add to what the gentleman above said - the main issue with tests is that they're single-dimensional. So, for the purpose of testing alone, you have to do things algorithmically, i.e. if the question in question (no pun) starts with someone being in acute respiratory distress, everything else is secondary because ABCs come 1st and O2 should be given immediately. In reality, as been pointed out, ripping the packaging on the NRB, uncoiling the tube, hooking it onto the portable, putting NRB on pt = about 15-20 sec, vs sticking them with epi = 5 + 10 sec and immediate relief, then you add supplemental O2 to it and the pt isn't critical anymore.

 

[exodus]

To add to what the gentleman above said - the main issue with tests is that they're single-dimensional. So, for the purpose of testing alone, you have to do things algorithmically, i.e. if the question in question (no pun) starts with someone being in acute respiratory distress, everything else is secondary because ABCs come 1st and O2 should be given immediately. In reality, as been pointed out, ripping the packaging on the NRB, uncoiling the tube, hooking it onto the portable, putting NRB on pt = about 15-20 sec, vs sticking them with epi = 5 + 10 sec and immediate relief, then you add supplemental O2 to it and the pt isn't critical anymore.

I hope you're not going to administer medications like epi without assessing your patient first.

 

[SpecialK]

I hope you're not going to administer medications like epi without assessing your patient first.

It depends on what you mean by "assessment". The single most important treatment for anaphylaxis is adrenaline. If I rock up to a patient who has a history consistent with allergen exposure and clinically obvious signs and symptoms of anaphylaxis I would give them IM adrenaline before fluffing around taking a full set of observations and getting a detailed history. At most I'd palpate a quick systolic blood pressure.

It's a bit like going to somebody with asthma who is speaking one or two words per breath. Do they need a full set of obs to be taken first? No.

In both these situations; is taking a set of obs going to change what you do? No. Does it matter what the blood pressure in the patient is in the patient who has clinically obvious anaphylaxis? No. Does is matter what the severe asthmatics SpO2 is initially? Not really no. Neither of these are going to change what you do, you are still going to give adrenaline or salbutamol regardless.

If taking the obs are not going to change what you do and the patient has a time critical problem then take them afterwards

I know the textbook talks about the primary and secondary survey and history and examination but, nothing is ever textbook in medicine.

 

[exodus]

You've spent 8 minutes responding to the patient, spending 2 minutes doing an assessment will not hinder the care. As far as someone talking in one to two words per sentance? You better get a whole set of breath sounds and potentially a 12 lead if they're not dry. Several things cause SOB, and just because they have a history of one thing causing it, doesn't mean that's what it is now.

 

[Tigger]

You've spent 8 minutes responding to the patient, spending 2 minutes doing an assessment will not hinder the care. As far as someone talking in one to two words per sentance? You better get a whole set of breath sounds and potentially a 12 lead if they're not dry. Several things cause SOB, and just because they have a history of one thing causing it, doesn't mean that's what it is now.

In the context of other signs of anaphylaxis (especially angioedema) I have no issue immediately giving IM epi. There are few time sensitive emergencies, this is one of them.

 

[Gurby]

Thanks Chewy. I also found the question that was giving me difficulty.

"
A 38-year-old female was bitten by fire ants while at the park with her kids. Your primary assessment reveals that she is semiconscious, has profoundly labored breathing, and has a rapid, thready pulse. She has a red rash on her entire body and her face is very swollen. You should:

Choose one answer.


A. perform a rapid secondary assessment.


B. administer 0.3 mg of epinephrine.


C. place her supine with her legs elevated 6″ to 12″.


D. assist her ventilations with 100% oxygen.

"

So in this case the answer was 'D.' And that is simply because oxygen always comes first before anything right? If D. was not there, the answer would have been B I'm guessing.

I still think the answer should be B. You could even argue this based on the ABC's: her airway is being occluded due to the allergic reaction. Either way, you passed the NREMT - now you can stop worrying about what "NREMT standards" are, and focus on what's best for the patient.

 

[Jim37F]

Also remember in the real world that you are rarely, if ever, without a partner. So one partner can open the airway/apply oxygen/BVM, the other can simultaneously get that Epi pen on board.

 

[SeeNoMore]

Also remember in the real world that you are rarely, if ever, without a partner. So one partner can open the airway/apply oxygen/BVM, the other can simultaneously get that Epi pen on board.

You forgot the standing take down and c-collar first : )

 

[Akulahawk]

Thanks Chewy. I also found the question that was giving me difficulty.

"
A 38-year-old female was bitten by fire ants while at the park with her kids. Your primary assessment reveals that she is semiconscious, has profoundly labored breathing, and has a rapid, thready pulse. She has a red rash on her entire body and her face is very swollen. You should:

Choose one answer.


A. perform a rapid secondary assessment.


B. administer 0.3 mg of epinephrine.


C. place her supine with her legs elevated 6″ to 12″.


D. assist her ventilations with 100% oxygen.

"

So in this case the answer was 'D.' And that is simply because oxygen always comes first before anything right? If D. was not there, the answer would have been B I'm guessing.

As another said, the correct answer isn't the oxygen per se, it's the assist her ventilations... The fact that 100% oxygen is in the statement doesn't make it any less true. It could simply stop there and it's still the answer. This patient has a problem with the ABC's, in this case, an Airway/Breathing problem. So the textbook answer is to support the breathing. The main difference between "real world" and "classroom" is that you do simultaneous actions in the real world where classroom breaks down things into distinct steps. This is so you get to understand the steps that must be taken and (hopefully) a sense of priority of those steps. The next immediate thing to do is, if she has an epi-pen available is to use it. Through the question description, sufficient information is conveyed that enough of an assessment has been done to pull the trigger on the epi.