croaker260

Actually , bioavailability of rectal drugs (as a generalization ) tends to be about 0.8 where IV bioavailability approaches 1.0.. as a general rule. See CHBARES comments on 0 order elimination above.

Not the one I was looking for, but I ended up using it in my project anyway. Thanks!

The other side of this is that unfortunately, even in the US, DC FEMS takes the cake for dysfunctional EMS systems and anything goes. Detroit Fire/EMSby coparison has a huge level of dysfunction, but most of it is beyond the control of the street level provider. DC FEMS has no excuse.

OK, those who know me know I have an interest in street drugs and lecture a lot on them as well as try to keep abreast, etc. So its not often that I get stumped. In a HIPAA SAFE, HYPOTHETICAL (wink wink) galaxy far far away.... EMS unit was requested to assist local LEO with a patient in opioid withdrawal The patient in question was being detained for a period in time while an investigation is going on. As this period of time progressed, the patient became dope sick (withdrawal) to the point LE were somewhat concerned and wanted to have the patient assessed. The patient in question uses IV opioids 8-10 times per 24 hour period, typically crushing and desolving prescription opioids. he has been following this pattern of use in excess of 2 years. What the patient takes largely depends on what he can get, but typically Oxy or Dilaudid 8 mg. The patient will combine with meth as the mood strikes, and also will use Heroin as needed if he cant get his normal fix. So, not that abnormal. Unfortunate, but not abnormal. Here's where it takes a turn into left field. The patient also reports that in addition to IV opioid use, the patient routinely uses Vodka and/or everclear instead of water to disolve the pill fragments in. he reports that he has also been doing this essentially uninturupted for the previous two years. The patient reports its a more complete desolution, as well as a more intense effect on injection. My questions/discussion points are: 1- Knowing that this route would bypass 1st pass metabolism, what is the thoughts on tolorance, and/or toxicity? 2- Given #1 above, and the reported duration of use (2 plus years) what is the risk for alcohol withdrawal and DT over the next 12-48 hours? 3- what is the prevelance of this practice? I've posted this to the Docs and other knowledgeable people and recived the same puzzeled looks.

Many thanks guys, but no, none of those. The Mort study I already have as a foundation reference in my proposal, but I need this specific artcile for a specific point.

I am writing a proposal, and am trying to recall a study I read many years ago. It was a study that reported that # of ETT attempts, independant of other difficult airway factors, also increased the difficulty of the ETT attmept. In other words, everytime you placed the blade in the mouth of the patient the chance of failure increased. IIRC the chance increased to 25% by the third attempt. It was from long enough ago that I didnt scan and PDF it. For the life of me I cant find that study now. I am 75% sure it came from the ASA or from the Annals of Emergency medicine, but I could be wrong. My google-fu and pubmed-fu and kung fu are all failing me today. Ive been looking for two days. Anyone recall that study and have the citation? or betteryet the actual PDF? Many Thanks.

I was 90% sure that PR used the NREMT also, being a US terratory

This is an excellant overview of the science and theory. http://www.epmonthly.com/archives/features/no-desat-/ I personally have had it save my ass on at least on occasion and prevent a difficulty airway . It was a adult male in status SZ for about 60-90 minutes prior to 911 call, how had been trached int he past. His family finally called us after they shoved a plastic toddler spoon in his mouth and caused further trauma. Anyway, multiple Bezo's at max doses had failed to break the SZ, and the patients SPO2 was dropping (was abotu 65-70% on NRB) . He was also hyperthermic from fever and/or muscle activity. Airway positioning and suctioning was poor due to trismus. We were literally facing a crash airway, but with his prior trachs and anatomy, RSI/MAI was the last thing I wanted to do. Remembering this tool in the tool box, I dropped the NC at 15 LPM as we prepared for the inevitable RSI. Immediatley (under 2 minutes) his SPO2 came up to 97-99%. Being very happy with this, we continued transport, and he was subsequently intubated after three attempts with a glide-a-scope by the anesthesiologist (we had called ahead and they were waiting). Looking over the docs shoulder during the attempt, I was really glad we didnt have to try in the field.

We also use the CAREVENT ATV+CPAP at my service, and at my PT gig. At my main service we use a different CPAP, but otherwise both are very pleased with them. Ive used them on a variety of adult and large ped patients. I have not used them on the very small.

For those of you that have these devices, or have trialed them: What make/model are you guys using in your individual services, what guidelines do you have for their use, and any lessons learned from your experiance?

I think what ERDoc is trying to say is HOW did the "Paramedic" "clear" ( a misuse fo the term) the c-spine. What assessments did he perform. What he is wondering is if he did it "correctly". Saying Selective Spinal Immobilization (AKA "Clearing the C-Spine" ) protocols dont work, if they were misused in the first place, is not an accurate, or helpful, statement.

We currently use Ketamine in my area, and I do not recall seeing anything like trismus, other than the brief fasciculations you occasionally see with succs. That said I routinely use a little Midazolam pre-intubation in my "cocktail" as well (2.5-5 mg). I started using this back when we used etomidate instead at the recomendation of a local doc, as we were seeing myoclonic fasciculation /trismus with Etomidate. Since I aded a little versed, havent seen it since. So that would be my recomendation. I know some medics think that using ketamine removes the need of Midazolam altogether, but I think they work well together. With a paralytic too , of course.

Hehe I left TN in 1998, arrived at ACP for academy "December 7th, a day wich will live in infamy forever"... So yeah, its been a while. I try not to think about it too much. And its a good thing you put WE in that statement about old and gray...

http://www.hulu.com/watch/539028 "E-meth"

http://www.adaweb.net/paramedics/AboutUs/StandingWrittenOrders.aspx The specific protocol that pertains is here: http://www.adaweb.net/LinkClick.aspx?fileticket=_jCsKmENMhE%3d&tabid=4660 The protocol as written does not sufficently emphasise the true paradigm, shift. As a single sentance states, the KED and LSB are for extrication, not for immobilization. As anywhere, there are always some things to complain about...it is EMS after all...but yes, its a great place to practice. I've been here 15 years and counting.

Sorry I havent posted in a while. My life has been crazxy busy.... So, I am giving a street drug lecture as a conference... as I am wont to do on occasion, and a thought occurred to me. We are seeing these "Vaping" stores, products, patients explode in numbers in this area... an exponential increase in this nich market. Even among health care providers. Now I am NOT going to speculate the pro's and con's over traditional tobacco use....But I have a question. It seems to me only a manner of time before someone puts any number of illicit adulterants in the liquid they use for this. My guess is someone, somewhere probably already has tried it. My personal bet is on opioids. But could be meth, or anything else. Has anyone actually seen this (illicit/recreational street drugs combined with Vaping) in their area?

For what its worth: We have had a SSI protocol officially written since the late 1990's very early 2000's..but IF you did immobilize someone , it was all or nothing (read "full LSB/colalr immobilization"). 6 months ago we finally got a new protocol in place that we have been working on over the previous 18 months getting buy in from all stakeholders...trauma, neuro, ED, Fire, etc. NOW (as defined over the previous 6 months) we Still have an SSI protocol that the assessmnet/ exclusion criteria are very similar...., but the defalt is c-collar only immobilization with the patient in a supine position on a soft matress, self extrication from cars/couches/bar-stools is clearly allowed (two step rule AKA "traveling", with assitance from providers). The KED/LSB ONLY when specifically justified. Scoop is prefered for supine patients when possible. This is the new every day standard. NOT the rarity. And we are a medium sized service (22K/year calls) In all seriousness, I have used the scoop more than the past 6 months than I have in the past 23 years. And I have used the LSB less than 10 times over the same period.

First of all, really good discussion. Bravo. Second, the contrindications/major concerns for suxs in our setting are: 1- Mysthenia gravis..While i have never personally seen this played out, my understanding is that it significantly prolongs Sux's duration making it comparable to other long acting paralytics. Since we do see these MG patients in the field, in this case I would do a more MAI than a true crash RSI..in otherwords heavy on the ketamine and benzo's/opioids and avoid succs. 2- Hyper-K+ is a real concern in the prehospital setting, but short of EKG changes we only have our detective skills to assist us to detect Hyper-K+ as most 911 agencies do not have readily available lab values. As I have seen a patient code in this very scenario.... here is my advice: Disclaimer: THE FOLLOWING IS SIMPLY A STREET MEDIC TIP HARD WON OVER THE PAST 20 PLUS YEARS AND IS ANECTDOTAL... As a general rule, if I find a patient in severe distress who would warrent RSI/MAI and they have a history of poorly controlled DM (with or without diagnosed renal failure) , or renal failure from any cause... then I avoid sux and use other pharmacological alternatives. I can think of at least 5-6 cases in the past 5 years where this has likely prevented adverse complications from giving sux in a hyperK situation (i.e. cardiac arrest). Not a lot, and certainly this is just anectdotal...but there it is. Your personal milage may vary. I think its important to differentiate the diference between the induction phase of RSI/MAI in airway management, and the maintanence /post induction phase here, as vec (combined with other agents) is a reasonable choice in the post induction phase for many services. But ypou and I are in total agreement that it is a veyr poor choice for the induction phase.

So, we have finaly started it. We pulled the trigger and now have a protocol for SSI (Which we have had for about 12 years...but under the old protocol, those we immobilized we did with full immobilization) . Under the new protocol...those we still immobilize (unless major trauma) we are only immobilizing with a c-collar. We are only using the LSB for extrication. Also, in training, the emphasis is to use the scoop instead when possible. About 10 years overdue if you ask me. Anyway, here is our protocol if your interested. its pretty simple. For what its worth, we are strongly considering dropping to only two boards and adding a second scoop stretcher for this. -Steve Appendix: Q TITLE: Selective Spinal Immobilization Protocol REVISED: June 10, 2013 1. BACKGROUND: This protocol is intended to allow selective exclusion of full spinal immobilization in patients with a low index of suspicion for spinal injury and to use the long spine board and/or scoop stretchers for extrication purposes only. 2. PROCEDURE: Cervical Spine: In order for providers to defer cervical spine immobilization (i.e. the c-collar) in patients with mechanical potential for injury, ALL of the following criteria must be met and individually documented. 1. No posterior neck pain or tenderness. 2. No intoxication. 3. A normal level of alertness. 4. No focal neurologic deficit. 5. No painful distracting injuries. Note: For elderly patients >65y/o, patients with any underlying baseline mental dysfunction such as dementia or other chronic neurologic conditions, rheumatoid arthritis, chronic steroid therapy, severe osteoporosis or who are chronically bedridden, higher levels of concern for cervical spine injuries are warranted and lower thresholds for using a c-collar should be instituted. Note: Axial loading of cervical spine is not recommended. Thoracic and Lumbar Spine: The long spine board is intended as an extrication device and should be considered as such. When at all possible, the scoop stretcher and/or KED devices should be used to move the injured patient to the stretcher and removed as soon as possible. For any patient with: 1. No tenderness of midline upper, mid or lower back. 2. No intoxication. 3. A normal level of alertness. 4. No neurologic deficit or incontinence. 5. No painful distracting injuries. If the above criteria are met, then extricate/assist the patient to the stretcher with the least manipulation of the spine as possible. If the patient has any of the above: utilize the appropriate transfer/extrication device (long spine board, KED, slider board or scoop stretcher) to move patient to the stretcher that will cause the least amount of mobility of the back. Once the patient with suspected/known back injury is placed on the stretcher, remove the extrication device as soon as safely possible and keep the patient in the supine position for transport/transfer to the appropriate destination. Any further transfers of the patient with a known or suspected spinal injury should be done with a slider board observing precautions not to manipulate the spine. Physician PEARLS: In patients at extremes of age, a normal exam may not be sufficient to rule out spinal injury. Padding (inflatable mattress, towel rolls, etc.) is recommended when appropriate for patient comfort. Posterior bony cervical-spine tenderness is present if the patient reports pain on palpation of the midline neck from the nuchal ridge to the prominence of the first thoracic vertebra or if the patient has pain with direct palpation of any cervical spinous process. Patients should be considered intoxicated if they have either of the following: 1. A history provided by the patient or an observer of intoxication or recent ingestion of alcohol or other mind altering substances such as benzodiazepines, narcotics or recreational drugs. 2. Evidence of intoxication on physical examination such as an odor of alcohol, slurred speech, ataxia, dysmetria, or other cerebellar findings or behavior consistent with intoxication. An altered level of alertness can include any of the following: - A Glasgow Coma Scale score of 14 or less. - Disorientation to person, place, time, or events. - A delayed or inappropriate response to external stimuli, or other findings.

OK, my comments: 1- This only becomes a big deal if we make it a big deal. As I live/work in Idaho, we encounter this a fair amount and ITS NOT A BIG DEAL. 2- Most CCL/CCW owners are very mindful and knowledgeable of the law, public safety, and are very sensitive to discrimination and constitutional issues. …often many times more so than the average EMS provider. So, trying to be badge heavy no-it all will not work out to a good patient rapport. 3- Exactly what you do will depend on your location. In a very rural area (like most of Idaho) waiting for LEO is not practical. so, when possible , I like to express alternatives. Possible acceptable solutions: If there is a sober adult with the patient, then they can take charge of the weapon. if there is not a sober adult present, and you feel comfortable, render the weapon safe (open the bolt/slide, remove the mag, engage the safety, etc). If you dont feel comfortable, it is perfectly acceptable to have the patient (assuming he is sober and cooperative) render the weapon safe for you. I usually do this when he is removing it. from his person. A third option is to lock it up in the vehicle or in the house. I am a little reluctant on this only if it is not secured in something that LOCKS, like a gun safe or similar device. I would rather give it to a person. But that just me. I have done both with no problems. Finally, if you have no other options, you can render it safe and transport it in an outside compartment or (as in our case) in your narc box (ours is also a gun vault.). This is what I usually have to do If I discover a weapon during transport (, knife, pistol, bible, whatever) anyway When possible I store it in the holster (assuming there is one..most legit gun owners carry in some kind of holster) both for protection of the finish and/or an added layer of safety. What I do not do: Give the weapon to a juvenile, a non-sober friend, or leave it unsecured on the scene. Transport a weapon that isa not rendered safe. Allow the patient to keep the weapon physically on him. I am polite, and I explain the alternatives, and I let the patient make a choice. One of the "choices" he can make is to go to the hospital by other means. I have not had anyone chose another option. I never leave a weapon where it ay be easily accessed by a minor or a child. In that case, and if the patient has no other alternatives, then I call LEO to secure the weapon. I have only had this happen once. Dad was having a serious medical emergency and his 14 year old son was in the house. Fortunately we in suburbia so LEO arrived quickly and was very understanding. One final comment: Obviously having an LEO seems to be the best solution, but over the past several years the increasing gustopo nature of the anti-gun crowd and unjust ways some restrictive gun laws have been enforced would make many normally docile gun owners become very upset. Without getting into politics , look at the criminilazation of gun owners on Colorado and New York just over magazine size. At the stroke of midnight previously law abiding citizens were made criminals, and many more are afraid of the same thing happening to them. This has made many law abiding well intentioned gun owners very distrustful. No one wants to have a medical emergency and suddenly end up in legal trouble. Letting the gun owner you are respectful and supportive of his rights, and looking to find alternatives with the LEO being the last option, is IMHO a good aproach.

We are a ground 911 service. We carry vec and have for about 8 years or so and have done some form of RSI/MAI for about 15-20 years. We do not use it for induction at all, it is only used for maintenance of paralysis in conjunction with opioids and benzo's (typically Versed and/or Fentanyl) . We currently use combination of Ketamine, succs, opiods and benzo's for induction. Vecs biggest downfall is its longer duration , Therefore it is only given after the tube is secured, ETCO2 and other monitoring are in place, and a c-collar in place. It has a longer effect than succs, typically 30-45 minutes. For that reason, we often use it side by side with Versed and Fentanyl which have similar clinical durations as well. In otherwords, when I administer vec, I strongly consider readministering Versed and/or Fentanyl as well. Of course general patient situation, hemodynamics, and clinical judgement all play a role.

I appologize, a more accurate statement is that there are increasing recommendations to go to the SMS...based on the same studies that are critizing the GCS. I do not have any data on the number of agencies that are actually doing this. I also know that we are hearing some of the same rumblings from out trauma and neuro services and I expect a formal shift to something else with in the next 18 months, and it seems that the SMS is the main canidate for replacing the GCS.

http://croaker260ems.blogspot.com/2013/07/the-triple-check-for-safety-is-it-time.html Thoughts?

FWIW, the GSC is on its way out. Most agencies are going to the simplified motor score (SMS) but I personally like the FOUR SCORE better. SMS: http://onlinelibrary.wiley.com/doi/10.1197/j.aem.2006.05.019/pdf FOUR Score: http://www.coma.ulg.ac.be/images/four_e.pdf

uhm..Im in Idaho... We are pro-gun, Pro-rights, and dont have near the racism problems the south has...so ..uhm...not really.