scope2776

Here is our "Procedures" section of our protocols. On page 243 is NG insertion. It's a fairly large PDF file. http://coloradospringsparamedics.com/Attri...7Procedures.pdf

Haldol IV is great, it works quickly and with little or no extra side effects - this is what i've heard. As far as IV admin in our area it's off the books, as in it's a commonly accepted practice to do it IV, but it's not really documented IV. This is more common in hospitals. Ethical or not? I dunno, just telling you how it is. Currently our protocol calls for 5mg IM only, it seems many medical directors are not sticking there necks out for IV admin quite yet. I've heard that IV admin is still being evaluated by the FDA or something.... People are still angry about Inapsine being taken away...... The onset of action of Haldol is like 5-15 min IM, that's why I laugh at this guy I saw who had it attached to his stethoscope :roll:

We have no limitations on pn control for abdominal pts. I won't totally snow them with meds so the doctors and nurses can get some kind of assessment... The administration of Morphine to a pt with cholycistitis or other gallbladder pathologies can actually make the pain worse by contracting the sphincter of Odi. Therefore in the pt that presents with pain, that through history and assessment, I believe to be related to the gallbladder I will use another pn med or a benzodiazepine.

Thank you Doczilla and AZCEP for the resources and your insight!!!

Wow... my sentiment exactly....

What are some of the finer points of reducing a fracture or dislocation with no distal pulses? What are a few things we should know, that most likely have not been taught in class? And what are some things to avoid doing? All I was taught is you pull it inline. If you can find a link to another site or article that'd be great!! Thanks!

Wow, cool, etomidate for cardioversion? Have you ever used it? I noticed you also have versed. I've always heard versed as being the superior choice for cardioversion... have you been able to compare either? Your etomidate pain relief dose is almost our RSI dose (0.2mg/kg).... that's kinda sad.... Thanks for the great responses!

Wow... that is simply unacceptable. Where in New Jersey? Is that still the rule??

Do you feel you have the ability to adequately control your patients pain? I believe many EMS agencies are short-changed when it comes to their ability to control pain and whereas this is one of the most positive impacts we can make in caring for patients. Also many painful experiences are made more painful by extractions, moving and transportation to the hospital, therefore EMS agencies should have aggressive treatment protocols. Please share your pain medication protocols or other tips you have for pain management as well as any medications you prefer. If you voted no please explain why. And what you think would improve your situation. I would also like to know if anyone has protocol for, or has used, pain medications IM. For example using in a pt with stable vitals and extreme pain before an IV has been established or if one cannot be established for whatever reason, before you move/extricate them. Any advice on the practicality or safety of this method? Here we have Morphine, Valium, and Fentanayl. Morphine is given in 2-4 mg doses, but also has protocol for 0.2mg/kg IV. Standing orders for Valium are 5-10mg IV adult and 2-5 mg pediatric. and Fentanayl is 1mcg/kg with a max of 100mcg. We are allowed to administer all of these together at will without calling med control. We are also allowed to administer more with med control permission, which normally isn't a problem. We also can call in for morphine 0.05-0.2mg for pediatrics. And we are held accountable for using capnography, pulse ox and having every patient we give pain meds to on O2. There has been talk of expanding pain protocols if more paramedics do this.... Thanks!

Wow! Thank you for the response! Maybe our medical director (for our Paramedic program) is mistaken or didn't make the differentiation between topical, neb and IV lidocaine.... It's interesting you use 0.3mg/kg etomidate for RSI. It seems when all the doctors get together to write protocols for EMS IV drugs they decide to give us less for some reason... even paralyzing drugs or sedatives for RSI, even when the point is to make the patient stop breathing. Maybe they think 0.2mg/kg will wear off quicker than 0.3mg/kg. We use Succicholine, for a paralytic, at 2 mg/kg and Veccuronium, once the tube is confirmed, at 0.1 mg/kg adult and 0.2 mg/kg pediatric also. After RSI we have standard protocols for 1 mcg/kg of Fentanayl. It has been my experience that 1mcg/kg won't control most patients pain, so I don't know how that same dose will sedate a paralyzed patient. I am wrong about increased ICP with etomidate.

Lidocaine may also be useful for pretreatment of the severe asthma or COPD patient where "numbing" of the trachea and larynx may be beneficial. At least this is what our med director thinks. I may be wrong, but I also recall a side effect of etomidate being increased ICP. We also pretreat pediatric patients with 0.02mg/kg atropine. Our pretreatment dose for lidocaine is 1.5mg/kg. We are able to use 0.2mg/kg etomidate with RSI. Is your medical director thinking about allowing you to do "crash intubations"? Just snow them with etomidate and tube? If so I hope he's giving you guys tons of education on pre-intubation airway assesment and such. One of the contraindications to RSI here is a Mellienpatti IV, anatomically difficult airway, inability to cric, no combi tube or other bale out, inability to get a mask seal, or just if the medic doesn't think they can get the tube. After 6 months on the job as a medic, they allow medics here to take the RSI class taught by our medical director, which includes from what i've heard a hard test at the end...

you guys take the pre-filled syringes out of the boxes?? huh, where do you keep the plastic syringe part?? Also, i didn't notice any pediatric concentrations - D25 and 4.2% sodium bicarb?? Wow, 200 mg Lasix??? that's a bunch, what's your standing order? 110mg Epi 1:10,000.... and possibly another 10mg vial? cool.... lol

Yes! Totally forgot! Mag would defiantly be something to try... toss up if it would have worked or not...

Very difficult case... the kind of case you shouldn't blame yourself about... really unfortunate. The whole time I was reading it, all I could think about was RSI. I know you may or may not have this wonderful (and scary) tool. Epi IV was the only thing that would have helped him at the decompensated point you arrived at. But b/c the pt was combative you couldn't get a line so you couldn't do any drugs IV including RSI.... You ended up giving Epi for the arrest anyway - a whole mg. Very tough call...

First off hind-sight is 20/20, so with that said: The child is in no need of urgent medical attention, this I can surmise from the exscrupulous details of the scenario. The child may even be receiving better, or at least the standard, medical attention in Mexico. Am I right in guessing the MOTHER AND CHILD ARE ON THE UNITED STATES SOIL, but not within the "border-zone" that is strictly enforced? The mother is illegally present in the United States. The child is a citizen. So obviously there is some sort of legal responsibility of care to provide to the child who is a citizen on US soil. Also there is the responsibility to not transport a known illegal alien. The solution is better cooperation with the local LEOs and border patrol. Maybe meet up and write out protocols for this situation or establish a number to call in the event of a sticky situation like this, etc. Also, if you would put the surrounding 500 miles without EMS cover by going out of service by transporting these patients, maybe your agency should look at assembling protocols for Paramedic Initiated Refusals. Because I would refuse these guys. I voted no transport because the daughter is not in need of medical attention and the mother is breaking the law. Plain and simple she is breaking the law and by transporting her you may also be breaking the law. Maybe have LEO dispatched to take care of mom and transport the child if you think she is really in need of medical care. I mean it kinda makes me sound like a jerk, but if you are making the decision to transport illegals into this country, for whatever reason, you are making the decision that they do not pose a threat to the citizens of this country. And guess what - that's not your job, that's border patrols job. It's out of your scope to decide who enters this country. I mean, it's far out there but, what if you transported terrorists into this country??

Wow! Great responses! Thank you very much... I understand where you guys are kinda coming from now. It seems the common consensus is to withhold nitro for acute right sided compromises, or be prepared to deal with a more serious drop in BP. I think i will be more comfortable doing a XII lead before NTG admin in the future, unless the pressure is 150 sys +. You're right it dosen't take long at all to do a quick XII lead. Yep! That's exactly the question I was asking, thank you. I have heard great things about nitro drips... a department close to hear has them. Do your departments have nitro drips? I've heard you can only do them with a pump, as it turns out to be like 2-4 gtts/min.

From my post on another thread: This may seem a little harsh but - and i do have plenty of EMT-I friends - plain and simple, there should only be two levels of prehospital providers. EMT-Basic and Paramedic. I think it's best not only from an education and patient advocacy perspective, but from a public perception angle. I already have to correct enough people calling me an "Ambulance Driver", I don't want to have to deal with people mistaking me for an Intermediate or whatever. Hell, not only does the general public have a hard time understanding what we do and the medical interventions we provide, most of our colleagues in the medical services have no idea either. I think it's just ridiculous that there are such things as EMT-Epi and EMT-Defib. I think as members of professional agencies such as the NREMT or NAEMT - or whatever state EMS agencies we belong to - we need to advocate the removal of recognition for these "Intermediate" levels. I've heard the argument that not recognizing Intermediate levels will hurt rural areas. This is simply not true. If you want an expanded scope as an EMT for your special circumstance, then have a conversation with your medical director. And if the state doesn't allow some expanded practices, then have a conversation with your congressman. That's how it's supposed to work. Maybe your medical director could actually train and sign off your EMTs on the special skills. Or hire a Paramedic! As a Paramedic student just finishing up school I feel like I have such a basic and entry-level knowledge of advanced care and cardiology/pharmacology. It's hard to describe, but it's like i'm on the cusp of ALS, and I think any education level below Paramedic, such as Intermediate, that picks and chooses ALS skills - not focusing ALS education or mindset, just skills - is below that entry-level understanding. And this cheats patients. Whereas there is increasing pressure for Paramedics to justify practices such as intubation (EMT-E are allowed to intubate!?!?!?!) or the administration of cardiac drugs. And whereas many other ALS providers are continually challenging the Paramedic's ability to provide certain interventions based on lack of education. Then there is little if any justification for Intermediates to provide the same advanced skills. Furthermore, I think it would be a great idea to increase the EMT-Basic curriculum to absorb some of the Intermediate stuff and requiring Paramedics to have degrees. But hey, that's a whole other conversation. Also some more good replies in this thread

Hello! I'm a Paramedic student and I would like to have a discussion and hear your thoughts on the administration of nitroglycerin to patients with right-sided heart failure, either chronic or acute. It has been my experience on this topic that many doctors, nurses and paramedics have differing views. As a result of special circumstances, my class is co-taught by two professors this year; and they even have differing opinions. There are many knowledgeable and experienced medics on this board and I would like to hear what you have to say! For chronic heart failure I'm thinking about the patient whom you are called to for "cardiac concerns", with obvious signs of right sided failure - such as swelling, JVD, jugular reflex, cardiac history and such. But not signs of pulmonary edema, etc. For acute failure I'm thinking about the patient with chest pain that has Atrial Infarct (rare), or inferior wall MI with right sided involvement. Per our protocols nitro is contraindicated for patients with a sys BP < 100. So giving nitro to these patients who have come to this point (cardiogenic shock) is out of the question. I know nitro can have a significant impact on the patient's preload, and the treatment of choice for any hypotensive pt is fluid. Here we only have SL (0.4 mg) spray, no nitro drips. My question is, per your experience, what have you done with patients who are right on the cusp? With like a sys of 110 upwards? Has it been your experience that nitro has bottomed these people out particularly quickly? Or do you wait on their pressure? My question on the chronic patients is do you continue fluid therapy even if sys is above 100 to try and increase preload as much as possible to help the heart? Or do you just go ahead and give niro per protocol? (Given of course no other contraindications to fluid are present.) My question for the acute patients with CP is first do you give nitro after a line has been established, but before you do a 12 lead? Or do you wait until after a 12 lead, when there pressure is around 110-130 sys, to rule out inferior MI? Also is your goal to give fluids until there pressure is good enough to give nitro or not give nitro at all? I have relatively little experience in the field and have a good grasp on the mechanisms at work, but am kinda looking for what your experiences on the street have been with this. Thanks!

Hello! I'm Casey a Paramedic student in Colorado Springs just finishing up Paramedic school and looking forward to internship. I've been a lurker here at EMT city since EMT school and just started really contributing in the last few weeks! Great info here that has helped me through school!! I recommend this site often! I'm also a telemetry tech at a local hospital and have very strong opinions about pre-hospital care education and professionalism. You'll usually find me posting in any ECG threads... lol nice to meet all of you!

We never discussed professional organizations in EMT or P school. I'm a member of the NREMT and NAEMT. What are the other EMS organizations out there or what are the ones you guys belong too? As far as i'm aware these are the only two national organizations???

Okay, yes you all right, a clinical course of action cannot be made solely on an EKG... it was just in exercise in thought process, and the type of patient I might see with this particular strip. Does the ACLS book even have info on BBBs? :roll: Our Mosby's Paramedics text certainly does not cover MI in LBBBs and neither does Garcia "12-Lead ECG"; beyond be aware for possible MI. I also have Marriott's "Practical Electrocardiography", which I will try and browse for the particulars. (but it is pretty dense reading lol) Anytime in class we talk about LBBBs it's always, treat for a possible MI and don't read too far into it. I know there are some advanced criteria for determining an MI with a LBBB. And I do know it's a little easier to tell with a RBBB. I know LBBBs will have normal ST elevation and RBBBs cause ST depression, so any variation in this atypical presentation may indicate MI. Also, I know in our protocols (for the county EMS) it just indicates to treat for MI, of course if the patients symptomatic, etc. Are there some steps you use to look for possible MI in LBBB AZCEP? Thanks for the enthusiastic replies!

Okay, I understand what you're asking... First, it might be helpful to look at sinus arrest as a result of another pathology or the result of another rhythm, not necessarily a rhythm of its own. Second, there are a couple of different terms: SA block is normally the result of a non-conducted impulse from the SA node. (No P waves) The P to P interval will remain unchanged. Sinus Pause/Arrest (still no P waves) is a variable time period in which the SA node is not working. The time interval is not a multiple of the normal P to P interval. Therefore the P to P interval will not "march out". Normally a sinus pause is less than 3 seconds and a sinus arrest is greater than 3 seconds. A patient in true SA block "rhythm" is in full arrest. SA pauses/blocks are normally seen in the compensatory pauses after abberently conducted beats (PVCs, PJCs, etc). The myocytes need to "recharge" or continue to gather electrolytes for the next impulse that were depleted by the last depolarization. Therefore in this sense it's more of a result of another event, not a rhythm of its own... understand? The lesser pacemakers cannot fire at this point because they were just depolarized with the last premature beat and also need to "re-charge" or reach their action potential. This is of course assuming the automatically of the SA myocytes has not been directly suppressed by pathological process such as hypoxia, channel blockers, trauma, ect. In which case the pt is also in "arrest". Hope this helps...

Whew... calm down.... Maybe I worded myself wrong... but yes characteristic LBBBs cause diffuse ST/J-point elevation. I meant to say, if there was any confusion about STE, it was because it was caused by the LBBB. Not the other way around lol.... This is a case where I asked for a treatment based solely on the machine, without a pt evaluation. Based on this ECG alone I would have no problem with X1 0.4mg SL NTG, 324 ASA and O2... assuming as I did that their pressure is above 100 sys. Even if their normal is this nasty ECG, a little ASA never hurt anybody...

Excellent! Totally agree 100%

There's really no story on this one, I think I got it from class. Just going through the butterfly collection and thought I'd share. I didn't black out the machine interpretation because, as most of you probably know - and if you're new you should find out - those interpretations are not always accurate. Usually I disregard them all together. I have a great strip that illustrates this... just how wacky the interps can be... i'll try and post it. This is indeed sinus tach with a LBBB. The ST elevation is characteristic of a LBBB. There are however a couple of premature beats (beats 3 and and 3rd from the right). I think they are either PVCs or PACs, I think those are P waves... i dunno. Based solely on this 12-lead I was looking for treatments for ischemia... Even if my patient was asymptomatic, i'm still going to give 324mg ASA and maybe some nitro (pressure depending) and you bet you socks O2. This is a very concerning ECG, a ischemic heart beating fast, throwing premature beats. I would also wager on an underlying MI. Thanks for the comments!