Paramagic

The side effect profile of ketamine is no more bothersome than any other analgesia in common use. The most common side effects are easily managed with commonly carried ALS drugs such as benzos or atropine (or glycopyrrolate , but I'm picking not many ambulances stock that)

Knowing the side effects and having had a fair amount of experience with various analgesic options, I still think ketamine is the best drug ever.

I always find it interesting reading these threads to look at what people consider to be aggressive/appropriate analgesia. People sling around doses like 5mg, or 2mg or whatever. Does no-one else find it curious that pretty much every drug is given on a weight based formula (0.1mg/kg, 3mcg/kg, whatever) yet with morphine we come up with some arbitrary number like 5mg every 5 minutes.

Personally I give 0.1mg/kg morphine as my initial bolus, followed by 0.05mg/kg after that until the pain goes away (or equivalent fentanyl doses). I will obviously change this for certain populations, dropping my initial dose or increasing my subsequent dose, or whatever, but none the less it is always a weight based approach as well.

Ketamine is also, without doubt, the best drug ever, for anything, anywhere.

Exactly. Our date format is dd/mm/yy, today is 12/6/12 for us. Rock_shoes did a nice job with the interpretation though. Being Canadian, we have to know the conversion format for the dates, as well as the metric system because the Yankees refuse to conform.

dd/mm/yy makes far more sense. So does the metric system for that matter. Although it seems medicine is at least catching up with the civilised world and you hear far more Doctors using centimetres and so on (although the next person I hear saying sonametre is going to get punched in the throat... I'm looking at you Weingart,..)

We use fentanyl and midazolam as our routine agents for induction (with suxamethonium for paralysis). Generally speaking they work well, however, as the others have said, midazolam on it's own (or fentanyl + midazolam without paralytic agents) is very much sub-optimal.

I like the regime Kiwi describes, ketamine for anyone with hypotension or potential for hypotension, midazolam + fentanyl for people whose brain has already exploded and who have a BP of eleventybillion over 90. And rocuronium would be my choice of paralytic.

Midazolam and morphine make a nice infusion for ongoing sedation and analgesia though, they are needed in lower doses so there are less issues with hypotension.

I like the way you think, but why not try the bougie first; if you get it in there's an absolute 100% guarantee you've intubated the trachea when you slide the tube overtop.

Maybe it is just me, but I do not like using styleted tubes, I have used them a small number of times and just didn't really think it was for me

I work with a fair number of medics who take the same approach. I disagree with it. The bougie is the first step in the difficult/failed airway approach for most of us. If things go wrong it is important to change something in my technique and If I have already used the bougie I now have one less thing I can change, one less step in the failed airway route, one less chance of successfully intubating.

If I am predicting a shitty airway for whatever reason, then I may break out the bougie straight away, but otherwise I want to give myself every opportunity to pass the tube successfully.

I also do as zmedic does, verbalising everything, even when I am the senior medic at the scene. Intubation is a two medic job here, so I like to let the other medic know what is going on. I also like them to do the same for me, so that I know if things are going south, rather than sitting in silence, sweating, wondering if they are going to get the job done, whether I should step in, whether we should abort the attempt and so on.

Doczilla also raises very important points. We have a 99% success rate for intubation, and a decent part of that is not just knowing how to intubate, but when we should intubate, or when we should leave it to someone else.

No epi, atropine or amiodarone looks like acls is becoming less "a" and more just "cls"

Just means we need to make sure that as stuff is removed we push to get what's added in its place, or even a larger/full level of acls meds

No, what we need to push for is a more evidence based approach to pre-hospital medicine, not getting more stuff to put in our bags to prop up our fragile egos.

Which, funnily enough, is what the removal of atropine represents.

That is staggering. Regardless of whatever other clusterf**ks went on, no waveform capnography = no intubation. End of story.

I agree with usalsfyre and also with systemet. Quite aside from any errors that were made by the providers, there are some systemic issues that need to be addressed. It is really not appropriate to expect crews to transport sedated, ventilated patients without proper equipment. That means waveform capnography and proper ventilators. I'm not a fan of having to use a BVM in these situations, but I'm equally unhappy with having bullshit, cheap, nasty ventilators.

BVM's have their place, both as an initial option when we just need to get air in and out urgently, and as part of a "failed ventilator" plan, but we really need to be more cognisant of the importance of proper lung protective ventilation strategies, both on 911 calls, and most certainly on IFT calls.

I fear there has been a bit of misinterpretation in what I posted.

Using lidocaine to reduce the development of ectopic beats, in the setting of a presumed AMI, is reasonable. It should not take precedence over managing the underlying problem, but reducing the occurrence of ectopic beats, and rhythm, should be a consideration. Limit the ischemia/injury, limit the development of dysrhythmias, and maximizing the cardiac output are still measures to shoot for with an active MI.

Sorry for taking so long to reply, the silly season has indeed been silly this year.

Azcep, I am still unsure what you mean by reducing ectopic beats with lidocaine in an AMI. This is exactly the scenario where we used to start lidocaine infusions, with the rationale being that ectopics can lead to R on T, R on T leads to VF, VF kills people. Seems reasonable, until we found out that it didn't make any improvement to mortality or morbidity, so we stopped pouring a pro-arrhythmic cardiac depressant into people with a vulnerable myocardium.

What would be your trigger to give lidocaine in someone with AMI? How many ectopics, or what type? What about re perfusion arrhythmia and ectopy, do you treat that with lidocaine?

Croaker, given this is an established inferior infarct, who tend to have a high likelihood of RV involvement, and that there is no evidence that nitrates improve outcomes (if there is I would be happy to recant, but there is none that I am aware of), all there seems to me to be is a 50/50 chance that one will tank this patient's BP due to them having impaired RV function and being preload dependant. (Right sided leads not being given here, and the incidence of RV dysfunction being arounf 40-60% depending on whom you read)

I could go with nitrates if you had a nice lateral or anterior with a booming blood pressure, but not for an inferior.

However, this is an established STEMI, not an anginal episode. I have no problem with using nitrates for an anginal episode to address supply/demand problems, but there is no benefit in nitrates for STEMI, only risk.

Procainamide is interesting, not something that is seen often in the field, although it's the more effective drug. Does it get used often? How do you manage the issues with the infusion and potential side effects? I presume you have long transport times?

It wasn't really the lidocaine part that has me scratching my head, it's the AMI with ectopy. I agree that the evidence supporting amiodarone over lidocaine is pretty damn poor, so that doesn't bother me. However there is a vast difference between recurrent VT and ventricular ectopy.

I'm sure many here will remember the days of "Holy crap, 3 PVCs and 6 second strip, start the lidocaine!" (or something similar) We used to think that ventricular ectopy was bad, and would lead to ventricular arrhythmia, via the magic of the R on T phenomenon, so we would go jumping on any PVCs as soon as we saw them. Eventually we realised that it was an absolute load of crap, so it mercifully went away. There's really no need to cause further problems by loading up on pro-arrhythmic drugs unless there is actually an arrhythmia (such as you describe above)

Lidocaine is still extremely useful for the AMI with ventricular ectopy.

Ahhhh...... what? Useful how?

Look, my issue is that when you are treating PEA, without looking with an ultrasound you don't know if the heart isn't beating, or if it's beating and the pressure is so low that you can't feel the pulse or if there is a pulse, but the person checking just can't feel it for whatever reason (amped up, lack of experience etc) People in asystole are dead dead. And those who are in vtach/vfib have a good chance. And while those in PEA are often on their way to asytole, it makes me very uncomfortable saying "PEA has a poor prognosis, so don't work it."

In the ER we generally work PEA until it turns into something else (like asystole). The reason that the ER often doesn't spend a lot of time on the Hs and Ts in those people is they tend not to still be in PEA by the time that they get there.

I respect what people are saying, and we shouldn't needlessly put people's lives at risk transporting arrests that aren't coming back. But I think PEA should either be worked on scene for a few minutes, if it turns into asystole then stop. If it becomes vfib shock. And if it's stays PEA it means that something is going right enough that the person isn't going into asystole. You can't sit there all day. Transport. At the very least there is a much better chance that there will be some sort of organ donation (kidneys, corneas) if you get them to the hospital.

However the rates of survival from in hospital arrest with PEA as the presenting rhythm are statistically almost identical to those in whom the presenting rhythm is asystole (12% versus 11%). So if these patients, already in hospital, and therefore presumably getting whatever it is that they get in hospital as opposed to out in the field, are still going to do incredibly poorly, what is it that putting providers and the public at risk going to achieve?

I agree that you can't sit there all day, which is why my protocols at least allow me to call off resus when a non-shockable rhythm is present and a reasonable effort has been made to resuscitate.

Excellent post. I think you made great points without ever relying on political correctness to shore them up...not an easy thing to do in this day and age.

Question though, on the above quote. As disease, starvation, and cruelty are also found throughout the human as well as the non human world, do we then allow them, or in fact embrace them because they are not aberrant? Each of those things might be said to be physically beneficial to human evolution, but how so with homosexuality if there is no procreation to be effected?

Dwayne

I don't think it's a matter of celebrating or embracing, merely acknowledging the fact of it's existence. We can accept that X exists (be it homosexuality, disease, death, so on) without applying a value judgement to it or attributing agency to it's being. If we remove ourselves, with all our cultural baggage from the equation and try to see a situation without the lens of out own value system it becomes easier to accept that what I see as the norm is not what others see as the norm, and broadly speaking there is no reason why my value should be any more important, relevant or "true" than anyone elses. Of course this (for me at least) applies to situations or events that are between consenting adults and do not cause harm to others or to society at large. Although that being said, we accept and indeed celebrate some things that do cause harm to society, such as consumption of alcohol (to excess), merely because it is an accepted cultural norm in Western society.

I may be wrong, but I seem to recall reading somewhere some hypothesis on the role of homosexual behaviour in terms of evolutionary theory. I'll have to go and see if I can find that or whether I am just making that up. It's entriely possible I made it up.

Can't be long, have to go to bed, but I wanted to make a couple of comments not directed at any individuals, but just a couple of things that have crossed my mind reading this thread. Some of them have probably already been covered, sorry if that is the case (you'll have to google the studies yourselves)

Homosexuality being aberrant: There is actually a large amount of homosexual behaviour in many different species, from "flings" to life-long pair bonding. So I can't really see how homosexuality can be considered to be against nature when it is so widespread in nature. It is certainly not a human only thing.

Marriage being for procreation. I am a heterosexual, white male, happily married for many years. We do not have children, nor do my wife and I intend to have children. Is my marriage then not valid because it is not for the purposes of procreation?

Marriage and social norms: Social norms change. We may not like it, but that is the way it is. In the same way, language changes. I hate text speak (LOL), poor grammar and so on (as I type these rambling, poorly constructed, nearly syntax free sentences ). But, language shifts and there is not a damn thing I can do about it. Ditto society shifting, societal norms changing, and so on. I wasn't particularly fond of the Reformation, but such is life; we adapt and move on.

Besides the religious aspects, I really can see no reason to oppose gay marriage. If society accepted polygamy between consenting adults, I too would be fine with that. I'm sure that will be a battle for another time.

Religion and education. There is a well established association between level of education and religiosity (I won't get into mental health and religiosity!) Low levels of education tends to be reflected in higher levels of religious sentiment, in particular of the evangelical type. Interestingly though, higher levels of education tend to be associated with less religion, but in some areas greater observance of religious ceremony (for example Catholicism or Judaism) Possibly the ceremony is appreciated for other aspects of it than the metaphysical or faith based aspect. Maybe more like meditation.

At the gym lifting 4-5 times a week. Consequently I deadlift 560lb for reps, squat 320, but only bench 260 (I hate chest). I'm 6'2" and 250lb. I really need to do more cardio. I really hate cardio. I hate cardio with a passion that is barely human. I hate cardio so much I now have explosive diarrhoea just thinking about it.

On the plus side I eat moderately well (with the occasional night shift take out meal, but calories consumed on night shifts don't count), I very seldom drink and have never smoked.

On iPhone so please excuse typos. I'm with bushy. This patient presumably has an occlusive event occurring, and I would have no expectation of nitrates doing anything beneficial. Nitrates have not demonstrated any benefit in AMI, and the risks of giving them far outweighs the non-existent benefit. I have never seen any compelling reason to give them to patients who are, or are potentially, preload dependent. I'm always perplexed by the idea of giving fluids to increase preload, in order to give nitrates to decrease preload. Strange and frightening...

The other thing (and I'm sure you'll be doing this anyway in the future) is that all my STEMI patients get defib pads applied, as it is very reasonable to expect arrythmia and/or arrest, especially in those early hours of the infarct.

Ahhh, I just didn't think that one through!

Sorry voranus, those are real calls. HLPP, give me a list of examples of your definition of BS calls, I will prove you wrong.

Code 3 response. Arrive at residence. What seems to be the problem? Answer: I'm out of cigarettes, can you go down to the store and get me some?

I'm not sure how being too lazy to buy your own cigarettes is an emergency.

Am I missing something here?

You are missing the fact that unions are BAD. Big companies are BAD. 911 services are BAD. Employees are BAD. I suspect also that patients are BAD. I'm not really sure that anything is good. Money? Disconnection from reality?

2 things: 1. I'll echo the general "huh?" from everyone else. That article says nothing about unions.

2. Thank god I don't work in 'public safety'

I don't disagree that forcing the tube is a very bad idea. I think that intubating is appropriate, but I too think it's not appropriate to go about it using a tincture of Brutane as opposed to doing it properly.

I probably should have expanded upon my quick post earlier, but I was in a hurry.

Fortunately Mobey has hit the nail on the head. We are not dealing with a well person who will wake up happily with some bagging. We are also not dealing with a person who will be able to bagged effectively without securing the airway better. Intubation seems absolutely indicated in this patient.

RaceMedic, you seem to have mixed up acute cardiogenic pulmonary edema with COPD: I agree with your treatment if this were pulmonary edema (except the diuresis part),

Gastric insufflation is not just a problem when it comes to vomiting and aspiration. It also impinges on the diaphragm, further reducing ventilatory compliance in someone who is clearly critically in need of ventilation.

I think tubing the patient was appropriate; I think that 'forcing' the tube is grossly inappropriate, and I think that not giving sedation and pain relief post intubation is criminal.

I'm still fascinated by this concept that all things carry the same amount of risk. I would love to see how someone lives when they believe that eating a sandwich carries the same risk as playing Russian Roulette!