saboats

5mg X3 q5min to 15 for STEMI with pulse >100... Statewide Standing order.... And it makes sense. It will <MVO2, and therefore decrease the damage. Also it is pretty much standard of care for all STEMI patients going to a cath lab when Dx in-hospital. If your medics are interp. 12leads, it's definitly makes sense... How are things in Ft Myers?

One thing to keep in mind is that bradycardia or heart block from dig toxicity specifically is parasympathetically mediated, and may respond better to atropine than other types of bradycardia and AV block. TCP in these patients is more likely than other to lead to a serious ventricular arrhythmia. This is why I correct ACLS instructors who say not to give atropine in high degree AVB.

Atropine is a *fairly* benign drug overall, so I usually give it a shot to begin with anyway.

'zilla

I like the fact that you are bringing this point up, as long as it is clear that it is specifically for dig toxicity, not all high degree AV Blocks... Good point!

It's not that it won't work, it can actually make the block worse. The Parasympathetic NS dosen't inervate into the ventricals so if you give a parasympatholitic medicication eg atopine to a pt in a 2nd degree type 2 or complete block, you will speed up the atrial rate, but won't have effect on the ventricular rate, meaning the SA node will fire at 120 beats a minute while the Ventricals are at 40... you will decrease any atrial kick effect even more, decrease minute volume, decrease BP and make the patient worse. Yes most protocols say you can consider giving 0.5mg while "preparing for pacing" but it could make things worse. Follow your local protocols, but I would have the pads ready if you try it...

yes according to ACLS protocols you can repeat atropine to a max of 3mg. they also state that if pacing is ineffective and the patient has poor perfusion you consider an epinephrine or dopamine infusion at 2-10 mcg/min. Atropine will most likely not work on a high degree block i.e 3rd degree or 2nd degree type II. Its more imperative that you get the pads on the patient.

I am re-writing our protocol for cardiogenic shock. Our medical director wants me to include Dobutamine (preload), Dopamine (afterload) and Epi drip for use of an increased vasopressor, and for bradycardia.

R/r 911

Just a qiestion for you about this... Is the medical director at all worried about the Beta 1 effects of an EPI drip in cardiogenic shock? Ovibously you want to increase pre/after load, and get + ino/chronotropic effects, but what about epi's cardiotoxic effects? Couldn't this stress the myocardium too much by increase MVO2 demand? At what point does he want to start an epi drip on these patients??? Not saying he/she's wrong, just wondering...

I am re-writing our protocol for cardiogenic shock. Our medical director wants me to include Dobutamine (preload), Dopamine (afterload) and Epi drip for use of an increased vasopressor, and for bradycardia.

R/r 911

This is also true with sepsis... If your patient is in septic shock, after inital fluid boluses of NACL or LR you want to give a pressor. Dopamine is the most common choice, and can be started immediatly after a couple of isotonic boluses. However you may want to start dobutamine soon after ( if you start it 1st, expecially with pedi patients you can have a significant decrease in MAP initially, the Dopamine will "blunt" this effect somewhat) but you may have to move on to EPI or Levo to get a good Alpha Response eg. clamp them down to raise MAP.... Just another good use for an epi drip...

The reason you can give glucogon in a BB OD is Glucagon converts ADP to cAMP by increasing the activity of the enzyme adenocyclase (which is what converts ADP to cAMP) the cAMP then binds to a receptor on the Ca++ channel allowing some ca++ in, this Ca++ binds to the sarcoplasmic reticulum causing the sarcoplasmic reticulum to release lots of

stores of Ca++ which will increase myocardial contractility and rate, thus

reversing the effects of the beta blockade. However it takes a lot to due this. Starting does of 5mg IV is normal, with repeated doses. Most EMS agencies do not carry enough for this to be effective. Ca++ Chloride also would work in moderate doses for this reason, CA++ Glucanate is better if it's an option.

At least when I go to the other coast, it takes less then 5 to 10 minutes to offload a patient, but becuase of the powers that be here, it takes sometimes over an hour and half to offload. They need to wake up. I've waited at CCH 3 hours and 45 minutues to offload a patient in the ER. It went as far as 6 units at one time were waiting to offload there all over an hour. Normal offload is 5 to 10 minutes, but that is onl right around 0800 and between 0300 and 0700. Anytime after those your a a wall flower for 15 minutes and beyond. Reguardless of priority. I've waited 23 minutes with a priority 1 GI bleed, extreme hypotension, in the hallway for a bed.

The only thing I can say about T1's. Is at least we have one, so we don't have to ship them to the next closest which whould be 3 hours north to Tampa after they've been stablized at a local.

Maybe someone at LCEMS should talk to the county commissioners or hospital administration about wait time. There are now "not-so-new" EMTALA/Cobra standards that dictate maximum wait times for EMS at an emergency department. If these standards aren't followed it will effect the hospitals ability to bill CMS and they can be fined. It was a bigger problem out west, where 1 hour was the normal 24hours a day for a while (holding the wall) but these new standards have fixed that problem a bit. A work in progress, but it is being addressed.

As far as EMS doing non-emergent interfacility transport: that is the system as it stands right now. The GAO just delivered a report to CMS that stated that the CMS payments for emergency medical transport are below the cost-per-call average nationally. If you want to talk about Ambulance Services not doing IFT or non-emergent work, then you have to talk about taxpayer funded, municiple 3rd service. If private EMS is still contracted to do 911, then this current system will remain the norm. If you switch to a 3rd service model, (which I think is the best, then you will see your taxes go up. Some services do off-set expenses with revenue, but this is not the norm, and the ones that do are projecting lossess in the next 5-10years because of CMS fee schedules that aren't keeping up with costs (like fuel!).

Private Ambulance/Ambulette services are not set up as "EMS" they are transport services that may have a 911 EMS contract or 2. The money isn't in 911, it's in transport - so either get the private company out of your area, and create a government based one, or you will just have to swallow the non-emergent runs. Sucks, but it's a fact.

Lastly; very early on in this thread, someone talked about not seeing PD doing private security work; ever seen a cop on the road at a construction site? :twisted: Flag men can do the same job for less, but yet there are still officers there, sitting in their car, "in case" . All public services provide some community based operations EMS is no different. And really is EMS a true Public Safety Service or a Public Heath Service? Things are interesting now in this field, for sure.

Scott, NR/CCEMTP

The above is correct. NACL is normally the best thing that EMS can do for someone with hyperglycemia. Fluid and Insulin are the basic treatments, since we prob don't have the insulin, start the fluid. If the pt develops either DKA or HHNK they are going to get fluid loaded in your favorite ICU. Absolutly correct!

Scott, NR/CCEMTP,