Doczilla

Their dizziness would have to be pretty freakin' bad for me to okay some valium over the radio, particularly if the patient was old. I'm not saying I wouldn't do it, but it wouldn't be a standing order. Benzos like valium are the drug of choice for treatment of excited delirium from stimulants like cocaine and meth. Because of the hyperadrenergic state, very very high doses are sometimes required. Versed is a fine drug for this, though you have to be prepared to re-dose the patient, since it won't last very long. The only time I've used thorazine is for refractory hiccups. I haven't seen it used much anymore in psychotic patients, largely because of several other good choices (haldol, geodon, zyprexa, +/- a benzo like valium or ativan). This drug is pretty old school. Thorazine's use is limited by its main side effect of orthostatic hypotension. You can sock the patient with 100mg of thorazine and leave him alone for a while. If you walk past the room, he remembers that he was mad at you and gets up to come after you, but gets all orthostatic and dizzy and has to sit back down. This hypotension can be severe. There's also the EPS to worry about. 'zilla

I agree with the other recommendations here with regards to evacuation and testing for CO. I think this is the most likely culprit. Something else to consider: folks of this age are sometimes given to mass stupidity, and an ingestion of a drug, plant, or something else should be considered. 'zilla

That's the problem with dizziness. So often the underlying "cause" is not something easily treatable. After looking in the ears, pike's maneuvers, CT head, CT angiogram or MRA of the cerebral circulation, electrolytes, thyroid panel, cardiac workup, etc., I shake my head as often as not. Most dizziness is not the result of an easily treatable condition, so we are left with the medications, which are very often not successful. 'zilla

Valium is not first-line therapy, but I have prescribed it when other drugs, like meclizine (Antivert) and scopolamine have failed. Meclizine and dramamine work on inner ear pathways in peripheral vertigo. Scopolamine has anticholinergic effects, and are thought to suppress brain pathways associated with vestibular function. Valium works on GABA receptors on many pathways in the brain, but we don't really know why it helps. Honestly, in people with vertigo refractory to other therapies, I've had none of them say that valium took it away. They do care a lot less about it, though. Folks with head bleeds (traumatic) who get dizzy are generally dizzy no matter what you do. After the 5th call from the floor nurse, after meclizine, scop, benadryl, and valium, I order more valium so the poor sod can sleep. 'zilla

Holy necropost, Batman. So Dwayne, now that you're all done, how does it feel looking back on this particular part of your experience? 'zilla

For us, traumas are paged out by the following criteria: Cat 1: airway compromise, intubated, hypotensive, penetrating injury to head, neck, chest, or abdomen, uncontrolled hemorrhage. This gets the trauma team (including the trauma attending), 2 respiratory terrorists, and 2-3 OR nurses in anticipation of the patient going direct to OR. The ER attending steps in and has ultimate responsibility for the airway, but that's about it. Cat 2: everything else that still falls under head trauma or multisystem trauma. This gets at least one trauma resident or PA along with the usual trauma team: 2 rad techs, 1 lab tech, 3 ER nurses (including the charge nurse), 1-2 ER techs. The ER attending is the only attending in the room, and has ultimate authority over patient care. That said, we usually just poke in, make sure that things are being done to our liking, and piss off. We have a lot of faith in the trauma residents and PAs (as well as in the nurses, who can tell when it's not being done right and will come get us). The ER doc has the option to call or cancel the alert, work up the patient like any other ER patient, and consult Trauma as necessary for eval or admission. The trauma team here is primarily surgery, but does include 2-3 ER residents per month. There are many places that have the ER perform the initial evaluation and resuscitation on all trauma patients (including cat 2) without the surgery folks, and contact or consult them only when necessary. This "tiered" response has been studied: 2 Tiered Trauma Protocol 2 tiered pediatric trauma protocol Patient outcomes with tiered trauma protocol Non-tertiary hospitals also may overtriage trauma patients as well: Secondary Trauma Overtriage And there may be ways to improve this: Secondary traige: early identification of high risk trauma patients presenting to non-tertiary hospitals Tiered trauma protocol, part deux What the trauma center should be: http://jama.ama-assn.org/cgi/content/full/289/12/1515 From the American College of Surgery The fact is that we accept a certain amount of overtriage from field providers to make sure that undertriage is done as little as possible. At a trauma center undertriage is no big deal, since the patient will be evaluated and if necessary the level of care quickly ramped up with little time lost. It's a bigger deal if the patient is taken to a non-tertiary hospital, who lacks the resources and regular experience to manage these patients, then has to transfer them out. There is also an understanding that we have on the trauma team: people survive some horrific s#it, some with hardly a scratch. EMS gets them out and to the hospital so fast that the hypovolemia has not had time to take hold and indicate the immediate need for surgery. We complain very little about overcalled trauma alerts by EMS, because we know that the mechanism was there and the patient wont declare the severity of his injuries for some time. 'zilla

They may not have all that much to restock. I started a patient on a glucagon drip, and got a nervous phone call from the pharmacy since I used up the entire hospital's supply in one bag for about 10 hours' worth. 'zilla

Regarding meningitis: N. Meningitidis is decreasing in incidence. The petichial rash is more typical of n. meningitidis than other agents. Strep pneumo comprises the majority of meningitis cases in the US. Rocephin (ceftriaxone) and vancomycin are the standard first line drugs here. An important point is that steroids (usually decadron [dexamethasone]) should be administered with the first dose of antibiotics to blunt the inflammatory cascade that comes from mass bacterial killing, and studies show reduced morbidity with meningitis when this is done. The lumbar puncture and cultures are helpful, but have to be balanced against the need for early treatment. Antibiotics may kill off bacteria evident on CSF gram stain, but may not eliminate the eventual culture of the organism, and will not mask the evidence of bacterial infection in the CSF (high protein, WBCs, low glucose), allowing the diagnosis to be reliably made. Therefore, cultures and LP should not delay treatment. As far as giving antibiotics in the field, there is far more to this than just "can we do something to help?" Adding any medication to a medic's armamentarium includes substantial risk and cost. There is the cost of stocking the medication, monitoring and replacing it when it expires, and initial and ongoing training. There is then the risk, not only of improper application of the medication, but of the chance of medication errors (selection of the wrong medication when they meant to administer something else, wrong dose, etc.). Based on the number of patients with clinically obvious bacterial meningitis who present to our ER (86 beds, 100,000 pts/year), I do not expect that most medics would see this patient in their career. I have yet to see one like that, though I have seen several cases of meningitis. Patients who fit this description are rare enough in our area that they constitute an "interesting case", that when they do occur, they are discussed with some interest among the EM, IM, and ID docs (emergency med, internal med, infectious disease). So with the rarity of this patient presentation, the minimal benefit of administering the antibiotic only slightly earlier, and relatively high chance of an error of medics having a drug that they administer extremely rarely, I don't think it's worth it in the systems I work with. 'zilla

If the patient is in cardiogenic shock, they need the beta 1 effects, and dopamine or epi would be indicated. Dobutamine or milrinone would be okay too, except if they are in shock, you'd have to add a second agent as a vasoconstrictor as well such as phenylephrine or vasopressin. Any agent with beta-1 effects, to include epi, dopamine, dobutamine, or norepinephrine, will increase myocardial oxygen demand, and there will be the potential for arrhythmia. Epi drip is something I rarely do in adults (and usually when I've got them on several other pressors), but do more frequently in children who need a pressor. Kids tend to handle the epi drips better than adults do. I agree with with p3medic on using it on a severe anaphylaxis, though none of my anaphylaxis patients have yet needed one. Contrary to your statement, saboats, we use norepinephrine more commonly here in adult sepsis than dopamine. Dobutamine is not indicated as a first line or second line drug for sepsis. It may actually be counterproductive due to the vasodilation that it causes which you alluded to. Children tend to get more myocardial depression with sepsis, so something inotropic is indicated like dopamine or epi. If the patient is catecholamine depleted, such as what happens after a prolonged period of adrenergic stimulation, then dopamine won't be effective, so I go with norepi or epi if the patient is refractory to dopamine. 'zilla

Glucagon can be given IV, and is for the other situations listed above (beta blocker overdose, need for inotrope in a patient with beta blockers on board, or for reducing smooth muscle spasm). It is not indicated in your clinical scenario. They need IV glucose, closely monitored blood sugars, and inpatient management. I'd put them on a D10 drip at whatever rate kept the sugars up, and check accuchecks q15 min. When you have IV access, there is no reason to treat hypoglycemia with glucagon. 'zilla

Meningococcus has taken a back seat to strep pneumo as a cause of most cases of meningitis since the vaccine is in fairly wide use, though it still has a hold on the young (59% of cases of children and young adults). It is extremely unlikely in the US that the causative pathogen will be known upon initial presentation, since strep pneumo and n. meningitidis are so prevalent. Viruses, particularly herpes, can do it too. The problem with meningitis is that if it is clinically evident without doing the LP, likely the patient is in extremely deep s#it. I have to emphasize the role of steroids in these patients, which should be administered with the first dose of antibiotics. Steroids will dampen the inflammatory cascade that comes with bacteria dying in droves with the first dose of antibiotics, and reduces morbidity and mortality. Our standard regimen here is decadron (dexamehtasone 10mg) + rocephin (ceftriaxone 2g) + vancomycin (1g) + acyclovir (800-1000mg) +/- ampicillin depending on age. Decadron and rocephin can be given IV push, or even IM if you have serious vascular access problems. Vancomycin should not be given IV push, nor acyclovir. Acyclovir is fairly harmless as a drug, so giving it is possibly helpful and extremely rarely harmful. If the patient is in certain populations, they should be given ampicillin as well to cover listeria (very young and very old). If the have HIV, they get everything as well as an antifungal agent. There are no EMS services in the state of Ohio that give antibiotics prehospital by paramedics (though physicians do) unless it is a "declared emergency", i.e., WMD or pandemic or serious public heath breakdown. This is by state law. 'zilla

I can't think of only one agent that could cause everything that you saw. Brainstem bleed would be immediately and readily apparent on physical exam, as p3 alluded to. Patient would be unresponsive, and respirations would shortly be erratic, strange, or absent. Hypoglycemia can cause some of the things you list, such as the diaphoresis and tachycardia (the body releases epinephrine and norepinephrine to attempt to increase BGL through mobilization of glycogen and production of glucose through gluconeogenesis, thus they are diaphoretic and tachycardic). So can cocaine, but you would expect dilated pupils. Speedball (cocaine/heroin mix) is a reasonable guess as well, with the pinpoint pupils, general sluggishness, and HTN with tachycardia (general sympathetic response). 'zilla

What most of you probably don't know is that Dr. Jermyn was working on a project to have EMS recognized as a subspecialty of emergency medicine, for which a physician could be board certified. He was a true believer in EMS and its field practitioners. 'zilla

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

Whether or not a drug or protocol is maintained depends largely on the success with it. If the drug is never getting used, there may be an issue of concern over potential errors in use. The less frequently we use something, the more likely we'll screw it up. If a large number of adverse events, errors, or bad outcomes are identified in chart review, then it may be appropriate to retrain the providers or pull it entirely. While there may not be any bad outcomes, there may be some "near misses" where a bad outcome was possible but didn't occur, or a provider reports that they "almost" screwed it up but caught it before harm was done. Cardizem is kind of a special case. The single dose carpuject that we've used in the past has been discontinued. Available single dose formulations used now have to be refrigerated. The only non-refrigerated kind is the AddVantage bag, which has 100mg in a 100cc bag. In our system, with 540 drug bags to be filled, we looked at how often it's used, transport times, relative cost of stocking, and the possibility of a dosing error, (particularly because the AddVantage has 4 doses of the cardizem in it) so we were afraid that some idiot would just run the whole thing in as a single dose. This kind of dosing error is likely to be irreversible and fatal. We looked into having a compounding pharmacy make single dose vials of powder for us to reconstitute in the field at time of use, but it was cost-prohibitive and labor intensive. If the patient doesn't respond to the adenosine and is otherwise stable, they can probably last the 20-40 minute transport time from our most outlying squads to the ED. Unstable narrow complex tachycardias need to be cardioverted, and should be diverted to the nearest ED. For us, the cost in stocking, training, testing, etc. was just not worthwhile when we looked at the "what if I don't have it" scenarios. Add in the burden of either a) requiring squads to refrigerate the drug bag, which most can't do without significant burdensome expense, or having a dosage form that is not a single dose like most other EMS drugs and therefore prone to error, we decided to wait until someone decides to make the single dose form in a reconstitutible powder like Solu-medrol or vecuronium. 'zilla

Good grief. The grammer, the spelling, the punctuation. I'm dumber for having read that post. #-o 'zilla

ERDoc, EMSDoc and I will be happy to hold a seminar on this if you keep it up. :? 'zilla

I have not heard this before, nor do I think that it is valid or prudent based on my clinical experience. I agree completely with using patient movers and sheet drags on elderly patients once in the hospital and not leaving them on the backboard, but believe that picking them up off the floor with a sheet is asking for trouble. If this clinical decision rule is based on any study, then I'd like to see it. I'm not saying that every geriatric patient should be mercilessly strapped to a backboard for the long ride to the hospital, but for these injuries, you must apply a c-collar and take some means to prevent unnecessary movement of the spine. Whether this is with a scoop or a vacuum mattress or just securing them well to the cot with ample padding to prevent lateral movement, you have to address the possibility of spinal injury. In hospital, we put on a c-collar and use manual stabilization when moving the patient from the bed to the CT scanner, etc. Dwayne- yes, I would immobilize both of the patients you described. Clinical decision rules such as the NEXUS criteria and CCR assume one thing: that the patient is at relatively low risk for spinal injury. Geriatric patients are not at low risk, for the reasons I listed in my first post. You cannot mindlessly apply a clinical decision rule to every population without fully understanding in what patient population it has been studied and applies. Geriatric patients are different creatures from the 27 year old who suffers the same mechanism of injury. The CCR specifically excludes patients >age 65 to prevent missing injuries like the one in this patient, and is found to have a higher sensitivity than the NEXUS criteria. WendyT, I'm not really sure what your post has to do with this topic. 'zilla

Mythbusters! 'zilla

What about it? 'zilla

NEXUS criteria do not apply to the elderly for exactly this reason. The Canadian C-Spine Rule specifically excludes patients over the age of 65, and NEXUS has not been validated in this population and therefore does not apply. They are at very high risk for fracture despite minimal mechanism of injury, have underlying bone disease such as osteoarthritis, lack much of the supporting musculature that younger patients have, and frequently perceive pain differently from younger patients. Physical exam alone in geriatric patients, for a whole variety of conditions, is notoriously unreliable. I have had dozens of elderly patients with c-spine fractures from ground level falls. I've found several c-spine fractures on elderly folks that were days or weeks old. Even in unstable fractures from these falls, neurological symptoms have not been present in many. This is one of those situations where you really do need to immobilize them, regardless of what your gut says. You can take the compassionate approach to c-spine with a c-collar and scoop or a c-collar and securing well to the cot, but you have to treat for this injury. 'zilla

This point was not lost on Jeff, who realized he was getting into a row with an unreasonable, agitated, and armed individual. It was at this point that he decided he would not continue to argue with her, and would sort it out later if she arrested him. 'zilla

The patient was not moved to the other ambulance. The original crew drove away with the patient. 'zilla

I'm going to chime in here because Paramedic Asher is a good friend of mine and has been for over 10 years. We were partners as paramedics and I frequently teach and answer questions for his paramedic classes that he teaches. He has close to 20 years experience in EMS, with over half of that at the paramedic level. He frequently visits me here in Dayton and precepts with me in the ER. A word about Jeff: you have never met anyone with the same calm under fire, dedicated study to the field of prehospital emergency care, and proactive attitude toward EMS and its providers. His decision-making in bad situations is spot-on. He is exactly the kind of medic you would want working in your system and teaching your paramedic students. He's the first one on my list of folks I would want taking care of me or my loved ones, and the first one I'd want to be riding with in the truck. What I can tell you about this CF is that Jeff did the best he could to provide appropriate patient care in spite of this other idiot paramedic trying to dictate who goes with which ambulance. The concern arose because this moron (who hadn't actually examined the patient) thought the patient needed a crew that could perform RSI, which he didn't. The transporting crew was an ALS paramedic crew. This was not an issue about billing or money. When things didn't go Mr Hart's way, he enlisted the help of his wife the deputy, who stepped over the line to try help out her husband, the moron. The deputy is certified as a First Responder. She would not be reasoned with, and when Jeff didn't acquiesce to her demands, she arrested him. I think this is a difficult thing for him, because he has an absolute respect for law enforcement, and has in the past enjoyed an excellent relationship with officers and deputies from the areas where he has worked. Jeff has remained silent on the issue because of company policy regarding talking to the media, but I know that it kills him to not be able to say what needs to be said; this deputy is an idiot, and her interference only hampered operations on what was a very difficult call to begin with. Likewise, this other paramedic is so ignorant he couldn't drive nails in the snow. 'zilla

Not no, but Hell no. It takes 3 years of full time training to be properly schooled in acupuncture/acupressure, despite what some fly-by-night "schools" would have you believe. To say that you can learn the techniques in a short class is nothing but a sham. I'd rather see the training time go to airway management, critical care decision-making, patient relations, or just about any other skill relevant to EMS before we start adding in this skill which takes extensive training and is not of much benefit to the patient in the prehospital environment. 'zilla