Doczilla

I use a variety of drugs for acute agitation. My standby is a combination of haldol (5mg) and ativan (2mg). The haldol treats acute psychosis, while the ativan provides more general sedation and counters the sympathetic outflow of someone who is truly amped up. By using the combination, I can get control without getting too many of the side effects from either (EPS from haldol and respiratory depression from ativan). I give these together as a unit dose, a "B52" that is typically given IM. After reassessment in 10 minutes, I can repeat the dose, and do that every 10 minutes until the patient is under control.

Local EMS protocol is 5mg versed IV/IM/IN as needed. They do not carry antipsychotic drugs.

Denver has had good experience with droperidol 5mg IM for agitation. They reviewed 1500 uses. While a decent percent had prolonged QT, they did not have any significant complications. Another study showed droperidol to gain more rapid control of agitated patients with less complications of respiratory depression than benzodiazepines. It's also a great drug for migraines as well as nausea. Our hospital took it off formulary entirely because of a death we had associated with it at 10 mg. There are several studies questioning the clinical relevance of the QT prolongation, and many, including myself, advocating for wider use. Excited delirium itself has a mortality rate of 10%, even when treated, so I think our one death is too little evidence to get rid of the drug. Lots of things cause QT prolongation, including haldol, zofran, phenergan, compazine, and reglan, and these our alternatives for treating migraines, nausea, or agitation.

Among the benzodiazepines, valium crosses the blood brain barrier a little faster than ativan. It can be problematic in the elderly because of active metabolites that may be present for up to 200 hours, but in healthy patients it is not really an issue. Ativan is our go-to drug in the hospital, but requires refrigeration, making it impractical for field use. Versed is a fairly "clean"drug without active metabolites and a fairly quick onset of action. Duration of action is much shorter than the others, so redosing may be needed. The nice thing about benzos is that they prevent seizures, as well as treat alcohol withdrawal syndrome, so if either of these are a possibility, they are a good way to go. People wring their hands about the hypotension associated with them, but my experience is that this is never a concern in an agitated patient.

Ketamine is another drug that is being used for agitation. As a dissociative anesthetic, you can treat the agitation without impairing their ability to protect their airway. But a benzo is recommended to prevent emergence reactions.

I've used atypical antipsychotics, usually Geodon IM, in the acutely agitated schizophrenic or manic with psychotic features. I've been happy with a dose of 10mg, which is light as far as the manufacturer's literature goes, but in my experience takes the edge off but doesn't leave the patient comatose. 20mg knocks them down pretty good, which is not a bad way to go if the patient will require transport somewhere. But for us, it makes it very difficult for the social worker to interview them.

If it's an agitated trauma patient, they get etomidate, fentanyl, propofol, rocuronium, and a ventilator. I do not screw around with these patients, as time is ticking away while you are waiting for the sedatives to work otherwise, and if there is a serious underlying injury, there is a risk of delay in diagnosis and treatment. For these patients, chemically paralyzing and intubating them may be needed to facilitate a decent exam and workup. There is also a linear correlation of likelihood of doing this with how many times the patient calls me "motherfucker".

'zilla

Dilaudid is a very effective narcotic pain medication. There is an added effect on the patient's sense of "well being", which I think is why so many drug seekers ask for it. The precautions about dilaudid are largely the same as any other opiate narcotic: respiratory depression, hypotension are possibilities. The duration of action is a good bit longer than morphine (6-8 hours as opposed to 2-4). Like any opiate, push slow. Typical initial dose for an adult in pain is 1 mg. For weight based dosing in pediatrics, 0.015 mg/kg.

'zilla

One problem with pumps is finding one that is durable for typical field use. There are some, but not all.

In my opinion, there is no place for math in the back of the ambulance. Dosing calculations are a huge source of medical errors, and potentially fatal ones a that. We should be using reference cards every time.

'zilla

A few things looking at this thread.

Mobey, I would not diagnose someone like you describe with "pulmonary edema and overlying chest infection". If they are febrile and short of breath and have crackles and/or wheezes on exam, my working diagnosis is pneumonia. I would not give this patient NTG (or lasix), as that would be asking for trouble. Bronchodilators, antibiotics, and fluids. Not to say it doesn't happen, but the diagnosis of pneumonia AND CHF is reached only after x-ray, labs, and observing response to therapy.

CPAP is fine for patients with pneumonia. Because these patients tend to be volume depleted, they have decreased preload already, and could therefore develop hypotension with the CPAP. That's fine, since we can treat that with IV fluids to increase preload. This is why NTG would also be dangerous in these patients. The CPAP will decrease work of breathing and increase alveolar recruitment and increase oxygenation.

There is quite a bit of literature on CPAP in the prehospital and in-hospital setting, which shows clear benefit in CHF, some benefit in pneumonia and mixed causes of respiratory failure, and modest benefit in COPD.

FHubble MW, Richards ME, Jarvis R, Millikan T, Young D. Effectiveness of prehospital continuous positive airway pressure in the management of acute pulmonary edema. Prehospital Emergency Care. 2006 Oct-Dec;10(4):430-9.

FPark M, Sangean MC, Volpe Mde S, Feltrim MI, Nozawa E, Leite PF, Passos Amato MB, Lorenzi-Filho G. Randomized, prospective trial of oxygen, continuous positive airway pressure, and bilevel positive airway pressure by face mask in acute cardiogenic pulmonary edema. Crit Care Med. 2004 Dec;32 (12):2407-15.

FRam FS, Picot J, Lightowler J: Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2004; CD004104

FBrochard L, Mancebo J, Wysocki M, et al: Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med 1995 Sep 28; 333(13): 817-22

FKeenan SP, Sinuff T, Cook DJ: Does noninvasive positive pressure ventilation improve outcome in acute hypoxemic respiratory failure? A systematic review. Crit Care Med 2004 Dec; 32(12): 2516-23

FDelclaux C, L'Her E, Alberti C, Mancebo J, Abroug F, Conti G, Guerin C, Schortgen F, Lefort Y, Antonelli M, Lepage E, Lemaire F, Brochard L. Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with continuous positive airway pressure delivered by a face mask: A randomized controlled trial. JAMA. 2000 Nov 8;284(18):2352-60.

FCollins S, Mielniczuk L, Whittingham H, et al: The use of noninvasive ventilation in emergency department patients with acute cardiogenic pulmonary edema: A systematic review. Annals of Emergency Medicine. 48(3):260-269, 2006

FHonrubia T, Garcia Lopez FJ, Franco N: Noninvasive vs conventional mechanical ventilation in acute respiratory failure: a multicenter, randomized controlled trial. Chest 2005 Dec; 128(6): 3916-24

FKeenan SP, Sinuff T, Cook DJ: Does noninvasive positive pressure ventilation improve outcome in acute hypoxemic respiratory failure? A systematic review. Crit Care Med 2004 Dec; 32(12): 2516-23

FMasip J, Roque M, Sanchez B: Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta-analysis. JAMA 2005 Dec 28; 294(24): 3124-30

FKallio T, Kuisma M, et al. The use of prehospital continuous positive airway pressure treatment in presumed acute severe pulmonary edema. Prehosp Emerg Care 7:209-213, 2003.

FKosowsky J, Storrow A, Carleton S. Continuous and bilevel positive airway pressure in the treatment of acute cardiogenic pulmonary edema. Am J Emerg Med 18:91-95, 2000.

Dallas has been using CPAP for a while now, and have approximately 1000 CPAP uses per year. They estimate that they prevent approximately 300 intubations per year altogether. Calculating the cost difference between an intubated patient and a nonintubated patient, which is about $100,000, they estimate that they save the healthcare system $30M per year.

In our system in Ohio at least, most of the patients getting CPAP are non-payers, so it's a significant savings if they can avoid being tubed.

There is some literature calling into question the use of lasix in the prehospital environment. Acute CHF can be a difficult diagnosis to make without ancillary studies.

Of 144 patients given lasix by EMS, 42% did not have CHF, 17% had pneumonia, dehydration, or sepsis. Of the 9 patients who died without CHF, 7 got lasix. So by giving it, we are only potentially helping 58% of patients, and outright harming 17%. This has led several systems to pull lasix altogether.

Jaronik J, Mikkelson P, Fales W, Overton DT. Evaluation of prehospital use of furosemide in patients with respiratory distress. Prehosp Emerg Care. 2006 Apr-Jun;10(2):194-7.

'zilla

Yes, you can come. As long as you speak English.

Actually, it's in Dayton Ohio.

Which is not any closer to Austin.

We have several spots for free training at the National Center for Medical Readiness in our Aeromedical Evacuation Course. This 12 hour course is designed for the medical provider that may have to prepare patients for transport via air during a disaster. During large scale incidents, civilian and military medical assets will need to interface to evacuate large numbers of patients from an affected area. Not all patients, or equipment, will be suitable for air transport on military aircraft. This course grew out of feedback from providers after Hurricane Katrina that some patients were inadequately prepared or poorly selected for air evacuation. This course will cover preparation for air transport, specific hazards of air transport and altitude, limitations of the air medical environment and monitoring, and preparing patients at an aeromedical evacuation staging facility.

The course is being offered on the following dates: Jan 12-14, Jan 20-21, Mar 8-9. More dates to follow. Funding is provided by a grant through the University of Memphis.

EMS providers, nurses, respiratory therapists, physicians, and students in healthcare disciplines are welcome to attend.

www.medicalreadiness.org

www.calamityville.org

Like us on Facebook: Calamityville, and WSU-NCMR

'zilla

I am not so sure, medics of the 80s had to pass real ACLS, and had less technology to make decisions. As far as ROSC and being released from the hospital in a productive state, I am not sure the numbers have changed a whole lot. To me its is kind of like the new whiz kid from college who got an agricultural degree, battling the farmer who has farmed for 50 years.

Our experience locally after institution of therapeutic hypothermia is that for patients who are cooled after ROSC, we have a 39% rate of neurologically intact survival to hospital discharge. This is consistent with data from other areas, posting an overall out of hospital cardiac arrest survival rate of around17%.

'zilla

Obtaining her phone number and following up on her condition is NOT a HIPAA violation. We do this as a matter or routine in our hospitals here. The medic was a care provider for the patient, and therefore has a right to know her contact info. Follow-up calls are an important QA tool, as well as a customer service tool. If he is "just" calling her for a date, it's a HIPAA violation.

To the second point, we are in an ethical gray zone. The medical board has held that it is not illegal or unethical for a doctor to enter a personal relationship with a patient, so long as he clearly terminates the physician patient relationship, and this does not overlap with the personal relationship. If he continues to treat her medically, he will have his license suspended or revoked. If he trades prescriptions for sex, then he's never getting it back.

What about treating friends or family members? The medical board has taken the stance that it is not kosher except in emergencies or minor illness. In a small community, it may be difficult for the medic to not be the care provider if the patient calls 911. That said, effort should be made, for example having his partner care for her if feasible.

That said, I think he's a creep. If he never called any other patient but this one, he'd have a hard time successfully arguing the medical necessity of calling her, and I would hope the chief gives him the boot.

'zilla

Tough to say, since this was not a pattern of behavior.

Let's say for example that I tell an off color joke, which the listener finds objectionable. The listener informs me of such, and I apologize and never do it again. It's the first time it has happened. Should I be fired anyway? Reason would dictate not, but then again, reason often has little to do with the minds of HR when it comes to perceived inappropriate behavior.

'zilla

I would have to be convinced that the palpitations and nausea are in fact from some sort of arrhythmia. Any of the antiarrhythmics we would give in this case could potentially complicate the picture or worsen the arrhythmia. I would not give an antiarrhythmic in the prehospital setting for someone with palpitations and nausea. If the patient's pacemaker has an AICD function, this would make me even less likely to administer an antiarrhythmic drug. The history is complex enough (and complaint ongoing for long enough) that I am shying away from wanting to "fix" the problem right away. I know that's not the question you asked (which Bieber answered very intelligently), but the thread has strayed into treatment territory.

'zilla

I am not a fan of flumazenil for the reasons stated above. You can unmask seizures caused by other coingestants, or cause withdrawal seizures in the patient who is benzo-tolerant or addicted to alcohol. Your only therapeutic choices once they occur is putting them in a coma with propofol or pentobarb. I do not think flumazenil has a place in the prehospital or ED treatment of benzo overdose. The only scenario in which I would give it is a patient that is not taking benzos or a drinker, after being oversedated with versed during a procedure.

Benzo overdose is not terribly harmful so long as you can protect the airway and ensure oxygenation. For the benzo overdose that is hypoxic, hypoventilating, or lacks a gag reflex, I just intubate them and let the drugs wear off. It is safer in my mind than the "instant gratification" of reversing the OD with flumazenil and causing status epilepticus, which could be life threatening. Even if unresponsive, if they have a decent pulse ox and a gag, I'm not going to intubate them.

I was not on the call, and the only info I have is what you have described here, but I can't say that I agree with the use of air medical transport in this case unless the flight crew had the ability to manage the airway that you didn't. A helicopter transport is very expensive, not as safe as ground transport (due not only to aircraft mishaps, but the inability to assess the patient in flight due to noise and vibration). The question to ask is, what benefit will be conveyed to the patient by transporting to the "big city" hospital rather than the community hospital? In trauma, the decreased transport time is helpful but ONLY if the patient goes directly to the operating room, which is a tiny subset of trauma patients. In MI, there is a measurable decrease in survival for every 30 minutes that catheterization is delayed. In stroke, the time delay may mean the difference between thrombolytic therapy (or percutaneous neurointervention) or not. But the vast majority of other patients, even critically ill ones, will not see much of a benefit in arriving at the hospital that much sooner. In ALS systems, we have the ability to treat shock, fluid resuscitate, manage the airway, start pressors, treat arrhythmias, and relieve pain. Is there any reason, then, for the risk we put ourselves, the patient, and the commuting public at risk by rushing as fast as we possibly can to the hospital? We are encouraging dangerous behavior on the part of our EMS providers by doing so, and conveying great expense at the same time.

'zilla

U Pitt

12/7 is full. Some slots left for 12/8.

It's a one day class, we just offer it twice.

'zilla

It's a one day class, we just offer it twice.

'zilla

Registration opens on Nov 1.

Several new scenarios, changeup in the intro lecture, lots of stuff to tickle the brain and damage your calm.

'zilla

Im glad I saw this post. I am on the fence on if I want to go into the fire service or LE. I heard a blurb about a tactical medic on a SWAT team and it caught my attention for obvious reasons. If i chose to go into LE will having my EMT-B give me an advantage over other applicants?

It would only help if the LE agency gives a pay differential to EMTs, or provides some sort of EMS or first response, which few agencies do. It will not help you get onto SWAT. Without street experience, it's unlikely to help you at all.

'zilla

Fair winds and following seas, my friend. Rest in peace, for you have surely earned it.

'zilla

http://med.wright.edu/em/CAPLab

Planning is in full swing. Web registration will likely open toward the end of this month.

'zilla

Endometritis would be my #1 worrisome diagnosis in this patient. Typically occurs postpartum or post D&amp;C. Fever and cervical motion tenderness would more or less clinch the diagnosis. Admission, antibiotics, and close monitoring. These patients can get pretty sick.</p>

Regarding pain control, we generally advise mothers to stop breastfeeding for a couple of days. If she's been diligently pumping, she should have a supply of breast milk stored up, but at 4 days, probably doesn't. Unfortunately, there is some dogma out there about formula, which is mostly untrue. Breastfeeding confers some immunity that the formula doesn't, but millions of babies across the world are raised on formula without breastfeeding and do extremely well (my own daughter included, since she was adopted at birth). Formula is so expensive because it is highly engineered to meet the baby's needs, and does an outstanding job.

'zilla

I can't think of any reason that benzos would be contraindicated in that setting. You don't want to drop their pressure too much if their ICP is up, and snowing them with too much drug will confound the neuro exam, but both of these concerns are a distant second in the patient who is actively seizing.

'zilla

Is there a specific definition of 'massive' in the medical community Doc? Or is it an 'Oh shit...he's gonna need a ton of blood' call?

Not criticizing as I can't see a down side to this either. Or, is there a down side to using it on patients that won't require massive transfusions? Say, the medic that freaks out of a distal, isolated amputation.

Pretty cool find...

Dwayne

We generally define "massive transfusion" as needing 4 or more units of blood to correct hypotension or acidosis. We draw the line here with our current protocols, because this is when we will start giving FFP and platelets with the PRBCs to prevent coagulopathy.

We can predict need for massive transfusion if we give 2 units and the patient is still hypotensive. It is, to an extent, a judgment call in the early phase. Someone who is tachycardic and hypotensive at the outset (and doesn't have a tension pneumo or pericardial tamponade) is class 3 or 4 shock and has lost a liter and a half or more of blood. But I've seen a number of folks who are a little tachy but do fine after a couple of units of PRBCs and some Normosol and appropriate pain management. If the patient doesn't really respond to crystalloids at all, then they will not only need blood, but a lot of it.

I don't think we really know what would happen if we were giving this out like candy to patients. CRASH2 didn't see an increase in adverse events, but there was some selection bias with the study, large as it was. I don't foresee it being an issue if given through a line that will later receive blood, or in a different line while the patient is receiving blood. Would I push it through the same line that blood is currently running in? No, but I wouldn't push any drug through that line.

The Army has paid a lot of attention to the coagulopathy that presents with large scale hemorrhage and transfusion. We've played with different ratios of blood to FFP and platelets. In favor currently is the 1:1:1 ratio. There are trauma docs who now say not to give any crystalloid at all, and resuscitate only with blood products (whole blood if it is available). I think this is unrealistic in many prehospital settings, but I see their point overall.

The military is pushing it out at all surgical facilities, and is encouraging prehospital use among the more highly trained medics (SOF, primarily). Not sure if this will make it out to every 68W just yet.

The CRASH2 study did not find an increase in thrombotic events such as PE and DVT. Additionally, unlike Factor VII, there is actual evidence of benefit.

'zilla

Tranexamic acid has been approved for use in the Joint Theater Trauma System Clinical Practice Guidelines, including for prehospital use in patients expected to require massive transfusion. Civilian price is $9/dose, (military price about $1.50/dose) and it is shelf stable at room temperature. CPG is posted on the US Army Institute for Surgical Research website, and is attached here. I believe some civilian prehospital systems will follow suit in the future.

'zilla

Excerpt from August 2011 CPG:

Joint Theater Trauma System Clinical Practice Guideline

Guideline Only/Not a Substitute for Clinical Judgment

August 2011

Page 4 of 24 Damage Control Resuscitation At Level IIb/III Treatment Facilities

5. Tranexamic Acid

Tranexamic acid (TXA), an anti-fibrinolytic agent, has been used to decrease bleeding and

the need for blood transfusions in coronary artery bypass grafting (CABG), orthotopic liver

transplantation, hip and knee arthroplasty, and other surgical settings. A recent meta-analysis

reported that TXA is effective for preventing blood loss in surgery and reducing transfusion,

and was not associated with increased vascular occlusive events. 4 (For additional

information concerning TXA, see Appendix D).

The early use of TXA (i.e. as soon as possible after injury but ideally not later than 3 hours

post injury) should be strongly considered for any patient requiring blood products in the

treatment of combat-related hemorrhage and is most strongly advocated in patients judged

likely to require massive transfusion (e.g., significant injury and risk factors of massive

transfusion). It may be utilized in circumstances when in the judgment of the physician, a

casualty has life-threatening hemorrhagic injury and high potential for development of

coagulopathy or outright presence of coagulopathy. Use of TXA within 3 hours of injury is

associated with the greatest likelihood of clinical benefit. Initial use of TXA after 3 hours

post injury may have no benefit and may in fact worsen survival. Therefore it is strongly

recommended that TXA not be administered to patients when the time from injury is

known to be or suspected to be greater than 3 hours.

a. Considerations for Use

TXA (intravenous trade name: cyklokapron) is supplied in ampoules of 1000 mg in

10ml water for injection.

Infuse 1 gram of tranexamic acid in 100 ml of 0.9% NS over 10 minutes intravenously

in a separate IV line from any containing blood and blood products (more rapid

injection has been reported to cause hypotension). Hextend® should be avoided as a

carrier fluid.

Infuse a second 1-gram dose intravenously over 8 hours infused with 0.9% NS carrier.

There are presently no data from randomized controlled trials to support

administration of further doses to trauma patients. However, if a patient has received

the initial dosing of TXA and continues to show signs of ongoing hemorrhage, strong

consideration should be given to re-dosing the patient as above.

TXA may be administered to patients requiring MT even if they have an associated

TBI.

Joint Theater Trauma System Clinical Practice Guideline

Guideline Only/Not a Substitute for Clinical Judgment

August 2011

Page 5 of 24 Damage Control Resuscitation At Level IIb/III Treatment Facilities

In patients who continue to have life-threatening hemorrhage despite TXA use and

adequate 1:1:1 resuscitation, clinical judgment is warranted as to the use of additional

pro-coagulant agents such as rFVIIa.

b. Storage

Room temperature (15-30° Celsius / 59-86° Fahrenheit). Storage at temperatures great

than these may reduce or destroy the efficacy of TXA.

6. Recombinant Factor VIIa (rFVIIa)

Recombinant Factor VIIa (rFVIIa) has recently been associated with improved hemostasis

in combat casualties, decreasing blood loss by 23% (see Appendix C for more information

on the use of rFVIIa). The use of this product should be reserved for those patients likely to

require massive transfusion (e.g. significant injury and risk factors) and is at the discretion

of the treating physician. It should be the judgment of the provider that the casualty has a

life-threatening hemorrhage and coagulopathy.

1) Usual Dose: 100 mcg/kg intravenously; may be repeated in 20 minutes.

2) Contraindications: Active cardiac disease.

3) Storage: Refrigerate (2–8°C/36–46°F) prior to reconstitution and use. The FDA

recently approved a room temperature stable product. This will be distributed

throughout the USCENTCOM AOR as the current supplies are exhausted.

ETA: I included the FVIIa guidelines for reference as well, and expect we'll see a lot less Novoseven use now with TXA being approved.

Kiwi, in answer to your question, we order lots of expensive tests because an educated scientific wild ass guess often simply won't do. Patients don't read the book, and terrible disease often lurks with subtle symptoms. Add to the barriers to care in this country with fewer primary care doctors, insurance that is hardly affordable even if you have a job, and a safety net of the ER which has to catch all those with no place else to go.

I have to ask, and I do t mean to sound like I'm belittling, but where did you get your ideas about care in the American system? A lot of it sounds, frankly, like cliff notes written by a journalist, not those of someone who had worked or lived within the system.