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akroeze

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Posts posted by akroeze

    ACEi Angioedema

    in Patient Care

    Posted

    I've had a couple of cases of ACEi related angioedema. I have seen severe edema of the face and lips, but have yet to have one where the airway was in significant danger of being compromised. My suggestion is that if the person is presenting with S/S of upper airway compromise and you have a significant transport time to perform conscious sedation or RSI and place an ETT or supraglottic airway. But from what I've read, none of our toys tools for treating angioedema in a histamine or inflammatory reaction such as epinephrine, albuterol, or diphenhydramine will have an effect on bradykinin induced angioedema.

    Unfortunately in Ontario we do not do RSI nor do we do facilitated intubation (it is EXTREMELY frowned upon at least), and at least in my particular region Cric is no longer in my tool box. So essentially I have routine intubation with no sedation and topical lidocaine only as an option or blind nasotracheal.

    ACEi Angioedema

    in Patient Care

    Posted

    Just curious what your rationale is for not giving adrenaline. You said she has poor sats,

    Her sats were dropping but by no means poor. She had gone from 99% at onset to 93% when we were there. A relative drop of 6% but still not a worrying number on its own.

    any other ss/sx worth mentioning? pulse and BP? resp. rate? chest sounds? work of breathing? general appearance? rash? nausea/vomiting? altered conscious state? etc etc

    All V/S are appropriate with clear air entry and patient is resting comfortably.

    I guess what I'm getting at is what else are you waiting for? and what are your indications for giving adrenaline?

    Anaphylaxis, which this was definitely not. Although if we got into airway compromise you could argue that it is in that realm.

    That does bring up an interesting point... is angioedema from ACEi REALLY an allergic reaction? From the reading I have been doing it seems there is no consensus. The general impression I get though is that it isn't really as histamine is not involved. The "best guess" is that ACEi also inhibit the breakdown of bradykinin which builds up and causes the angioedema. So is this truly an allergic reaction? Do they fall into a medical directive that is for "allergic reactions"?

    The pt got 50mg PO of benadryl, remember all drugs thet go enteral are subject to first pass metabolism. The dose was also 3hrs ago. so really, as far as bloodserum levels are concerned, she is not "maxed out" as far as therapeutic index goes. In fact, she is probably below.

    I would give 50IV myself.

    I can see that argument.

    I would have no problem trialing a local epi via nebulizer to vasoconstrict and somewhat make her more comfortable.

    In all honesty the thought didn't even occur to me until post-call (and of course I would have to receive an order from my base hospital physician to do it).

    Also, getting a little epi into the system is always a good thing during allergic reactions with airway comprimise as it does in fact stabilize the MAST cell, therefore inhibiting the release of more histamine.

    Is Epi going to help angioedema? Epi helps edema in anaphylaxis (as far as I understand it) by "reversing" the fluid leakage into the interstitial tissue... is the same pathology present in angioedema? I honestly don't know.

    I also may hit her with a Dexamethosone, or prednisone. It will help with the swelling somewhat, but moreso, we will be one step ahead in case this does go for shit later.

    Yeah, totally agree there. Unfortunately steroids are not in my arsenal. Otherwise it is probably the most ideal option.

    • Like 1

    ACEi Angioedema

    in Patient Care

    Posted

    Recently had an elderly female patient from a nursing home who had developed tongue swelling in the am which was progressively worsening. She is on Coversyl. 3hrs prior to EMS the staff administered 50mg Diphenhydramine PO with no noticeable effect. EMS was summoned when patient's sats were starting to drop and she was having a hard time speaking due to the edema.

    Are there any pre-hospital treatments that are effective here? She has already had a therapeutic dose of Benadryl therefore giving more is probably not indicated. She is not in extremis (and is 97 and has a LONG cardiac history) therefore Epi is probably not a great choice at this time, at least IM. Is there any benefit to nebulized Epi here? What other medications may help this patient?

    Cheers

    • Like 1

    Strip Tease 3

    in Education and Training

    Posted

    To satisfy your curiosity - I am a fairly new medic with 1 year of experience. I run in a very high volume environment and in the year, I have about 1200 calls under my belt. I am scrambling as fast as I can to become a good street medic. The challenges of this position leave me exhausted. I personally run an AVERAGE of 20 calls in a 48 hour shift. Standup 48's (where we get little to no sleep at all) are not rare. I figure another year on the street, then whammo - more education.

    It just blows me away that that is legal. My usual 12hr shift is non-stop run run run go go go and I am exhausted at the end of it. I can't imagine effectively and safely doing it 4 times in a row.

    Strip Tease 13

    in Patient Care

    Posted

    Spenac, I don't know if I advocate a 15-lead on every patient. There are indications, which can be found on a 12-lead, for 15-leads.

    EMS_Cadet

    Where have you read that Mobitz 2 almost always originates in the bundle branches? Mobitz 2 is commonly an infranodal block, but of the his bundle above the bundle branches. .

    Click >>>THE ANSWER

    Your link is broken!

    Here is a working one:

    Click >>>THE ANSWER

    Intubation FAIL

    in Patient Care

    Posted

    On a somewhat related note, the other night I did my first intubation as an independently practicing ACP :D

    Got it on the first try in a cramped room where I was positioned more beside the patient than at the top of their head.

    Sorry, just wanted to congratulate myself :)

    Permissive Hypotension

    in Patient Care

    Posted · Edited by akroeze

    Well looks like in Ontario we are right in the middle of the pack as far as that goes.

    When the patient is symptomatically hypotensive/hypovolemic without signs of fluid overload on chest auscultation, and has a systolic BP<100 (or SBP<[2 x patient age + 70] in patient <40kg) the paramedic may:

    a. For patients >=40kg: Give an IV fluid bolus to a maximum of 20ml/kg. Repeat vitals and perform a chest auscultations after every 250cc. Return to KVO when bolus completed, SBP is >=100 or chest auscultation reveals crackles.

    b. For patients <40kg: Give an IV fluid bolus to a maximum of 20ml/kg. Repeat vitals and perform a chest auscultations after every 100cc. Return to KVO when bolus completed, SBP is >=(2 x patient age + 70) or chest auscultation reveals crackles. In patients <40kg with suspected diabetic ketoacidosis, give IV fluid boluses to a maximum of 10ml/kg.

    So basically we are trying to keep them at 100 systolic.

    Interestingly our post-arrest protocol calls for maintaining BP >90 systolic.

    First Responder

    in General EMS Discussion

    Posted

    I know for sure EMT-Bs can administer oxygen, place oral and nasal airways, as well as combitubes. Not sure what else.

    First responders can't?

    Here the 40hr FR course gets you:

    O2, Defib, OPA, NPA, Backboarding, KED, Traction Splint and Vital Signs (including BP) training

    Only thing they don't get that you mentioned is combitube

    Percussion Pacing?

    in General EMS Discussion

    Posted

    It works, I've done it. Although, I found that more force needed to be applied than the prescribed "let your fist drop onto pt's chest," making it more of a precordial thump, but aimed just left of the lower end of the sternum. I'd say I used moderate force with my hand 6-8" above pt chest, and it definitely produced perfusing pacing beats.

    Attached is a snippet of the strip. The difference in beats, seemed to be related to the force used.

    With percussion pacing, though, I imagine you would have to worry about R on T phenomenon, or commotio cordis...

    Do your protocols allow for it?

    What made you decide to do this rather than putting the pads on and electrically pacing?

    UK FAIL

    in EMS News

    Posted

    It is common practice here that if one gets a call for a priority transfer out of town very close to the end of shift then they will go about it as usual but if the oncoming crew gets to base in time they will bring the spare truck over and swap out with the offgoing crew. Never is transport delayed in order to facilitate this.

    Confusing Patient Presentation

    in Patient Care

    Posted

    We had this patient last week who presented with dizziness and loss of balance when standing. He also began complaining of pain in his upper and lower extremities and all 4 Qs of his abdomen. En route he also began experiencing CP. He had no history of MIs or CPs prior, his EKG and VS were all normal. But he did have lung cancer and was undergoing hemotherapy which he had just finished the previous week. Could that be the cause of all his symptomps?

    Short answer is yes, it could be the answer. One of many many many possible answers.

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