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At my part time job teaching, Nitrous oxide is now in the AEMT scope. I know that in the 70's, 80's through the early 90's it was popular in some rural parts of the country and in the New England area but I honestly havent heard hardly anything about it in the past 20 years. I have heard its hard to even get FDA approved regulators for EMS anymore. I have two questions:

1- Does anyone out there have a NO specific skills sheet for credentialling this?

2- Is anyone planning on doing this? Is anyone currently doing this?

3- What are your lessons learned that might be useful for an educator who is unfamilier with this modality (other than personal use at the dentist).


Many Thanks

Steve

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Entonox is widely used in Canadian EMS as it is the only analgesic we have at the PCP (BLS) level. I don't have a "Skills Checklist" type page for Entonox, we check it off using the standard Medication Admin checklist. Here is the Drug Monograph we give to students.

Classification: Analgesic

Supplied: Compressed Gas Cylinder

Actions: An analgesic to reduce pain. Inhalation of a mixture of 50% Nitrous Oxide and Oxygen produces central nervous system depression as well as rapid pain relief.

Route: Inhalation

Dosage: Self-administered. As the patient becomes drowsy, the mask will drop away from the patient's face. Administration is patient controlled until pain is relieved.

Indications

1) Chest Pain

2) Musculoskeletal trauma

3 )Burns

4) Other conditions (labour pain, etc)

Contraindications

1) Inability to ventilate enclosed treatment area

2) Inability of the patient to comply with administration instructions

3) Suspected inhalation injury

4) Suspected air embolism or pneumothorax

5) Decompression sickness

6) Pt has taken Nitroglycerin in past 5 minutes

Cautions

1) Abdominal distension

2) Shock

3) Hx of COPD

4) Major facial trauma

5) Pt on depressant drugs

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When i had it, the information we were given was that in cold weather the two gasses would seperate in the cylinder, but anecdotally i would say (after providing more than just anaglesia on a couple of occasions) that the cylinder sitting for any period of time lets it seperate, so i always made a point of shaking it up before any use, not just cold weather

CPR said the thing about self administration.

I have never seen it on a side effects sheet but my experience is that many people devlope a thumping headache, similar to post GTN

Decompression sickness and bowel obstruction were a contra for us - never bothered to look up the bowel obstruction one.

You need both the demand valve with face mask and that little whistle thing atachment as well for it to be flexible enough to work in most situations

Edited by BushyFromOz

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We use it at BLS level (and above). With methoxyflurane and paracetamol being the only other pain relievers at a BLS level. We use it with a filter and mouthpiece, although you can also attach it to the same mask you'd use with BVM if required. From our clinical guidelines:

Preparation: 50% NOS and 50% O2

Mechanism of action: Unclear but causes analgesia via CNS

Indications: Moderate to severe pain

Contraindications: Unable to obey commands, suspected pneumothorax, suspected bowel obstruction, SCUBA diving within last 24 hours, or has diving related emergency

Relative Contras: Repeated use is associated with psychological dependence. bone marrow supression and neurological disorders. Patients with chronic pain syndromes who call an ambulance frequently are at high risk of developing adverse effects from repeated entonox administration and should be avoided in these patients.

Onset: 2-5min

Duration: 2-5min after stopped administration

Common Adverse Effects: Sedation, euphoria, nausea, metallic taste, auditory disturbances

Interactions: Increased effect when used with other analgesics or sedatives

Notes: NOS expands gas filled spaces in the body, hence its many contras. Not contraindicated in patients with chest injuries but is if pneumothorax suspected. It should be discontinued if associated with worsening respiratory distress in chest injury patients. Not contraindicated for abdo pain but is for suspected bowel obstruction which most commonly presents with vomiting and abdominal discomfort. Abdominal distension and reduced frequency of bowel motions or passing of gas may be present.

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The only service I know of in the area I used to work at that carried it was Johnson County Med-Act. Contact Bill Toon there. I don't know the number but you can google it or go to www.jocoems.org

He's one of their educational guys.

Capn.

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The only service I know of in the area I used to work at that carried it was Johnson County Med-Act. Contact Bill Toon there. I don't know the number but you can google it or go to www.jocoems.org

He's one of their educational guys.

Capn.

Really. Does med act still use it in johnson county?

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In the Emergency Department we use it quiet frequently to lightly sedate some paediatric patients for suturing and plaster application. While I can’t provide you with specific pre hospital care information we run off what the Royal Children’s Hospital in Melbourne recommend and are assessed by our paediatric clinical nurse specialist against their assessment sheet which is in the link below.

http://www.rch.org.au/uploadedFiles/Main/Content/comfortkids/Porter_nitrous_oxide.pdf

http://www.rch.org.au/clinicalguide/guideline_index/Nitrous_Oxide_Oxygen_Mix/

http://www.rch.org.au/uploadedFiles/Main/Content/mcpc/Procedural_Sedation_nitrous_oxide__theory_.pdf#xml=http://ww2.rch.org.au/cgi-bin/texis/webinator/search/pdfhi.txt?query=Nitrous+Oxide&pr=ektron-ext&prox=page&rorder=500&rprox=500&rdfreq=500&rwfreq=500&rlead=500&rdepth=0&sufs=0&order=r&cq=&id=51ec50905d

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Really. Does med act still use it in johnson county?

Thats why I posted what I remembered and gave the info for the OP to contact Med Act. I haven't worked there for a while so I was unsure.

Edited by Captain ToHellWithItAll

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We used to carry 50% nitrous on the trucks but the maintenance and possibility of abuse got to be to much so we took it off. That was about the same time we added fentanyl to our drug boxes so the nitrous seemed to be extraneous.

I pretty much stopped using nitrous in the operating room 5-6 years ago as did most of the people in my department. The downside (nausea and vomiting) seemed to outweigh the benefit. Nitrous does have a place in some systems but not in ours.

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