Unconscious Unknown Protocols

[ffpm41]

Check out this link, Dr, Bledsoe talks about the "coma cocktail" and how it has out lived it's usefulness in medicine along with ET drugs. He also wrote an article in the Nov 2002 JEMS on the "coma cocktail."

Dr. Bledsoe Handouts

Click on Prehospital Pharmacology.

Good Luck

[fireflymedic]

I had heard that they will be doing away with the "down the tube" method of drugs in a code due to the fact of unequal absorbtion, introducing fluid into the lungs, and general ineffectiveness. I heard that IO is more the way to go, and even heard mention of SQ as a possibility (I don't see why not, epi, lido are routinely done SQ in much smaller doses anyway, the person's gonna die anyway if you don't do anything, so why not give it a try?) Speaking of IO, anyone used the bone injection guns? I've not dealt with them, but curious as to those that have used them how they like them. Also, I know sternum and tibia are approved sites, but in my last PEPP class (taken Nov last year) the comment was made that the humerus, femur, and pelvis could be acceptable sites as well. I could understand the humerus and femur, but I would think the pelvis would have to be more carefully placed and slightly more difficult to stabilize....just a thought.

[fireflymedic]

FFPM41

The handouts from Dr. Bledsoe were great. Really does a good job of explaining stuff basically. Flumazenil was taken off our "coma cocktail" two years ago and now is only indicated if we know for SURE that is what the person took. Even then, it is done upon consult with med control due to the possible negative side effects. Where in the problem with that lies is your seizure patients who take valium, ativan, etc as an abortive medication, decide to try to committ suicide and take them all. Flumazenil just opens a whole can of worms that's just nasty to deal with. I'd rather have it dealt with in an ER than I would the back of my truck. More people, more resources. Are there actually services which still have this in their protocols (oops GUIDELINES ?)

[Dustdevil]

Unfortunately, what Spock sees in his local system is still pretty darn common in this country. And the current trend towards giving advanced skills to basics with a month of night school will only perpetuate the long outdated theory of cookbook protocols such as the so-called "coma cocktail." I remember when it became all the rage in the mid 1980's. I remember very progressive systems adopting such protocol as the holy grail and in fact mandating it be followed to the letter, just as Fire_911 suggested. If you decided to give D[sub:da04ab7df6]50[/sub:da04ab7df6] and not Narcan and Thiamine, or any combination thereof, they would question your competency and threaten to decertify you as an idiot.

I'd love to think that we have outgrown such lunacy as a profession. But the sad truth is, it still flourishes and will continue to do so in many parts of the country for years to come. And if your system still insists on such "protocols," your system sucks! Either your MD is an idiot, or he simply doesn't trust you because he thinks you are idiots. Either way, I would be looking for a better place to work.

[Ridryder 911]

I agree that is part of the problem of EMS and medics in general. We as have yet matured to be autonomous. When I see medics reply" I'll do what my protocol says and medical director says!" I think of little trained chimpanzees, or wonderful, faithful animal awaiting the next command and treat for a job well done.

I do understand the need in following policies, and can be frustrating, especially when it not so much the wrong treatment, rather not the most appropriate treatment.

I agree, I have not worked under strict "protocols" but once & then I quit, I have always been sure that they were included "medics discretion and were worded as guidelines"...

R/r 911

[Nate]

I once stood in line at triage while a paramedic from another service informed the doctor that he gave Thiamine because the patient was drunk. EMS is funny.

[zippyRN]

Flumazenil in a coma cocktail !!!!!!!

it's licenced (in the UK at least) for iatrogenic benzo OD only.

TOXBase tells UK providers not to give flumazenil unless you can totally rule out ingestion of anything other than Benzo's - even then it;s outside the licence for the drug - gets fun when you give it to someon who has taking say a tricyclic OD and you can't stop thefits ....

coma cocktails are a joke

give hypertonic glucose if the patient is hypo - fine

give narcan if there is strong evidence of opiate use

thiamine is not carried pre-hospital in the uk but it;s not unknown for some o f the chronic alchol users to end up gettign a 'yellow meanie' ( pabrinex - vits B+C) in their IV bag in hospital

[ffpm41]

One reason to drink in Europe?

Fortified booze.

[vs-eh?]

I read "coma cocktail".

I read flumazenil.

I read the same person who still has romazicon on the vehicle avilable to them and had it in a "coma cocktail" up until recently, say this...

...and even heard mention of SQ as a possibility (I don't see why not, epi, lido are routinely done SQ in much smaller doses anyway, the person's gonna die anyway if you don't do anything, so why not give it a try?).

Ummmmm...Think about that statement for a sec and think about basic pharmacokinetics. Now think about how those factors may be influenced in a cardiac arrest. I would like to see where you "heard" that SQ may be an option in an arrest. Drugs via ETT (while not very effective, if at all) at least have a somewhat predictable absorption and distribution. Where is one of the first places blood is shunted from during a shock state? Let alone cardiac arrest...

This "why not give it a try" attitude seems to be permeating this board recently.

PS - Not picking on fire_911medic, just some observations...

[fireflymedic]

VS-eh,

I appreciate your insight, but let me clarify a few things. First, I mentioned we took romazicon off our 'coma cocktail' two years ago. I wouldn't truly consider that a fairly recent change. It is still on our trucks, but ONLY if we are for sure that is what the person took, and on consult with med control. As I said before, due to the possible effects which can occur due to administration of it, I wouldn't give it unless I was 100% sure, and even still I would prefer it be given in the ER. Second, I stated that SQ was being discussed as a possibility, not that it was set in stone. Some of the docs at the local hospital were discussing the topic and were talking with us about it (we are fortunate to have docs that will talk with us, not disregard us as many do). They had the discussion in effect to a question I had asked following a code where we had a difficult time gaining IV access due to the patient's previous drug use causing poor veins. I had asked if epi would have a systemic type effect if given SQ in a cardiac arrest, or if it would have any effect. Was curious about this due to the systemic effects which occur when given SQ for allergic reactions. Lido though has a more localized reaction, so I would wonder about it. I know two different ballgames, but was on my mind. The doc was the one that made the statement, "why not". As I mentioned earlier, I am here to learn, I think you learn every day and if I can learn something that may benefit a patient one day, I'm open to the idea. I guess I should have been more clear in my statement, rather than making it sound as though it came from published literature. I'm sorry for the confusion there. However, I have seen strong support for the IO (just only if we could get them to run faster....ones I've dealt with were patent, but still ran slow-perhaps placement was an issue there?) I also mentioned that we are getting ready to revise our protocols, so there may be significant changes which are about to happen. I too have questioned the effectiveness of ETT meds, but I agree at least there was good efficacy behind attempting to deliver meds that way. I hope this clarified things a little better for you. Thanks again for the input.