WE ARE MOVING...
Paramedicine 101 is joining up with EMSblogs.com.
We will be moving to www.Paramedicine101.com.
It is still a work in progress right now, but don't hesitate to head over to the new site, because that is where all the new posts will end up.
Thank you for your loyalty as a reader. I hope this doesn't inconvenience you at all.
- Adam Thompson, EMT-P
Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study – abstract
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I have moved Rogue Medic to EMS Blogs. Also posted over at Rogue Medic and at Research Blogging.
Go check out the rest of what is available at EMS Blogs and at Research Blogging.
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Over at 510 Medic, there is an interesting abstract of a new article on treatment of tension pneumothorax. Frequency of Inadequate Needle Decompression in the Prehospital Setting.
CONCLUSIONS: In this study, 26% of patients who received needle thoracostomy in the prehospital setting for a suspected PTX appeared not to have had a PTX originally, nor had 1 induced by the needle thoracostomy. It may be prudent to evaluate such patients with bedside ultrasound instead of automatically converting all needle thoracostomies to tube thoracostomies.[1]
I have not read the full text.
510 Medic makes some important points and asks some good questions. Then 510 Medic asks -
So if we subscribe to the goal of “first do no harm” and those 15 patients didn’t have a pneumothorax induced by the procedure, is their discomfort worth proper treatment for the remaining 42 patients?[2]
I think that there is a more important question.
Should we assume that the presence of a pneumothorax is an indication for needle decompression?
A pneumothorax is not the same as a tension pneumothorax. Even the definition of a tension pneumothorax is not easy to agree on. I tend to treat with opioids what many others would treat with needle decompression. I have not had any of these patients deteriorate, while in my care. They received chest tubes in the trauma center.
Should we assume that the presence of a pneumothorax is an indication for needle decompression?
57 patients with a prehospital diagnosis of tension pneumothorax. Yes, EMS does diagnose, but that is a discussion for elsewhere. Yes, these patients were diagnosed by EMS with tension pneumothorax, unless we are suspecting acupuncture, because what other prehospital indication is there for sticking a needle into a patient's chest?
Out of 57 patients diagnosed with tension pneumothorax, only 42 patients had a pneumothorax.
How many patients had a tension pneumothorax at the time the needle was stuck into the chest wall?
How many of those patients would have been better off if treated with something other than a needle?
How many complications were there from the needle decompression?
Am I wrong to use italics to highlight the word decompression, since so many of the patients did not have anything to decompress?
We rush to perform procedures that we have little experience with. Isn't this a situation likely to lead to misdiagnosis?
Isn't the infrequent use of needle decompression for suspected tension pneumothorax likely to lead to operator error?
The actual occurrence of tension pneumothorax appears to be much less frequent than the prehospital diagnosis of tension pneumothorax. Isn't that an indication of a failure to properly educate medics?
Footnotes:
[1] Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study.
Blaivas M.
J Ultrasound Med. 2010 Sep;29(9):1285-9.
PMID: 20733183 [PubMed - in process]
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[2] Frequency of Inadequate Needle Decompression in the Prehospital Setting
510 Medic
Article
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Research: Prehospital Pain Management
Check this out...
I'm not sure why IV Fentanyl wasn't compared to Morphine, but the study is interesting none-the-less.
Prehosp Emerg Care. 2010 Oct-Dec;14(4):439-47. [Pubmed]
Effectiveness of morphine, fentanyl, and methoxyflurane in the prehospital setting.
Middleton PM, Simpson PM, Sinclair G, Dobbins TA, Math B, Bendall JC.
Abstract
Abstract Objective. To compare the effectiveness of intravenous (IV) morphine, intranasal (IN) fentanyl, and inhaled methoxyflurane when administered by paramedics to patients with moderate to severe pain. Methods. We conducted a retrospective comparative study of adult patients with moderate to severe pain treated by paramedics from the Ambulance Service of New South Wales who received IV morphine, IN fentanyl, or inhaled methoxyflurane either alone or in combination between January 1, 2004, and November 30, 2006. We used multivariate logistic regression to analyze data extracted from a clinical database containing routinely entered information from patient health care records. The primary outcome measure was effective analgesia, defined as a reduction in pain severity of >/=30% of initial pain score using an 11-point verbal numeric rating scale (VNRS-11). Results. The study population comprised 52,046 patients aged between 16 and 100 years with VNRS-11 scores of >/=5. All analgesic agents were effective in the majority of patients (81.8%, 80.0%, and 59.1% for morphine, fentanyl, and methoxyflurane, respectively). There was very strong evidence that methoxyflurane was inferior to both morphine and fentanyl (p < 0.0001). There was strong evidence that morphine was more effective than fentanyl (p = 0.002). There was no evidence that combination analgesia was better than either fentanyl or morphine alone. Conclusion. Inhaled methoxyflurane, IN fentanyl, and IV morphine are all effective analgesic agents in the out-of-hospital setting. Morphine and fentanyl are significantly more effective analgesic agents than methoxyflurane. Morphine appears to be more effective than IN fentanyl; however, the benefit of IV morphine may be offset to some degree by the ability to administer IN fentanyl without the need for IV access.
Pain management is one of those things commonly under done by paramedics. I believe common reasons for this lack of treatment include laziness, apathy, and disbelief. Paramedics don't want to do the added paperwork that goes with administering a controlled substance. They may not care too much about the pain that their patient is in, and are much more concerned about life-threatening conditions. Finally, the existence of drug seekers most-definitely decreases the amount of pain meds administered prehospitally. Whatever the reason, it isn't a good one. If your patient complains of pain, it should be treated. An ice pack or positioning may be enough for some, while heavy doses of potent narcotics may be required for others. We have the tools, now lets use them.
I have added the Wong-Baker 'faces' pain scale here to remind you of how to judge your pediatric patient's pain. The old one through ten severity scale is suffice for adults.
Learn It: Angioedema
Angioedema
Sometimes referred to as Quinke's Edema, angioedema is that swelling we see that is most apparent around the mucosal areas of the face. Consider Hives as swelling on the surface of the skin, and angioedema as swelling beneath the skin.
The most common cause of this type of swelling without the presence of Hives is hypersensitivity to ACE inhibitors.
ACE = Angiotensin converting enzyme. This converts angiotensin one into angiotensin two.
ACE inhibitors block ACE.
Bradykinin is a peptide that has a role with all forms of angioedema. It is a potent vasodilator that increases permeability and allows the accumulation of fluid within the interstitial space.
ACE is one of the main ways that bradykinin is degraded. So when we inhibit the production of ACE, we are then inhibiting the degradation of bradykinin. We then have this run away peptide and subsequent swelling.
Many patients that suddenly present with severe angioedema have been taking ACE inhibitors, such as lisinopril, for a long period of time. They may have never had any issues before, but out of no where have this severe reaction. This type of reaction is most common in the African-American population, but may occur in anyone.
There are other types of angioedema, including the traditional allergic reaction. Those are more well known and prepared for.
Treatment
As you can see from the pictures above, swelling may be within the oropharynx. This can cause an airway obstruction, and aggressive airway management should be advocated.
This patients may be obtunded and snoring as you enter the scene. They have been confused for diabetics, or acute coronary syndrome patients due to their initial impression.
It is common for these patients to undergo cricothyrotomy due to complete glottic obstruction. Moving quickly is imperative to prevent severe hypoxia and cardiorespiratory arrest.
The usual drugs used for anaphylactic reactions are indicated.
- Epinephrine to reduce the vasodilation.
- Crticosteroids & antihistamines.
So the next time you run on a patient that is presenting with swelling in the absence of hives, think angioedema, and act fast!
Fire & EMS Blogger Warning: Righthaven Lawsuits
Also posted at Star of Life Law.
Fellow Fire and EMS bloggers, if you have not heard of Righthaven, LLC, you might be soon. In the name of a federal copyright lawsuit. Here is what you need to know:
1. Righthaven, LLC is a Las Vegas company established to sue bloggers who clip news content. Most newspapers firmly request bloggers or aggregators take down infringing content and link back to the paper. By comparison, Righthaven goes directly to suing, without any request to take down.
2. Righthaven has issued more than 100 lawsuits since its inception. See Righthaven Victims. See also Righthaven Lawsuits.
3. Righthaven's first client was Nevada-based Stephens Media. The Las Vegas Review Journal is Stephens’ flagship.
4. Righthaven has just struck a deal with Arkansas-based WEHCO Media to expand its copyright litigation campaign, in which bloggers and aggregators across the country are being sued on allegations of infringement. WEHCO controls 28 papers, including the Arkansas Democrat-Gazette in Little Rock, and 13 cable stations largely in the south.
5. Go here for a complete list of Righthaven-owned domains and newspapers.
6. Go here for a Firefox add-on that will prevent you from accessing Righthaven-owned content.
7. From Clayton Cramer, The Armed Citizen, a Righthaven lawsuit victim:
"For those who think that this could be settled out of court cheaply: think again. Other defendants who have approached Righthaven without a lawyer to settle this matter have been told variously, "$7500" or "low five figures" for a single newspaper article infringement."
8. Here is some guidance on how to properly cite news articles on your blog. Post the headline of the story and then the first paragraph with a link to the original story. Like this:
Jogger was listening to iPod when plane hit him, coroner says
The (Hilton Head) Island Packet
Tuesday, Mar. 16, 2010
A Georgia man was running and listening to his iPod on the beach on Hilton Head Island when he was killed by an airplane that made an emergency landing Monday near Palmetto Dunes, the Beaufort County Coroner's Office said today.
The rest of the article can be viewed by clicking here.
Hat tip to Ryan Giles.
9. Police your site. Remove or update potentially infringing posts. Properly cite and link to news sources.
10. If you are a Fire/EMS blogger and get served with a Righthaven lawsuit, feel free to email me.
Drug Shortages Affect Those Still in the Dark Ages – Furosemide
I have moved Rogue Medic to EMS Blogs. Also posted over at Rogue Medic and at Research Blogging.
Go check out the rest of what is available at EMS Blogs and at Research Blogging.
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In the current JEMS, there is an embarrassing article. Drug Shortage Possible in N.Y.
It seems that the drugs that people are worried about are lidocaine, furosemide, 50% dextrose, and epinephrine 1:10,000 preloaded syringes. Here, I will discuss furosemide.
Furosemide is not appropriate for EMS patients, because there are more appropriate drugs, more appropriate other treatments, and it is too often given to patients who have pneumonia.
MANAGEMENT OF APE
Fluid accumulation in the lungs associated with APE, until recently, was attributed to excess accumulation of total body fluid. Accordingly, treatment of APE was aimed at removing excess fluid from the lungs by promoting massive diuresis. However, this explanation for APE could not reconcile the fact that APE typically occurs during early morning hours when fluid intake is minimal. The current explanation is that APE results from fluid redistribution within the body whereby a part of the intravascular volume is redistributed to the lungs as a consequence of increased intravascular pressure as outlined above.13 Primary objectives for the treatment of acute CHF are to reduce pulmonary capillary pressure, to redistribute pulmonary fluid, and to improve forward flow.12,13 These may be achieved by reducing LV preload and afterload, providing ventilatory and inotropic supports, and identifying and treating the underlying etiology of the syndrome (Table 3). It should be recognized that these treatment measures are intended for APE patients who are normotensive or hypertensive and not those who are hypotensive. The latter comprises cardiogenic shock secondary to severe LV systolic dysfunction; treatment of these critically ill patients is beyond the scope of this review.[1]
That is a big paragraph, but there is a lot of information in there. Enough to convince us that we should not be using furosemide to treat an acute onset/exacerbation of heart failure.
In the chart below, before furosemide in treatment there are plenty of other treatments. Notice that only oxygen comes before NTG (NiTroGlycerine) and the more severe the symptoms, the more NTG is given.
Mild symptoms - One 0.4 mg NTG spray/tab - repeated every 4 to 5 minutes.
Moderate symptoms - High-dose NTG, which is explained below.
Severe symptoms - Two to five 0.4 mg sprays/tabs at a time - repeated every 3 to 5 minutes.
But, but, but, but, but, . . . . . we can only give a maximum of 3 NTG - ever.
Then you need to get a better medical director, because your medical director has you killing patients.
Am I being too subtle?
Another treatment that is very effective is CPAP (Continuous Positive Airway Pressure) which is a BLS (Basic Life Support) skill, except where medical directors like to kill patients. When using CPAP (a form of NIPPV - Non-Invasive Positive Pressure Ventilation), NTG paste can be applied. Do not be shy with the paste, because nothing is absorbed well through the skin when the skin is pale. Pale means a lack of circulation. Also, since the appropriate dose is much more than standard NTG dosing, there is not much reason to hold back.
I disagree about the placement of CPAP at the bottom. CPAP should be started right away. This was published in 2003, so it is kind of old and conservative.
You call that NTG use conservative?!?!?
I do. I have given dozens of NTG in a period of 10 to 20 minutes and never had a patient experience any adverse effects while in my care or at the hospital. I have written elsewhere about the superstitious way we approach NTG.
Furosemide is in there, but only if the patient has peripheral edema. If there is no peripheral edema, is fluid overload the problem? That is a fluid redistribution problem. There is fluid in the wrong place, but that does not mean that the whole body is overloaded with fluid or that putting a bunch of fluid in the bladder is going to make things better. Moving fluid to the bladder does not mean that we are removing it from the lungs any more than we are removing fluid from anywhere else.
Click on the chart to make it bigger. I know I can't read any of it at this size. This is from the same paper as the paragraph above.
Well, that is just one paper. Nobody else would be so irresponsible as to recommend such large doses of NTG.
Then let's read about what they do in the ED (Emergency Department).
Most patients who experience CPE, however, do not have ECG evidence of an acute dysrhythmia or AMI. Treatment should therefore be aimed at redistributing the excessive pulmonary interstitial fluid into the systemic circulation, which improves alveolar oxygen-carbon dioxide exchange and hypoxia; therefore, pharmacologic agents that provide preload reduction and afterload reduction should be administered. In some cases, inotropic support is required also.[2]
What drugs do we use to provide preload reduction and afterload reduction?
Nitroglycerin
The most effective and rapidly-acting preload-reducing medication is nitroglycerin (NTG) [21–25]. Multiple studies have demonstrated the superiority of NTG over furosemide [21,24,26–28] and morphine sulfate [28–30] for preload reduction, symptomatic improvement, and safety. NTG can be administered in sublingual, IV, or transdermal form, although the transdermal absorption can be erratic in the patient in extremis. NTG also has the benefit of a short half-life; therefore, if the patient develops a precipitous fall in blood pressure (generally uncommon in CPE {Cardiogenic Pulmonary Edema} patients), the blood pressure should return to previous values within 5 to 10 minutes of discontinuation of administration.[2]
But what about the dose?
In one study [26], 3 mg IV boluses of NTG were administered every 5 minutes to patients who had developed CPE, a dose equivalent to a 600 mg/min infusion. This protocol was found to be safe, well-tolerated, and effective for these patients and associated with reduced need for mechanical ventilation and more rapid resolution of symptoms. Standard anti-anginal dosages of sublingual NTG with which most physicians are comfortable (ie, 400 µg every 5 minutes), has the bioequivalence of an IV NTG infusion of 60 to 80 µg/min. Physicians should, therefore, be comfortable with the safety of even higher dosages of NTG for patients who experience CPE and usually present in a hyper-adrenergic state with moderately-to-severely elevated blood pressures.[2]
That is 7 1/2 times to 10 times the standard dose of NTG - with no problems.
Maybe that maximum of 3 NTG is something that should be ignored. The AHA (American Heart Association) seems to be ignoring it. Just try to find a limit on NTG administration in the current ACLS, which is from 2005.
These papers are available in PDF format, so you can print them out and hand them to your medical director and/or to the other doctors in the ED.
These are important papers. Both are review articles. One is written for EMS, while the other is written for the ED.
If you are feeling aggressive, maybe you can write on the bottom, Call me about improving the protocols we use to treat our patients.
There is one problem with this. This will lead to fewer intubations.
The best intubation is the intubation that is prevented by excellent patient care.
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Footnotes:
[1] Prehospital therapy for acute congestive heart failure: state of the art.
Mosesso VN Jr, Dunford J, Blackwell T, Griswell JK.
Prehosp Emerg Care. 2003 Jan-Mar;7(1):13-23. Review.
PMID: 12540139 [PubMed - indexed for MEDLINE]
Free Full Text PDF
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[2] Modern management of cardiogenic pulmonary edema.
Mattu A, Martinez JP, Kelly BS.
Emerg Med Clin North Am. 2005 Nov;23(4):1105-25. Review.
PMID: 16199340 [PubMed - indexed for MEDLINE]
Free Full Text PDF
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EMS Educast Episode 67
Greg Friese from EMS Educast invited me to guest cohost on episode 67. On the show was David Page from the St. Paul EMS Academy.
Make sure to go check it out.
Thanks for stopping by,
Adam Thompson, EMT-P
Drug Shortages Affect Those Still in the Dark Ages – Lidocaine
I have moved Rogue Medic to EMS Blogs. Also posted over at Rogue Medic and at Research Blogging.
Go check out the rest of what is available at EMS Blogs and at Research Blogging.
-
In the current JEMS, there is an embarrassing article. Drug Shortage Possible in N.Y.
It seems that the drugs that people are worried about are lidocaine, furosemide, 50% dextrose, and epinephrine 1:10,000 preloaded syringes. Here, I will discuss lidocaine.
Lidocaine is not appropriate for EMS patients, because there are more appropriate drugs. Lidocaine is still used for cardiac arrest, even though there is absolutely no reason to believe that it does anything positive for the patient.
There is no evidence that any antiarrhythmic drug given routinely during human cardiac arrest increases survival to hospital discharge. Amiodarone, however, has been shown to increase short-term survival to hospital admission when compared with placebo or lidocaine.[1]
In other words, amiodarone doesn't work, but lidocaine is even worse.
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Lidocaine is also used for ventricular tachycardia
with similar lack of effect.Lidocaine terminated ventricular tachycardia in four of 31 patients, ajmaline in 19 of 30 patients (P<0.001).[2]
Lidocaine is no better than holding the patients hand or any other placebo. Spontaneous remission of ventricular tachycardia should occur in more than 4 out of 31 patients.
DC shock was used in 16 nonresponders (22.9%) to procainamide and 10 non-responders (50%) to lidocaine.[3]
Only 35% of patients improved after lidocaine. Maybe they improved because of lidocaine - maybe not. More important is that 50% of patients who received lidocaine ended up being cardioverted. Did they require cardioversion because of the lidocaine?
Would you recommend a drug that leads to half of patients being cardioverted?
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Footnotes:
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[1] Medications for Arrest Rhythms
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.2: Management of Cardiac Arrest
Free Full Text
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[2] Electrophysiological and haemodynamic effects of lidocaine and ajmaline in the management of sustained ventricular tachycardia.
Manz M, Mletzko R, Jung W, Lüderitz B.
Eur Heart J. 1992 Aug;13(8):1123-8.
PMID: 1505562 [PubMed - indexed for MEDLINE]
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[3] Efficacy of procainamide and lidocaine in terminating sustained monomorphic ventricular tachycardia.
Komura S, Chinushi M, Furushima H, Hosaka Y, Izumi D, Iijima K, Watanabe H, Yagihara N, Aizawa Y.
Circ J. 2010;74(5):864-9. Epub 2010 Mar 26.
PMID: 20339190 [PubMed - indexed for MEDLINE]
Free Full Text PDF
Table 3 is from this paper. As you can see, lidocaine is a joke compared to procainamide.
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Church of the Blog O Sphere: EMS Garage Episode 99
Also posted over at Rogue Medic. I have moved to EMS Blogs. Go check out the rest of what is there.
On the most recent EMS Garage - Church of the Blog O Sphere: EMS Garage Episode 99, we spent a bit of time discussing how to persuade people that we should change things and how we can determine what is the truth.
Listen to the show.
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