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
WE ARE MOVING...
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!
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