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.

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.

Ketamine 

• Creates a state of dissociation from reality.  
• Catecholamines (epinephrine & norepinephrine) are released.  
• Spinal reflexes are reduced.

• Indicated for anesthesia when cardiovascular depression must be avoided.  
• A commonly used induction agent to facilitate endotracheal intubation.

• Oral: Pediatric 6 - 10 mg/kg
• Intramuscular: 3 - 8 mg/kg
• Intravenous: Pediatric 0.5 - 2 mg/kg, Adult 1 - 4.5 mg/kg

I posted this article over at http://www.lifeunderthelights.com/ a few days ago and I thought it would good for here as well. I'm sorry that I've only rarely posted here, but I read this blog quite often and recommend it to all of my peers. Enjoy

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A few years ago I responded to a structure fire on the main engine out of my station. The fire was at a house that had been converted to a dog kennel and grooming shop just a few blocks away from the firehouse and was a short response time. It was a light-staffing day and we responded as a three person engine company. As the senior firefighter I was the acting company officer and my new girlfriend at the time, who just happens to be my wife now, was the backseat firefighter. Get ready for the “Awwww” moment… it was our first fire “as a couple”. There was a number of cool things that came out of the fire, but one of them was the fact that Gina grabbed *my* maul.

On our main engine, there’s an 8-pound maul (big hammer) that I grab as my tool of choice every time I jump off the truck for a fire. It just tucks so neatly in my SCBA’s belt and is so compact yet handy that I make a beeline for it every time. This time, Gina had taken it, so I grabbed a pick-head axe.

It’s amazing when I have my maul how every access problem looks like something that I can solve by whacking it with a hammer of some sort. On this fire, I learned that when one has an axe, every problem looks like it can be solved by some sort of chopping.

Moral of the story, Gina and I entered the structure, saved the pooches, and stopped the fire in its trucks with minimal damage. There’s actually a hilarious video that I believe is still on our department’s web site that I’d let you see if I didn’t hide the name of the department(s) I work for due to reasons of wanting to remain employed.

And, like a lot of posts I write, I told you that so I could tell you this about an EMS call I responded to an indeterminate amount of time ago. I have the honor and privilege to be the senior medic on most shifts I work and I precept a lot of students on the ambulance. This shift was no different and this 0-dark-30 call illustrates a point that I’d like to explain to you.

For this call, the primary ambulance out of our station responded because they were on the way back from another call and my partner and I responded in our ambulance because we were up on the alternating call rotation. They arrived at the poorly-accessible apartment complex a few minutes before we did and made first patient contact. As it turns out, the middle age patient had ran out of his/her prescription Lasix (a potent diuretic, or water pill) a week or so prior to the call and had been retaining a great deal of excess bodily fluid. The patient’s legs were markedly and grossly swollen and weeping fluid out of fluid filled blisters. The Patient called us because he/she could no longer stand the pain of the cellulitis (infection) that had developed. The patient had no respiratory compromise, his/her lungs were clear, and he/she really had no other complaints. The patient had an extensive medical history of organ failure and disease. He/she was fully alert and oriented, and was able to assist us as we simply picked him/her up and carried him/her to the cot.

As we were loading the patient up in the ambulance and I was about to get into the back to continue my assessment and treatment of the patient, the EMT from the other ambulance who happens to be an almost-done Paramedic student told me, “So those legs are the worst I’ve ever seen fluid wise, you’re going to push some lasix on this one”. I mumbled something and got into the truck. I was tired and wasn’t really able to form complete sentences at the time due to sleep deprivation. I continued my assessment where I found that the frail patient had a blood pressure in the 70 systolic range (Low!) and that in addition to retaining fluid in his/her legs, he/she was also retaining fluid in his/her abdomen and was probably in need of a paracentesis. I managed the patient with a (beautifully executed, I must say) IV stick into an impossibly small and crooked vein, and gave just enough fluid to bring his/her BP up a bit without adding to his/her fluid overload all that much. I put the Pt on oxygen and a cardiac monitor, which revealed a normal sinus rhythm without ectopy and obtained a 12-lead EKG as well, which was not indicative of any acute problems. The patient stated that his/her pain was managed by padding and positioning of his/her swollen legs and even though he/she complained of no breathing problems, I put him/her on a bit of oxygen via nasal cannula.

The transport was uneventful, although his/her blood pressure never did come up. The ER later diagnosed the Pt with complete liver failure and toxicity.

But the interesting part of the story is this, when I got back the medic student asked me about giving IV lasix to the patient, as we carry that in our medication stock and have it available as an emergency diuretic for patients in congestive heart failure and/or fluid overload with pulmonary edema and respiratory compromise. He was almost taken aback when I said that I didn’t give any.

I asked him if he did a full assessment. He said that he had tried… but that he didn’t have enough time before I arrived and we took the patient out to the ambulance. I gave him my assessment findings and the news of the very low blood pressure. He said that he agreed with me on not giving the lasix with the markedly low blood pressure but was curious when I explained that it wasn’t the reason I didn’t give the medication.

We in EMS, and especially new providers carry our own hammers… our treatments and medications that we’re able to give in the field. Medics that use these treatments more often are called “aggressive” and it is a badge of honor. In fact, in some cases, aggressive field treatment is indeed warranted and improves patient outcomes. However, in a lot of cases it is not indicated and patients benefit from what we don’t do more so than from what we could have done.

This patient didn’t have any respiratory compromise and while he/she obviously could have benefited from the dieresis or removal of the excess fluid, she didn’t meet the criteria for emergent field administration of lasix, which is respiratory compromise from pulmonary edema. I made the decision to let the physician evaluate the patient and determine the best treatment path that would fit in with the patient’s ultimate plan of care. I didn’t believe that the patient would ultimately benefit from my administration of lasix twenty minutes earlier than the ER could have done it if the physician so chose.

Every treatment we administer must be given with a full assessment of the risks and benefits to the patient for doing so. Every EMS person should familiarize themselves with the long-term care paths of the conditions we treat and try to maximize the long-term benefit to the patient with the acute and short-term care we give. Not every problem is “a nail” and sometimes the hammers we carry aren’t the best ultimate solution for excellent patient care. Remembering how we as EMS people fit into the grand scheme of the overall healthcare system and in the ultimate care paths of our patients will help us all to do what we’re supposed to do, which is to provide excellent and appropriate patient care.

It is also of note, I guess, that Gina rarely steals my maul anymore. Now that we’re married… I “give it freely” to her.. What’s mine is her’s, as they say.

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The original post has some pictures of the fire and of the doggies that my wife and I saved on our first "Fire Date" - It can be seen HERE

As a new member of Paramedicine 101, I'll be quick with the introductions: I'm an EMT-Paramedic in North Carolina and have been in EMS just long enough to have never recertified. I'll save you the trouble of looking up NC's recertification schedule to let you know I'm green! Recently I was on a call in which a patient choked on a piece of cabbage. The patient was able to clear the foreign body airway obstruction on their own, but continued to have the sensation of choking. Our site MD recommended the administration of 1 mg Glucagon slow IVP in order to alleviate the discomfort. The only alternative usage I had been aware of was for β-blocker overdose.

After this call I found I could not escape these alternative usages of Glucagon! Sitting at the station one night I read a passage in Galvagno's Emergency Pathophysiology where he noted Glucagon could be administered in refractory anaphylaxis, and at that point my mind had been blown enough that I decided it merited an entire article. The structure of this article and the dosages are based on an excellent article by Charles Pollack: Utility of Glucagon in the Emergency Department with a host of support from interesting journal articles. Many of the uses Pollack gives are omitted as they have dubious applications in the field. So sit back and enjoy some well known and not so well known indications for the administration of Glucagon!

• Hypoglycemia
• Symptomatic bradycardia secondary to β-blocker overdose
• Symptomatic bradycardia secondary to Ca-channel blocker overdose

• Steakhouse syndrome
• Refractory anaphylaxis
• Severe asthma (little support)
• Refractory CHF (little support)

• Hypoglycemia: Adults: 1 mg SQ, IM, IV; 2 mg IN. Peds: 0.5 mg SQ, IM, IV; 1 mg IN. Neonates: 50 mcg/kg SQ, IV. (should accompany glucose resuscitation)
• Symptomatic bradycardia secondary to β-blocker overdose: 10 mg IV bolus, 1-5 mg/hr maintenance infusion. (should supplement standard treatment)
• Symptomatic bradycardia secondary to Ca-channel blocker overdose: 2-10 mg IV bolus; consider maintenance infusion. (should supplement standard treatment)
• Steakhouse syndrome: 1 mg SQ, IM, IV, may repeat.
• Refractory anaphylaxis: 1 mg IV q 5 min; consider 3-5 mg IV; consider maintenance infusion. (should supplement standard treatment)
• Severe asthma: 1-2 mg IV; 1-2 mg nebulized. (paucity of literature to support this use)
• Refractory CHF: 0.01-0.05 mg/kg IV bolus, 1-3 mg/hr maintenance infusion. (paucity of literature to support this use)

• Pollock CV: Utility of Glucagon in the Emergency Department. J Emerg Med 1993; 11: 195-205.
• Rosenfalck AM, et al: Nasal glucagon in the treatment of hypoglycaemia in type 1 (insulin-dependent) diabetic patients. Diabetes Research and Clinical Practice 1992; 17: 43-50.
• Love JN, Howell JM: Glucagon Therapy in the Treatment of Symptomatic Bradycardia. Ann Emerg Med January 1997; 29:181-183.
• American Heart Association. Part 7.3: Management of Symptomatic Bradycardia and Tachycardia. Circulation 2005; 112; IV-67-IV-77.
• Stadler J, et al: The "steakhouse syndrome". Primary and definitive diagnosis and therapy. Surg Endosc 1989; 3(4):195-8.
• Glauser J, et al: Intravenous Glucagon in the Management of Esophageal Food Obstruction. JACEP June 1979; 8: 228-231.
• Handal KA, Riordan WM, Siese J: The lower esophagus and glucagon. Ann Emerg Med November 1980; 9: 577-579.
• Galvagno, Samuel M. (2003). Emergency Pathophysiology: Clinical Applications for Prehospital Care (pp. 195-200). Jackson, Wyoming: Teton NewMedia.
• Lieberman MD, et al: The diagnosis and management of anaphylaxis: An updated practice parameter. J Allergy Clin Immunol 115 (2005); 3: S483-S523.
• Gavalas M, Sadana A, Metcalf S: Guidelines for the management of anaphylaxis in the emergency department. J Accid Emerg Med 1998; 15: 96-98.
• Compton J: Use of glucagon in intractable allergic reactions and as an alternative to epinephrine: An interesting case review. J Emerg Nurs 1997; 23: 45-7.
• Wilson JE, Nelson RN: Glucagon as a Therapeutic Agent in the Treatment of Asthma. J Emerg Med 1990; 8: 127-130.
• Melanson SW, Bofante G, Heller MB: Nebulized Glucagon in the Treatment of Bronchospasm in Asthmatic Patients. Am J Emerg Med 1998; 16: 272-275.
• Marik PE, Varon J, Fromm R: The Management of Acute Severe Asthma. J Emerg Med 2002; 23: 257-268.

Here is a case where you need to think and act outside the traditional area of your education.

A 68 year old female patient with osteoarthritis was discharged from the hospital following surgery for a proximal fractured femur, at the greater trochanter. The patient's physician ordered 5 mg of coumadin P.O. daily four days ago. The patient was not sure if she took her medication one day, so she took twice the amount the next day. And then took twice the amount the day after that. Her daughter, a nursing administrator by trade, arrived to check on her mother, and after questioning her mother's ability to self medicate appropriately, counted the tablets and found three missing, and assumed her mother took them. Instead of calling her mother's physician, she calls an ambulance.

You respond and find the patient laying in bed, alert and oriented with vitals all withing normal limits.

1. Why was this patient prescribed coumadin and what is the normal dosage range? What are the pharmacodynamics of this medication?

2. What are the possible consequences of the patient taking too much Coumadin?

3. What should you assess for or warn the patient about since she has taken a large dose of the medication?

4. What do you need to teach the patient regarding her medication, especially in regards to missing a dose or managing her medications at home?

5. What labs should the patient's physician be monitoring? What will be the therapeutic range?

6. Does this patient need to go to the hospital? If not, what assessment findings would warrant an ED visit? If so, what laboratory values will the hospital check? Is there anyone you should call for advice or is this an automatic transfer to an ED? If the patient needs seen or stat lab work, is the ED the only option for this patient?

I have been procrastinating on approaching this topic. I will start off by reviewing a study that assesses pain management before and after continued education. The results are pretty interesting. I know this a subject of particular interest to Rogue Medic, so don't be surprised if he chimes in with some added opinionated criticism information.

INTRODUCTION: Pain is a common symptom evaluated by emergency medical services (EMS) providers. Hospital pain management programs began in the early 1990s based on a multidisciplinary approach and principles of total quality improvement. To date, these programs have had limited exposure in the prehospital setting. OBJECTIVES: To evaluate the effects of a pain management educational intervention (EI) for paramedic caregivers. METHODS: All ambulance providers from ten urban and suburban fire departments and two private ambulance companies participated in a three-hour EI during a quality improvement project. A survey was performed prior to the EI and repeated one month after the EI. A two-month collection of EMS runs for pain complaints was performed prior to the EI and repeated one month after the EI. Data analysis was performed using descriptive statistics and chi-square tests. RESULTS: The authors reviewed 397 surveys and 439 EMS runs for pain. Overall, after the EI, paramedics' knowledge of basic pain management principles increased from 57.3% to 74.9% (17.5%; 95% confidence interval (CI): 14.9%-20.2%;) paramedics' utilization of nonpharmacologic pain therapies improved by 32.2% (95% CI: 25.3%-39.2%; p), but there was no significant change in the use of pain medication (20.2% to 24.5%). There were 51.0% (95% CI: 44.1%-57.9%; p) improvement in documentation of pain severity, 24% (95% CI: 21.2%-26.8%;) improvement in documentation of pain characteristics, and 13% (95% CI: 7.4%-18.7%;)improvement in pain reassessment following intervention. CONCLUSION: As a result of a three-hour educational intervention, paramedics had an increased understanding of pain principles, were more likely to provide prehospital nonpharmacologic pain therapy, and were more likely to document the results of their interventions.

2 x 7 x 6 gtts
min.

Answer: 30 gtts/min. (1gtt/2sec.)

DD x Wt x SS

C x T

In this part I am going to go over drug concentrations. This is a vital part of your drug calculation.

Becoming an educator was one of the most eye-opening experiences I have had since I first started in EMS. Remembering what it was like being a student, and stripping away all my experience was a pretty hard task. Since I have started teaching I have noticed some trends. I am hoping to provide another resource of education for the prehospital clinician. Where better to start than the areas I see the most people struggle.