AZCEP

When the patient can hold, and use the device correctly, the MDI with spacer is a more effective method of drug delivery. It will produce a smaller droplet size that is absorbed faster than the same drug through an SVN.

The vagus nerve is still there, the effects of the system really aren't fully developed. So, when we do something to stimulate the vagus nerve, it will tend to overcompensate when it responds. The adult system is being used much more often, so the sudden release of Acetylcholine won't result in as large a reduction in sympathetic effects. The use of Atropine in the hospital is more related to the amount of time they are with the patient, than a indication of parasympathetic activity. When prehospital has a kiddo with a bradycardia, we focus on the more likely reasons they are bradycardic. Oxygenation issues come first, sympathetic next. If you are with this kid long enough, and have adequately oxygenated them, and supplemented their SNS with your epinephrine, and haven't gotten a response, trying some atropine might be worth taking a look at. If the PNS is having little to no effect anyway, then blocking it's action is not going to gain any great result. Kids are sympathetic driven. They need oxygen to allow the mitochondria to create more ATP. They need sugar to provide the fuel for the sympathetic system to burn. Atropine can be useful in specific situations, but for most, kids only need oxygen/epinephrine/sugar.

We carry a total of 6 unit doses of 2.5 mg each, along with 4 of 0.5 mg Atrovent Solu-Medrol Decadron as an alternative Epinephrine PVC

That situation sounds like it would fall into the "penetrating trauma, below the level of the suit." I'd be tempted to try it, if not for the extra time that it would take to apply to the patient in a "HOT" situation. Tourniquet, and rapid removal from the situation might be a more prudent strategy until better stabilization could be performed.

Up to age 6 years, the parasympathetic nervous system is poorly formed. From 6- about 10 years, the parasympathetic begins to have more effect on the cardiovascular system. Depending on the context in which you are considering using it, Atropine probably won't give any great response. For pre-intubation, Atropine is used to blunt the sudden increase in vagal tone created by manipulating the oropharynx. For bradycardia, the Vagus nerve is not having a direct effect unless it has somehow been stimulated through other means. Under 6 years, kids are purely sympathetic. Running, moving, growing, then energy supplies run out, and they go to sleep where they fall. Between 6 and 10, the parasympathetic is beginning to exert more influence. After 10, the systems are more like an adult.

Poison control is your friend. Ice to the site worsens the problem by focusing the venom at the site. Save a life, sacrifice a limb, not recommended by most. For BLS providers, keeping the site below the level of the heart, clearly marking the progression of edema, vital sign support as allowed, and ALS intercept. Once ALS is involved, pain relief, further vital sign support as needed, and transport. Some ALS providers are allowed to use antivenin, but this is a pretty rare situation.

Wait, wait, wait, I know this one. That's how much of them we want to pick up, right?

That's pretty comical, considering I just had one as well. Only mine was 60+, male, thin, no gas So much for the clinical indicators, eh :roll:

Good tip there, thanks Doc. I've only used the racemic epi in the most dire of situations. Peds with epiglottitis and adults with upper airway edema, and got good results from them. These patients were probably not going to be walking out of the ER anyway, but it is good to know they will be there a while.

PALS and PEPP are put out by the same people at the American Academy of Pediatrics so the information is nearly identical in regards to these medications. We do have the option of inline SVN treatments, but I've had better luck using it with the BVM, than down the ETT. Purely anectdotal, I realize, but that is my experience. Typically if a patient gets intubated before the breathing treatment, I will use IM/IV epi instead of down the tube. I suppose I could try an atomizer to deliver it into the lungs directly, but haven't had an opportunity present since we've gotten them.

Racemic epinephrine is well suited to stridor causing conditions like croup and epiglottitis, but there are better agents for asthma. If you've used a maximum dose of albuterol/atrovent and haven't gotten any results, you might consider IM epi rather than SVN.

If you look closely at the PALS/NRP guidelines they tell you in so many words to have reference material readily available, and to NOT rely on memory for the critical patient. The Broselow system provides for height specific equipment sizes that have been shown to not change significantly based on body mass or age. Knowing that you have the equipment at hand that you will need makes a tough situation that much easier to work through. The Broselow bag is not intended to carry medications, and they don't recommend IV fluids be regularly stored in them either.

I've had experiences on a nearby reservation of a similar ilk. These people would consume anything and everything in search of a "buzz". No beer, try mouthwash. No mouthwash, try rubbing alcohol. No rubbing alcohol, try Windex. No Windex, try Drano. It just gets sillier from there. Things like gasoline, lantern fuel, anything that has -hol in the ingredients list is up for grabs. Amazing really that more haven't been fatal.

Getting the student to consider alternatives to the treatments they want to perform is how you can teach this. When the suggestion of an unsafe treatment is made, and the student can't see the error, gives the evaluator an idea of how the student is integrating information. The difficulty breathing patient that gets treated with albuterol and NTG, the tachycardic patient that is treated with fluids and pressors. There are a number of different scenarios that could be used. I will commonly use the altered mental status scenario for this purpose. Just because there are so many possibilities, I don't have to have an endpoint set until the student starts giving options for treatment.

Critical thinking is what you use when the protocols fail to provide an answer for your situation. How many "62 year old male, fall between the toilet and the tub" protocols have you seen? Are you just going to grab the patient, and pull them to where you can apply a device that is in a protocol? Or will you think about how to limit pain, control the movement, and make the patient more comfortable while you are doing it?

In the setting of heart failure, you might use the drugs mentioned for severe bradycardia, or slow heart rate. The atropine would come first, and is in a purple box, but the drug itself is diluted in sterile water and has no color. The next step would probably be a transcutaneous pacemaker. If these were ineffective, you might consider using dopamine first, then moving to epinephrine. Dopamine is commonly in a bag of IV fluid that field providers don't have to mix. Epinephrine is in a brown box, or a dark brown multi-dose vial. Again, the drug itself doesn't have much color.

How do the injured get into the aircraft? I can see it being useful for resupply, but if you are picking wounded off the battlefield, how exactly are they supposed to get in and off the ground without drawing fire? Sounds interesting, if not half-baked.

As Rid and mike already said, there doesn't appear to be any delta waves in the leads provided. This does not mean they aren't there, they just aren't in the leads you are dealing with. I would also expect to see some degree of irregularity in the rhythm during the tachycardia with WPW. Most commonly it will be associated with an atrial ectopic rhythm, and that just doesn't present here. The use of Amiodarone would be reasonable if you have it available, but as you can see, it can slow the underlying rhythm down to much. At least they did not use a calcium channel, or beta-blocker for this patient. Those agents would have made things entirely too interesting. Procainamide would be a consideration, since you are able to measure the underlying QT interval. Lidocaine really won't do much to help if it is in fact WPW, but since we can't reliably use the information provided, it would be considered as well.

Nope, nope, nope. Don't buy it for a second. If the best strip you got was what you are showing here, then I have a hard time believing that anyone else got anything much better. There could be all types of different electrophysiologic changes going on, but from what is here WPW isn't one of them.

Are you referring to the polymorphism, or the changing amplitude of the ventricular complexes?

While actively ventilating, just enough to create chest rise. I will agree with vs though. Reference material ranges pretty widely. :roll:

I had a teenager take 50 mg/kg a few years ago. We didn't get notified until 14 hours after the fact, and following the N-AC treatment she did okay. Probably due to having a previously undamaged liver, though.

You mean there's something wrong with having a bootleg copy of "Star Wars"? Good stuff there!

I like the idea of having something HELP with the heaviest patients. I also like the idea of not having to lift anyone at all. Just as soon as the teleportation technology is available for public use, I'm all over it. Until then, put down the donuts and coffee, do some physical training that simulates your job function, and quit whining.

The way our pharmacist described it, the oral dosing of Mucomyst works better for Tylenol ingestions, than the nebulized route. Could be that was his experience, but I'd be in favor of either over neither with the number of APAP overdoses we see. Particularly with the uproar we cause by using charcoal for the same patient. Doctors just don't like having to double/triple the dose of the Mucomyst because we used it. I'll pick something else to argue about.