AZCEP

Now, let's take a step sideways and think about how Amiodarone will do what it says it does. As the rate of electrolyte movement increases the degree of block of the sodium channels increases. This is the beta-blocking effect, which will work on the stimulus formation in the SA node, and the conduction through the AV node This is the part of the program where the potassium is trying to move back into the cells, because of the prolonged phase 3 of the action potential, the potassium can take longer to move in, although it is not directly blocked from doing so. At the same time, the sodium is trying to move out of the cell. Because of the sodium channel blockade mentioned, the sodium will try to find other ways out. The potassium channel fills this need nicely, and the action becomes a physiologic block. This is caused by the increased use of the calcium channel by the smaller potassium ion. Because the potassium channel is blocked by the outward movement of the sodium, the potassium tries to find another route into the cell. Since the calcium channel is much larger than the potassium, the potassium ion will try to move in through it. With the changes in the pathways for the electrolytes to enter/exit the cell, the conduction of the impulses is also slowed down. The vasodilatory effects are really hit and miss. Some patients are very sensitive to them, and some don't respond at all to this effect. This property is related to the Class II anti-dysrhythmic properties noted above.

This is perfect timing Ace! Paramedic students, running through a number of departments, spouting what they know from the textbook, only to be shot down by a "clinical impression" from seasoned medics. We have all had this type of scene. Glucometer, ECG, SpO2, Capnography, NIBP, all telling us information that just doesn't fit with what the patient looks like. When the number doesn't match what the patient looks like, which do we trust? Our tendency is to believe the monitor, because that is what we were told by the service rep of the device. It is reliable, we can trust it, or can we? I like the use of the word CONFIRM in the article. When H & P tells you one thing, and the technology tells you the same, slam dunk. aussiephil, one question: How is treating anything possible without first deciding what the problem is, or diagnosing it?

It becomes a matter of thinking through the problem. Will every patient need an opitate, maybe not. Would it perhaps make long term management easier, maybe so. The use of the opiates is truly a "consideration", not an absolute. I'm not willing to advocate that every patient needs them, and should get them. I'm also not willing to say that no patients should be given the benefits of them. Tachycardia, HTN, decreased response to the sedative of choice, should all play into your decision making. Using a little Morphine/Fentanyl might make a lower total dose of Versed/Etomidate/Ativan/Diprivan possible. Good points to think about in the mean time.

Amiodarone got placed in class III due to it's major effect, which is K+ channel blockade. It also has class I-Na+ channel blocking, class II-beta blocking, and class IV-Ca++ channel blocking properties. Because it does all of these things, in varying degrees depending on the patient, they had to put it somewhere. From http://www.rxlist.com/cgi/generic4/cordarone_iv_cp.htm : Amiodarone is generally considered a class III antiarrhythmic drug, but it possesses electrophysiologic characteristics of all four Vaughan Williams classes. Like class I drugs, amiodarone blocks sodium channels at rapid pacing frequencies, and like class II drugs, it exerts a noncompetitive antisympathetic action. One of its main effects, with prolonged administration, is to lengthen the cardiac action potential, a class III effect. The negative chronotropic effect of amiodarone in nodal tissues is similar to the effect of class IV drugs. In addition to blocking sodium channels, amiodarone blocks myocardial potassium channels, which contributes to slowing of conduction and prolongation of refractoriness. The antisympathetic action and the block of calcium and potassium channels are responsible for the negative dromotropic effects on the sinus node and for the slowing of conduction and prolongation of refractoriness in the atrioventricular (AV) node. Its vasodilatory action can decrease cardiac workload and consequently myocardial oxygen consumption. Also on the administration side: Admixture Incompatibility Cordarone I.V. in D5W is incompatible with the drugs shown below. Y-SITE INJECTION INCOMPATIBILITY Drug Vehicle Amiodarone Concentration Comments Aminophylline D5W 4 mg/mL Precipitate Cefamandole Nafate D5W 4 mg/mL Precipitate Cefazolin Sodium D5W 4 mg/mL Precipitate Mezlocillin Sodium D5W 4 mg/mL Precipitate Heparin Sodium D5W Precipitate Sodium Bicarbonate D5W 3 mg/mL Precipitate So because it will precipitate with the sodium containing solutions, perhaps that is why it is recommended to use D5W to mix instead of NS.

Most of the time, we don't have the extra help needed to hold the semi-sick kiddoes still enough to get the line secured before they rip it out. If the kid tolerates it, fine, if not I will go without one. Knowing that when they go out, I can get one isn't really a good fall-back, but often that is what it comes down to.

Look for some of the vehicle extrication sites. www.extrication.com has some good information in this direction Each manufacturer also has submitted the safety information to the DOT, for report to rescue departments. Worse comes to worse, you can always spend an afternoon crawling aroung the carlot to find these things out on actual cars.

Yeah, okay, I think we understand more clearly now.

For Amiodarone specifically, because of it's actions as a sodium channel blocker, you wouldn't really want to use NS to mix it. The bigger issue is the container. Amiodarone will leach some of the material out of a standard IV bag/tubing. None of the solutions are absolutely recommended over any other one. You would probably need to find out from your medical control why one and not the other.

Google is your friend. www.hybridcars.com

Morse Code is still in use as a repeater identifier by the FCC. It doesn't have any utility as a way to communicate information person-to-person. Not enough interest in maintaining the skill, and the technology has moved well beyond it.

Between the differences in education and available facilities, this may well be an apples to oranges comparison. We tend to have more PCI capable facilities with medical directors that would prefer a delay to definitive care, than to extend the education that is already in place.

Old School?

Let me add: Education is a mix of the time you spent in class and the experience you have yet to receive. Use the experiences of your peers to speed your own ascension to the top of your game. No matter how much time in class, how much time in the field, how many procedures you have under your belt, somewhere, sometime, you will have a patient that you are not prepared for. Understand this happens to everyone. You will not be the first, and it is an experience you have to go through, often on your own. Your response to this will help to determine where you stand in the grand scheme of prehospital care. If it happens early in your career, you will be tempted to find something else to do. If it takes a little while, you will be better prepared, and it will be much easier to handle. Learn to use the "old guys" for the support you need. They may not be entirely enthusiastic about pumping you up, but rest assured, they have all been through the same problems you are going through. They understand what you are dealing with like no one else can. Unless you act like a complete idiot, they will want you to succeed. If for no other reason, they won't have to work as much, if you do succeed.

Ugly situation all around. Almost sounds like someone is in bed with AMR to allow this to happen. Destroy the current provider, AMR comes in with a low-bid, and looks like a hero. Unfotunate, but not unheard of. Sounds like a similar situation to the one in Louisville.

Some of the clues had to be there, right? Existing debt, capital needs, and other financial difficulties? Is that manager speak for I need a new car/office/house, but this agency doesn't bring in enough money to let me buy them? Sounds like this has been going on a while. It is just now reaching a point of no return. Good luck to you.

Let's get the National Scope of Practice together, so that we know better how to educate the providers that will have to meet it. This could probably go the other way, as well, but I like to know what the goal of an educational program is before I try to put one together. All of those are good suggestions, but I went with the NSOP.

Job #1 AS Fire Science, typical fire chief in the area Job #2 MSN, Head of the Education Department. It's contract work, so I'm not sure if it would qualify. If I don't like how things are going, I can leave real easy. Job #3 BSN, ER Department Manger If mangagment doesn't understand how to use their resources, then the educational level doesn't really mean much. No matter how many plaques you have on the wall, employees want to know that you have their best interests at heart. If EMS is to advance though, the department management needs to elevate with everything else. EDUCATION, EDUCATION, EDUCATION. Even more important than location.

What size does a 6.0 mm convert to in French? Isn't a 36 Fr the biggest NPA available for most places? This patient's family now has their name on a sign in front of the hospital I'd wager. Still, that is one impressive Cx Xray. :shock:

This is a good time to use the Activated Charcoal. As long as the patient is not unconscious, 1 gm/kg should do nicely. Secure an airway, supportive care, large IV to support blood pressure/perfusion status, transport to one of those places with all of the doctors...

Find yourself an airway manequin and practice the modified jaw thrust. It, like most patient care techniques, takes a little practice to get good at it. You will quickly realize that it is much more difficult to perform than the head tilt-chin lift. I'm not sure I've ever heard of using an NPA for flushing the eyes. The nasal cannula is right handy for this purpose, but the NPA would seem to put too much volume into the face. OPA's are great for a BLS airway, providing the patient has no gag. If they do they tend to want to show you what they had for lunch. Instantly making airway management questionable at best.

Come on now. There is too much good information here to let this thread die. Someone out there knows the differences between them, and how they will present So I re-submit: PIH, PreEclampsia, Eclampsia

I think the question was more as a consequence of other treatment, if we could intitiate contractions. I doubt the FL_Medic was intending to walk into a scene and push some Vasopressin so he could deliver a baby. God, I hope that was the direction he was going. :shock: Naw, the question was directed somewhere else.

Students teach things all the time. See the "Things you didn't know until you had kids" thread for proof. It is a reasonable question based on the pathophysiology, but it looks like you stopped a bit short in thinking it through. No problem there. The willingness to ask the question is the most important thing you need to have. Otherwise, you tend to think you are always right, in how you are thinking. I just don't believe I've ever seen anyone with similar questions. Very impressive for a new provider.

The steps are clearly indicated, but I'm willing to discuss them a bit further. 1. Prepare equipment/personnel/patient: Get the tools out, including back up devices. Assign roles for each provider. Place the patient in an optimal position for the procedure 2. Preoxygenate: Non-rebreather at 15 lpm for at least 5 minutes, more if possible. You are trying to eliminate the residual nitrogen, and build a degree of oxygen reserve 3. Premedicate: This is where your question lies. L-O-A-D Lidocaine-1.5 mg/kg Opioid-Fentanyl is preferred, Morphine would be acceptable but has some negative side effects. Atropine-Primarily for kids Defasiculation-If you have Roc or Vec available, now's the time to use a bit. This step should happen 3-5 minutes prior to administration of the paralytic 4. Paralyze: Succinylcholine/Etomidate go in. Wait 40-50 seconds before you put the blade in the mouth 5. Protect: Cricoid pressure until tube is secured in place 6. Placement of the ETT 7. Post Intubation Management: Verify tube placement, Secure tube, Attach monitoring devices, Release cricoid pressure In step 3, the Lidocaine can be deleted unless there are signs of head injury or excess sympathetic response (Tight Head/Tight Lungs). The opioid is used to blunt some of the sympathetic response. Fentanyl has less cardiovascular effects than Morphine. Atropine is mandatory for kids under 10 years, or for repeated Succinylcholine dosing. The Defasiculation dose is 10% of the paralyzing dose. I hope I got all of the steps. It's been a while since I've had to write them down.

You sit in the station dreaming this stuff up, don't you? :? Not exactly a situation that is likely to occur, but what the heck, I'll bite. Vasopressin and Pitocin are both Pituitary hormones. When the signals to release one occur, in large enough volumes, the other can be released as well. As endogenous hormones this may be a factor to consider. As exogenous administrated medications, the chances are greatly reduced. One factor would be the Vasopressin's half-life, and the amount of time that it took to accomplish a ROSC. Another would be the fact that when hormones are introduced from outside the body, the healthy gland will limit the release of anymore of the involved hormone. The negative feedback mechanism accomplishes this. Possible? Sure. Probable? No. You would probably need to administer an inordinately large amount, shortly before ROSC to get the response you describe.