Doczilla

I have heard of it in the setting of rescue therapy that diabetics can self-administer at home (or a family member can administer) for drops in BGL. I haven't really heard of it much around here in EMS, so I went back to the literature. A Pubmed check revealed some small pharmacokinetic studies that show it may be of benefit (though the form and dosage of the glucagon varies) both in adults and children. Two studies suggested that IN glucagon did not produce as "sustained" a blood sugar level as IM, but one study said the volunteers didn't have as much nausea. All the studies were on healthy volunteers or diabetics, and some had hypoglycemia induced with insulin beforehand. I didn't see any studies on glucagon in emergency patients. The literature on it isn't awe-inspiring, but it makes logical sense. I don't see any harm in it, since glucagon is already a recognized treatment for hypoglycemia, and it may be of benefit. 'zilla

For spitters, the non-rebreather oxygen mask can always be medically justified, and would never be called into question as being appropriate. Surgical mask is not really medically justified, but is harmless as an intervention (it's DESIGNED for people to breathe through it), and may be just as feasible. Pillowcase is probably a bad idea. A full pillow with both hands over it: don't go there, though we've all thought of it. Agitation and combativeness are signs of a medical emergency, whether induced by substances (EtOH, cocaine, meth...) or by a medical problem (hypoxia, hypoglycemia, metabolic derangement, head trauma) or by psychiatric disease. Agitated delirium is closely associated with in-custody death. Agitation and combativeness are in themselves a medical emergency, and I am a believer in liberal use of medication (benzos, particularly) to treat the condition. I believe the risks associated with the agitation, increased HR and BP, accidental or purposeful self-injury, and sustained physical activity outweigh the risks of the medication. Settling them down with some versed or valium may also permit a more complete medical evaluation and continuous monitoring. Of course, getting a blood glucose level and oxygen saturation and neurological exam are absolutely necessary. I have also paralyzed and intubated a number of folks in the ER to gain control and allow a medical exam. Refer to local protocols before trying this. 'zilla

Drugs that are feasible to be given IN in the prehospital environment: versed (midazolam) valium, though only in concentrated form fentanyl morphine narcan ketamine Ativan has relatively inconsistent absorption through mucous membranes, though a pharmacokinetic study of IN ativan looked favorable. Epi is only given IN for local vasoconstriction, such as for a refractory nosebleed or in preparation for a procedure like nasal intubation or NG placement. Lidocaine is only given IN for local anesthetic effect. Neither epi nor lido are absorbed from the nasal mucosa in sufficient quantities to be systemically effective (say, in cardiac arrest), though systemic effects are uncommonly but sometimes seen. Haldol is not yet in widespread use, but there is a tiny pharmacokinetic study, so we may see this sometime in the future if further studies pan out. Note that the drug has to be a concentrated form, or it will simply run down the back of the throat as liquid rather than clinging to the nasal mucosa and absorbing. 'zilla

All emergency medicine residency programs have an EMS requirement (mandated by the RRC so a program confers board eligibility), which is usually fulfilled by EMS ride time. 'zilla

I am glad that the CDC is investigating, and that so far they haven't linked a cause of death to the vaccine. A lot of parents who suffer a tragedy such as the loss of a child will want to pinpoint a cause, especially when none is immediately evident on autopsy. It may seem that this recent vaccination is a likely target. As ER Doc says, proximity does not mean causality. Unfortunately, it might take a lot to get this out of the collective consciousness. That whole vaccine-autism thing is still a misconception that many parents have, propagated by the internet, that many hang onto despite excellent well-designed multi-center trials disproving any link. The patient having an "anaphylactic" reaction several days after the Gardasil shot? Not bloody likely. The implications of the marketing of this thing are brilliant: a vaccine against a cancer, the silent part of it being that it is caused by a sexually transmitted virus that can be prevented through protected sex. We can make our daughters "one less" by giving them a shot without bringing up the ugly discussion of :shock: birth control and safe sex. It's the ultimate redirect to avoid an uncomfortable conversation. 'zilla

I don't think it's beneficial in cardiac arrest if you are giving epi IV or down the tube. We give puffs of albuterol and combivent inline with the ventilator circuit in intubated ICU patients for COPD, pneumonia, pulmonary inflammation, asthma, etc. You can hear wheezes in intubated patients. There is the "silent chest" syndrome wherein you will not hear any wheezes, if they are so tight that they aren't moving air at all. 'zilla

That definition is incomplete at best, and incorrect in areas. All the men will be crossing their legs now... A fractured testis or ruptured testicle is defined by rupture of the tunica albuginea and extrusion of the testicular contents. You can have a fractured liver, fractured spleen, or fractured penis. Frequently these gain the term "fracture" because of their gross appearance. A fractured spleen looks grossly (and on CT) like a solid rock that is cracked or broken into pieces. Same thing with the fractured liver. Fractured testicle looks like a broken rock on ultrasound, with hypoechoic hematoma in the middle of the parts that are separated. Fractured penis looks grossly like a broken arm or leg. Fractured testis, from emedicine: 'zilla

Yes, it's possible. And painful, too. 'zilla

Glucagon takes a significant amount of time (45 min) to raise the BGL, and depends on adequate glycogen stores to begin with. It will maintain BGL levels longer than just D50, which can get metabolized very quickly after administration. Don't use this as a reason to give all hypoglycemics glucagon. It's expensive and carries significant risk. Standard of care is still D50 followed by a high-carbohydrate meal. Patients who have taken insulin or oral antihypoglycemics may have a BGL drop after administration of the D50. Folks with sepsis may also metabolize the glucose quickly. This is why it is very important to STAY with the patient and watch them eat and ALWAYS recheck the BGL before you get that refusal signed. Patients who are on oral agents only or long acting insulin (Lantus) or who take an OD (intentional or accidental) of oral agents must be taken to the ER and are frequently admitted. Always transport these patients. I have documented drops in BGL on these folks 6 and 8 hours after they took the meds, despite being fed and appearing fine upon initial assessment. I don't screw with these folks any more, and rarely get any push back from the admitting services for it. 'zilla Edited for clarification: Glycogen stores.

First, sugar is a carbohydrate. I'm not sure what your first sentence means. Second, while thiamine is an essential vitamin, particularly for folks with impaired glucose metabolism, I have not heard of it preventing renal failure in someone who is acutely hypoglycemic. Thiamine has been given empirically before D50 administration to prevent Wernecke's encephalopathy, which has been seen in anecdotal reports after D50 administration. We have moved away from this practice, instead concentrating on administering the D50 as soon as possible. For chronic alcoholics, they'll get thiamine in the banana bag. Third, and what I think you're getting at, is the patient should be fed as soon as practical in order to get a load of complex carbohydrate to stabilize the blood sugar. D50 has about 100 calories in it, so not very much. It's enough to get them over the hump, but they'll need a larger load of simple and complex carbohydrates to maintain an appropriate glucose level. 'zilla

Not surprising, since she's just about as old... :twisted: Bwaahahahahahahahahaaa.... 'zilla

You're right, it is controversial. In theory, the fluid bolus will help increase urine output and "flush" the stone. In theory, the ureter is blocked, and increasing UOP will increase hydronephrosis and pain. Neither has really been proven as far as I know. A 2006 study in the Journal of Endourology (how could I have been missing this journal all these years?) showed no difference in pain scales or stone passage rates between those receiving 2 L saline bolus over 2 hours or 20cc/hr, essentially KVO. A 2005 Cochrane review found no credible evidence of benefit of aggressive hydration or diuretics to increase UOP. I give a fluid bolus if the urine looks concentrated on UA (high spec grav) or if they have been vomiting a lot and might be dehydrated. Since I usually give good hefty doses of narcotics for kidney stones, a little fluid to prevent hypotension is not a bad thing. Bottom line, I don't do it routinely, but sometime will. I don't think there is any reason to get real excited about it either way. 'zilla

Stemetil is a brand name for prochlorperazine, or compazine. This is, as I stated before, standard treatment. DHE (dihydroergotamine) is a vasoconstrictor. It's actions are similar to those of the triptans: Imitrex, Relpax, Zomig, etc. This is another well-recognized and accepted treatment. As far as kidney stones go, we'll usually give stones a chance to pass for a couple of weeks before doing lithotripsy, as long as there is no sign of UTI. Studies of Flomax in kidney stones show very high spontaneous pass rates with stones up to 10mm. 'zilla

I'm coming late to the discussion as usual. EM:RAP did a program within the last 2 years about treatment of migraines. The American Academy of Neurology recommends the following for treatment of acute migraine headache in the emergency department: metoclopramide (Reglan), prochlorperazine (Compazine), or droperidol. Something about the anti-dopaminergic action. I've had excellent results treating people with reglan, IV fluid, and toradol for migraines. As far as pain control for kidney stones, I don't see a big advantage of one narcotic over another, so long as they are properly dosed. Morphine, fentanyl, dilaudid, demerol, whatever. Toradol, as an NSAID, is an excellent choice, as the prostaglandin inhibition decreases ureteral spasm. I typically use this in concert with morphine and zofran or phenergan. Going home, they get percocet, motrin, phenergan or zofran, and flomax. Across the pond, steroids (prednisone, methylprednisolone) are used instead of or in conjunction with NSAIDs. 'zilla

Congrats! Strong work! For reference, 27 is considered average, and the lowest that most places will consider. 34 is VERY competitive. The writing sample score is generally ignored. 'zilla

Like most things, there are shades of grey here. Adenosine is okay for re-entrant tachycardias, including Wolff-Parkinson-White and Lown-Ganong-Levine, as long as the re-entrant tachycardia involves transmission (anterograde, the right way) down the AV node. WPW with a (relatively) narrow complex falls into this category, and adenosine is the drug of choice for this type of re-entrant tach. WPW that has a wide and ugly complex has a high chance of running retrograde up the AV node (this also looks a whole lot like v-tach). These rhythms have a high likelihood of having an underlying atrial fibrillation. The key here is that the AV node is still exerting some influence over the heart rate. Take out the AV node briefly with adenosine, and this sets up uncontrolled conduction across the Kent bundle of the atrial fib, leading to an even more rapid heart rate. To simplify things when you've got a high heart rate and aren't sure if you want to give adenosine or amiodarone, go by the complex. If it's wide and ugly like v-tach, it probably is, and you should treat with amiodarone or lidocaine. Amiodarone is effective for WPW and to some extent for atrial fib, so you're not really doing a disservice to the patient if you didn't catch the WPW and thought it was v-tach. If it is a narrow complex, even with a delta wave, you're okay giving the adenosine. And if they are unstable in any way, skip the antidysrhythmics and synchronize and cardiovert. 'zilla

"No, but she might give you E. Coli." 'zilla

I can cure that, but we'll have to treat your boyfriend too. :twisted: Thanks everyone for the kind words. Since I've been moonlighting, I've been working as an attending for a year and a half and have therefore been easing into it, but it's nice to be done with all the residency stuff, particularly call... 'zilla

[staving off the hijackers with strong situational awareness and a heads up to the Air Marshal] The green urine from propofol is incompletely understood, but generally felt to be benign. I have seen it once in one of my ICU patients. It was there for a day or two, then resolved on its own. It is not part of the propofol infusion syndrome, which is defined by rhabdomyolysis, acidosis, arrhythmias, renal failure, and/or liver failure in someone on long-term propofol infusion or extended propofol anesthesia. 'zilla

Sexual assault victims will respond somewhat differently to the trauma based on their own personal experiences. There is very little that you can say that is universally applicable. The best thing that you can do is be compassionate. Do not try to "make everything better", since you can't. It is important that the victim knows you are there to ensure her (or his) safety and comfort. Apart from that, there is not much you can do. Collection of evidence, getting details of the experience, getting victim statements, none of these are important to do in the prehospital environment, since they will be done at the hospital by trained sexual assault nurse examiners. Just don't be uncomfortable with long silences. Letting her sit quietly with her thoughts is okay. If she wants to talk, fine. If not, don't make her. 'zilla

FormerEMSLT297 is correct about CONTOMS, and I believe he would know better than I do about what USPP is doing with it. At present, it doesn't exist in its former form. Reposted from an earlier thread in this forum (your search-fu is weak): Virtually anyone can issue such a certificate, since there is no regulating body or standard curriculum to define it. It doesn't mean much to have "EMT-Tactical". The only question is whether or not a SWAT team or educational program will recognize your basic 5 day TEMS course as a valid prerequisite for membership/advanced training/whatever. Schools offering a comparable program: Tacmed (www.tac-med.org) Global Operations Response Group (www.gorgrp.com) RTI (www.emtt.org) ISTM (www.tacticalmedicine.com) National Tactical Officer's Association (www.ntoa.org) Cypress Creek EMS (www.ccems.com/catt_team/class.html) 'zilla

A larger volume makes it easier to push more slowly, which is a good idea with most IV meds (not adenosine, before some wiseass beats me to it). There are times when the higher concentration or high rate of infusion will cause more histamine release and localized itching/hives from the morphine, and this is often lessened by diluting it and pushing slowly. There is also less of a chance that the ambo will go over a bump and you will inadvertently push the whole thing too fast. Many of the nurses dilute the meds before pushing them, and many do not. And I agree with the concentration/med math thing. 10cc makes things awful easy. 'zilla

I have done this procedure many time. It's pretty straightforward. I have never seen, nor until now heard of, using something called a Turkel needle for this purpose. My google-fu tells me it is a serrated bone biopsy needle. The thing to know is, if you manage to puncture the lung parenchyma (which you will not do if the patient truly has a tension pneumo), it will make no difference when compared to the lung injury that occurred to create the pneumo in the first place. They are getting a chest tube anyway. The tiny puncture will heal itself without any problem. We get several folks in here that are decompressed by EMS erroneously, and most do fine with observation and without the need for a chest tube. I have had the distinct honor of initially missing a tension ptx in an ICU patient on a vent (with chest tubes in place bilaterally). Figured it out about 10 minutes into the code when the pre-code chest xray came back. 'zilla

This is standard practice for our police departments when transporting any prisoner. 'zilla

This is incorrect. tPA has a 3-6% mortality rate when used in acute stroke. This is what I tell patients (actually, it's better when drawn out with little dots): of 21 patients with a stroke, 9 will get some improvement with or without the tPA, 9 will not get any improvement with or without the tPA, 2 will get better because of the tPA, and 1 will die as a result of the tPA. 'zilla