croaker260

To be clear, it has not been removed from ACLS but simply from one of the protocols. There are a lot of drugs in that are not in that protocol that in the science documents are still permissible. Again...graphic novel version of ACLS vs. the unabridged Book version of ACLS. Well, let your freedom of practice and your paycheck be your guide. Here where I work I my docs will listen to me when I point out this stuff and usually we agree. If you work somewhere else where the ..ahem ...lines of communication are more one sided.....well your results may vary. But yes, in theory you are correct. But before I made my stand on this or any ground I would READ the documents and the supporting research, and be intimately familiar with the clinical science....not just simply regurgitate what some crazy old beat up crack-pot medic said on an internet forum.

IIRC, the incidnce of EPS type s/s with Inapsine was slightly less than with phenergan and haldol, but more than with reglan and/or compsine. So .they do happen. Just not "a lot". In our orders we have a reccomendation to co-medicate Haldol with Benadryl, but it wasnt required with Inapsine. Before they yanked it(due to the FDA's BS black box warning) I had given it hundreds (thousands even?) of times with only 1 incidence of PS, so I cant say that co-medicating with benadryl is indicated "routinely" (see other post on atropine... can I have a +1 for cross thread humor?)

What? Uhmm.its a pneumatic device, no wires, no sensors, only the pressure cuff and the pressure hose...unless someone wants to fill me in on a peice of equipment I am unaware of.

I prefere the KISS principle. Stick your tonge out and he with the larger tongue , rides. Opps, wrong KISS. I meant K.I.S.S. In otherwords, figure it out with your partner. What ever works, ....works. Nuff said. There are clearly FAR MORE important things going on than playing "no, its MYYYYY TUUUURRRNN".

Saddly, no one is actually looking at the "evidence" before responding. For the record, the AHA ACLS textbook is pretty much the "ACLS graphic novel" for the masses. If you want to begin to get into serious ACLS/paramedicine, you START (but not end) here: http://circ.ahajourn.../18_suppl_3.toc The answer to your specific question on Atropine is here: http://circ.ahajourn...ppl_3/S729.full The specific text is HERE: Also please not the definition of CLass II recommendations: NOTE: It did not say it was BAD, just that it was removed because it was a class IIb, not IIa recomendation, and that ROUTINE use is not recommended. Your exact defiinitin of "routine use" may vary. Here is mine (feel free to disagree): Atropine may still be considered in specific situations. If I have a patient with a PEA that is a SLOW PEA (i.e. a bradycardic PEA) refractory to other interventions (i.e. H/T evaluation and vasopresors, and good CPR) then that is not routine use, It is patient specific use. BTW, I also discussed this with our local cardiologists as well with good results. So, you may or may not agree with me (and that is fine) , but put a little thought into the disagreement. Review the literature. Regardless, Let me clearly state this for all to hear, because it is a HUGE soap box for me. Any discussion of ANY AHA ACLS/PALS recommendation, one should review the science documents first. It will often answer any questions you may have and help you undrstand them better. Thank you for your time. Croaker

If you look in the instructors section, I posted a link to a CE on opioids I wrote a few years ago. http://www.emtcity.com/files/file/14-opioid-review-for-ems-providers/ Check out pg 21 for discussion of opioid maintance programs. Also, I can tell you both from research, and my personal observations, Methadone is used way more for chronic pain than detox. Especially since the FDA/FDA tightened up restrictions on Oxycontin, methadone has slipped in to fill its space both clinically and illicitly.

Flipping it upside down should not effect your readings. When you consider that we are listening manually at the same location regardless of the orientation of the cuff..... The orientation should not effect effect the instance/volume of the Korotokoff sounds. Using similar logic, the orientation of the BP cuff does not effect our palpated pressure as our location of palpation does not change either. I cannot think of a reason the physics would change with an automatic pressure cuff either. What does make a HUGE difference is (as previously mentioned) the SIZE of cuff. It also makes a huge difference what your tubing is draped over/ran across if you are getting an automatic reading. If its going to be picking up excessive road bumps/vibration then your readings may be off.

Nope, Idaho for the past 13 yrs, and in the south prior to that.

SOrry about the double post above, my computer glitched during the posting and for some reason it double posted.

What he said, with one exception. TECHNICALLY, its only if you BILL ELECTRONICALLY to medicare/medicaid. SIlly, huh? But if you are one of the few agencies that still does total paper billing (Has nothing to do with how you write your PCR BTW) , then you may not be covered under this, but chances are you are still covered under other statutes at the federal or state level. Now, for a "tip of the iceberg" of the complexity of HIPAA. Sometimes non-medicare/medicaid agencies may also be indirectly covered under HIPAA, under something called a business associates agreement. Basically, if you use an E-PCR, your HIPAA covered agency is required to get one of these with the E-PCR vender so they dont disclose information that they may be exposed to on YOUR E-PCR's. Other examples are the venders for drugs that supply hospitals, or drug/medical equipment sales/service reps that may assist clinicians in a hospital/agency/etc with new equipment or therapies, but arnt technically covered under HIPAA by them selves. You see this a lot in specialty wards, ICU's and ORs in hospitals and clinics, and during research trials. Finally, some HIPAA covered agencies try to require these of other governmental agencies that they interact with, like first responders, contract transport agencies, etc....though there is mixed opinions and mixed success with this. As a general rule, a governmental dispatch agency that is separate from the HIPAA covered EMS agency is NOT required to abide by HIPAA. Where it becomes confusing is when you may have a Non-HIPAA agency PSAP dispatch, but a HIPAA covered agency running a SAP or similar function (like an EMS agency doing their own dispatch, or a hospital run poison control center assisting a non-HIPAA dispatch agency). I know , clear as mud, huh? ANyway, here is the IMPORTANT POINT: There was a recent HIPAA related discussion on the NEMSMA google listserve. One of the posters made a very important point. "In my experience, most managers should not follow their gut feelings about what HIPAA allows. The law is usually more restrictive than we think it is.". The only people you should trust is your "privacy officer" or a Lawyer with EMS AND HIPAA specialties. And sometimes they get it wrong too. Another made the comments that HIPAA is both very complex and not intuitive at all, as you can see from my "tip of the iceberg" discussion above. (Sorry Brother, I tried to help out with your double post but am on a 100 year old computer in the middle of the jungle. It completely hosed the formatting when I deleted the bottom half, not sure why, and this is about as close as I could get it to the original. Note to all. It was formatted perfectly before I started screwing with it.....Dwayne)

Isnt this the group of slime balls that sued EMTCity.com a while back? Heheheh. http://www.wired.com/threatlevel/2012/01/bar-eyeing-righthaven/ More here: http://en.wikipedia.org/wiki/Righthaven

Use of a spacer has been shown to improve medication delivery of a MDI over use of the MDI alone. Especially in children.

Respectfully, I dont know who YOU are, much less your little trick. That said I am aware of the importance of a spacer, though we tend to use NEBS more, and CPAP with NEB in line if we need to get more agressive but dont want to intubate.

As you may or may not be aware, Dr. Wesley has done a lot of work on this, his webpage is here http://emsunited.com/profile/KeithWesley ANd of course a wonderful article he wrote is here... http://www.sehsc.org/news/cspine.htm I have a study from canada somewhere that looks at the incidence of clinically significant pain and other sequla from LSBs, but it may take a bit.

Yes and no, I Have some citations that discuss Benzo's for toxicological induced agitation as being better than any of the Haldol , inapsin, or similar drugs , and by default it seems that (IIRC) 99% specifically discuss Valium specifically though that may be because of the age of some of the studies... I will have to dredge them up later though as I have a full day today and I am getting family aggro to get my butt off this computer and outside for family fun , LOL But, to explain myself.... I prefer Valium for its profile: slower more even onset than versed, longer duration than versed, and less respiratory depression than versed at clinically equivalent doses, whereas those differences are exactly the reasons why I prefer Versed over valium for RSI/MAI/Post ETT sedation (as opposed to combative patient sedation which is what we are discussing here)

THis is a topic I feel strongly about. First: Kiwis forst comment on verbal de-escelation is right on.. Second: Failing #1, an immediate risk assessment must be had. Severity of the patient, Safety (yours and Your patients), risk of occult pathologies, co-morbid factors(obesity, drug use, prolonged exertion, withdrawal, trauma) , risk of agitated delirium (or what ever name you wish to use), and presense of stimulant drug use all must be taken into consideration in a manner you can clearly articulate after the fact both in your documentation and to a board of inquiry if things go horribly wrong. THIRD: You must understand that when you interdict in a combative patient, especially when you restrain one, even when you do everything right, sometimes things go horribly wrong. Make sure you are prepared. FOURTH: THe things that alter these patients are wide and complex. AEIOU-TIPS ..remember. Never assume they are "just a drunk", or "just a psych". FIFTH: You must understand the concepts of Excited/Agitated delerium and positional asphyxia (and how they perpetuate each other). Undestanding is the first step to mitigation, and in some cases a degree of prevention. SIXTH: The things that we control that may kill these patients can be broken down into 5 H's. Hypoxia, Hyperthermia (from exertion), H+ (Acidosis), Hyperkalemia (from Rhabodo, muscle breakdown), and "High and Mighty" syndrome (not taking them seriously). We can treat all of these through a combination of decreased stimulation, sedation, position, and environment. Oh yes, education too (of ourselves and our peers) Now as far as sedation, I strongly favor Bezo's, specifically Ativan or Valium...They are predictable and their side effects are as well. Haldol, Inapsine, Phenergan, and other non-narcotic medications we used to use all have way to many side effects and problems that are the last thing you want to manage in an agitated patient. The only reasosn we ever used them as much as we did is because there was a bias against using "controlled substances" in EMS for many years...so we perpetuated bad medicine. BTW, as Kiwi and I are discussing in another thread, I dont favor Versed for these patients, unless you have nothing else. Valium is way better for sedation outside of RSI. Besides, Vailum is actually preferred in cases of cocaine toxicity, and (IMHO ) likely preferred in all drug induced hyperdynamic crisis. Contrary to Kiwi's statement , we (at least here locally, when other efforts fail..its not first line by any means) do this here in the US, but perhaps we see more methamphetamine, cocaine, bath salts, and general alcohol/drug related stupidity through out the US than they do elsewhere. Not sure that is something to brag about though..... My luck with Versed IN has resulted in narcotic snot being blown across my uniform...but thats just me. (I do like it for SZ activity though...)

Kiwi, 1- DO you guys just carry Versed over there, or do you carry other benzos too? Just wondering. As said before I can think of several different benzo's better suited for anxiety.. 2- Obviously ..as some one previously said, we are both seeing different patients based off of a rather poor description. As a side note, it still amazes me how we can be talking about the same drugs, interventions, and medicine, and allegedly speak the same language...but our vernacular is so completely different. Can you imagine if we were talking in person and our accents and pronunciation was a factor too?

Kiwi, OK, first do we even want to know what the heck morning clonnies are???? Now, I think there is a bit of misconception, not all of my anxiety patients get a benzo, and those who do get valium, or ativan (when we carried it), not versed. And to be clear, the ones who get a benzo are those whose anxiety component is REFRACTORY to other more routine interventions AND where their anxiety is compromising care, assessment, or safety. They (at least in my mind) must meet both criteria. Well, in this case I think we all can agree that this probably was not an anaphylaxis patient, though we will never know for sure. Lets assume for arguments sake it was though.... I think that in a true anaphylaxis patient, with actual SEVERE presentation, the clinical effects of the drug would be a minor concern compared to the delay caused pursuing an anxiousness path of treatment or care, regardless weather that care involved a benzo or not. Which returns us to the my original post a while back, the important lesson here is the importance of a good history (Good Data), followed by good assessment (More good data), combined to make a identifying the problem correctly (data analysis) followed by a good decision which would lead to an appropriate action. The problem is the history that he obtained was tainted, poorly acquired, and incomplete. HIs objective assessment was better, but he ignored most of what it was telling him. This tainted his analysis of the situation and thus his actions.

I also agree that there is a difference between "walking" a patient and letting a patient "walk". Everything is situation dependent, but I have walked the patient you pretty much just described, sometimes forcibly, when the situation (i.e. crowds in the bar, tight confines, "stairs" dictated it. Sometimes even "walked" patients who were barely standing, patients who I would have never walked otherwise in their house, but the "scene dynamics" were such that they were going to be walked out now or I was considering walking out without them. Once I even walked out a GSW victim with a shoulder wound to the ambulance that was in the staging zone...because the "hot zone" became to "hot" (the shooting was a mini MCI at a party, and the LEO crowd control...didnt control the crowd). SO Ideal? no. Once size fits all approach? That doesnt work either. When I was supervising, and I would observe some questionable behavior (like walking patients), I would of course ask the crew about it and base my judgement on their response. If it is derogatory to the patient, poorly worded, or simply "just because its 3 am and Im tired" kind of response, it is a no go. It it was articulate and based on clear reasoning, I accepted it. SO can you articulate your reasoning to walk the patient on something more than laziness or fatigue? I think the OP did OK articulate his reasoning. Can the opposing poiont articulate his as well? Unless he hops on here we will never know. Chances are its 50% misperception on both sides. SO I dont think the OP was wrong, but there may be two sides to it..or there may not be. Its a lesson learned regardless. SO I will close my rambling with a thought of a different vein: For those services that have policies on not walking the patient, how many of you think its for "safety", or for "billing". We all know, (or you should if your dont) that medicaid and medicare dont pay for may transports where the patient can sit or walk. There are countless examples of (at least non-emergent) calls where "fraud" (yes, the legal term FRAUD with the medicare penalties and jail time) occurred where the patient was walked, but due to service policy (or outright fraud) was documented as being stretcher born. Thoughts?

Outside of a theorectical effect on coronary arteries (important in ACS/MIs) , and of course allergic reaction to opioids, the opioid's histamine release tends to be realtively benign. Additionbally, certain opioids have this effect more than others. Codiene and heroin tend to have it more often, whereas Fentanyl have it very little at all. Well, the answer is "Adult Diapers". (in otherwords...depends. Get it. Depends lol) It depends on your service protocols. It depends on your medical director as well, who may or may not have much influence on your protocols depending on your state. Here locally giving opioids strictly for sedation (outside of RSI/mai/intubation, wich is assumed to be painful anyway ) is definitly not a common occurance, but we have a process called a SWO Diviation that you would do this if you had good justification, you would just have to justify yourself later. Personally, I understand that opioids have anxiolytic effects, but given the risk vs benifit and the general pharmacological profile I would go with a benzo instead. Valium most likely, though ativan could be useful in this role. I like valium for this better though, just not impressed with Vit A.

Ok I slept on this all night and I remembered something that may fit the s/s. VCD .. Vocal cord dysfunction can present with many of the s/s and often has a strong anxiety component. Of course the history is still pretty thin, we don't even have an age or a complete history... Which is the real lesson/issue

I had to look that one up (its been a LOOOOOOONG time...pun intended). GROOOOAAAAN!

Actually Kiwi, Levine's sign is something that used to be quite common in the texts over here in the US, not so much anymore...unfortunately.... I can't speak for elsewhere. One of those things instructors like to torment their students with. Kinda like Grey-turner's and Cullen's sign. So I don't think he was pretentious, just using the common vernacular of the area.

Slow down all.. remember hind sight is 20/20. I agree that epi was a little much, but I also recall that up to 40 + % present with no external skin signs or swelling. Anaphylaxis can be very difficult to Dx due to its huge variability in presentations and causes among patients, yet life threatening when severe. If the medic withheld epi and she dies would we be singing the same tune? Instead of slamming, lets break this down piece by piece with pro's and cons and learn from it. Now...I want to state this respectfully...its always tough to arm chair quarterback....here are my thoughts: The subjective history you presented (I cant speak to what you actually obtained) is a bit thin. A detailed subjective assessment would be useful to you figuring out what is/isn't going on, including AMPLE history. This would give insight into the ongoing medical conditions the patient has and what (if any) impact they had on your call. A patient on B-blockers, ACE inhibitors (which have their own Anaphylaxis mimic properties) and statins would imply a pre-existing CAD, and therefore a more cautions approach in regards to the EPI. By contrast, a patient with anti-depressants, benzo's/anti-anxiety meds, and SSRI's would imply an anxiety component, and therefore perhaps administering some Benzo's of your own. Finally, a more detailed PMhx, especially regarding her allergy to flowers would be useful. If she simply has hay fever, this is one thing. If she has been intubated before..that is another. Her physical assessment is essential too. I will take you at face value when you say lungs are clear, although I will state I have seen numerous providers tell me that when the lung sounds were not clear, merely silent. You paint a clear clinical picture of a patient who is either quite ill, or quite anxious, or both....presenting in severe respiratory distress, yet shows no signs of actual anaphylactic/anaphylactoid reaction. An ETCO2 waveform would be very useful...and impartial/objective assessment, of her respiratory distress as well. Looking for ETCO2 levels and waveform morphology would be useful to rule out some things. Given the vitals, combined with your physical exam, and the presentation in congruent with an anaphylactic/ioid reaction... I am leaning toward a very dramatic and convincing anxious reaction. But I wasn't there and a more detailed AMPLE history would be useful in looking for pitfalls. I cant rule our chemical exposure (cleaning compunds, floral agents, something unaccounted for), stress, etc. In this case, Obviously all the basic VOMIT medicine is called for ( VOMIT as in Vitals, O2, Monitor, IV and Transport) I cant speak for the practice in your area, but without convergent validity indicating other more serious pathology...more targeted treatment is not advised. I would be very tempted to try a low dose of ativan or valium to clear up the anxiety / drama, and see what symptoms (if any) the anxiety was masking. In our service, we can medicate severe anxiety (refractory to other interventions) , especially when it is becoming an obstacle to the care of the same patient. NOW, with that said, I want to state that there are too many unknowns. I think this stresses the importance of a good environmental, physical, and subjective assessment.. and that how we all..all of us...some times can have a call run us instead of us running a call. And with that, I think this brings a scene from a movie to mind. I think you got caught up in quicksand. We all can sympathize, even if we dont admit it.

Actually the 8:59 rule is from a seattle /king county study that was well done, but dates BEFORE the advent of AED's, but in a time /era when people (laypersons through doctors) took CPR much more seriously than we do today. Thankfully we are slowly returning to that mindset. TOday AED's have moved defib out of the relm of paramedics into the relm of laypeople. With the advent of AED's and CPR, I think that a repeat study would find that AEDs and QUALITY CPR matter in the first 4 minutes, but that the arrival of ALS becomes much more variable.