croaker260

SO here a question: All things being equal, which would be your fist choice opioid? For orthopedic pain? For cardiac? I have always leaned rather strongly toward Morphine, but would liek a feel for your impression on the effectiveness of Dilaudid side bey side with morphine. Preaching to the choir here. Part of the problem is the huge profit is mainly in drugs that are still on patent. Once it drops off, the profit margin drops because now any one can make the "generic". Thats why so many of the drugsthat are in shortage are the drugs that have been around for 50 years....(give or take) So, stopping production also boosts the demand, then increases the profitt margin. The PHARM companies are participating in all sorts of market manipulation. Just look up the NItro Spray. A year or so ago it was around a $100.00 bottle..before that much less. Now its pushing 300-600/bottle!!!! Tell me that's not artificial inflation. Because of this we are going back to tabs...its simply too expensive to keep buying the spray.

Good information , thanks. FWIW, We typically dilute our Fentanyl to 10 cc in a flush, so diluting the dilaudid wont be a big deal.

Hey all, we are switching from fentanyl to Dilaudid due to a shortage of fentanyl availability. Go figure, huh? Anyway, I have only used it a handful of times in the past so my personal experiences is limited. I was wondering is anyone else using it out there. How do you like it for pain control, how about for an adjunct in RSI? Any other tips and tricks you would care to offer?

There is a fear of pneuomothorax secondary to air trapping in COPD and Asthma. This rarely happens, if ever. Now, this is different than the very real concern of pneomo's when the same patient is intubated, or in trauma. Now, I would add more, but chbare has already done an excellent job especially about stinting open the lower airways and aveoli.

R For a bit of trivia, Rogain IIRC was originally a medication for HTN. Just as viagra was originally intended to be a nitrate for HTN and ACS. Now from my reasearch for the presentation I posted above, I wish I could recall the original sources: The earliest description of positive pressure airway support applied to a spontaneously breathing patient appeared in 1912, when Sterling Bunnell, an anesthesiologist, reported the use of a Teter mask to maintain lung expansion during thoracic surgery. He used a slider and spring mechanism to oppose exhalation. In 1936 Poulton and Oxon designed a ‘pulmonary plus pressure machine’ to treat pulmonary edema. This was the combination of a vaccuum cleaner and an adjustable spring valve. The air was warmed by placing a hot water bottle in the dustbag compartment of the vaccuum cleaner and by sucking the air from in front of an electric fire! Barach in 1937 worked with aviation researchers and applied positive pressure by face mask to pilots flying at high altitudes to prevent hypoxemia. In 1956 Avery et al reported ‘internal stabilization’ of flail chest utilizing intermittent positive-pressure ventilation. In 1967 Ashbaugh (who was a contemporary and friend of R Adams Cowley IIRC) used term CPPB to describe positive end pressure used in conjunction with IPPV supplied by a ventilator. This led to confusion as CPPB had originally applied to spontaneously breathing patients. The term ‘continuous positive airway pressure’ was coined in 1971 by Gregory et al to describe an elevated airway pressure therapy for spontaneously breathing, intubated neonates. CPAP has supported countless neonates while their underdeveloped lungs matured. It was, and in many places still is, the primary mode for weaning patients from mechanical ventilation. Current application has expanded to include adults and more recently patients without an artificial airway. In 1972 Civetta used CPAP to treat acute respiratory failure (ARF) and in 1973, Barach used CPAP for COPD patients. In the early 1980s, CPAP was tried successfully in patients with obstructive sleep apnea, who experience airway obstruction with resultant apnea caused by relaxation of airway muscles during sleep. In the later 1980s, CPAP helped reduce work of breathing and improve oxygenation in patients experiencing respiratory distress following cardiac surgery. CPAP also was tried with congestive heart failure patients, also with encouraging results. In 1981 JB Downs et al invented a new venturi device for administering CPAP. This was known as the Downs generator and was first marketed as the Vital Signs 8230. In 1982 Sarah Kielty expanded the definition of CPAP to include adults and more recently patients without an artificial airway. The successes during the 1970s led other investigators to treat a variety of diseases with mask CPAP. So, CPAP has an extensive History prior to ASA... Side note: Does on/off lable apply to devices, or just medications?

Ok, for what its worth, here is our states CPAP training wich I helped develop. http://www.slideshar...ng-presentation We have had CPAP for about 4 years now give or take, and it has been HUGELY successful. We use it for CHF, Asthma, pneumonia, any of the non-traumatic respiratory causes including COPD. The pressure parameters are different (10 mm H2O for CHF, and 5 mm H2O for everything else) but the decision process is based on the severity of respiratory failure and the desire to avert intubation. With that in mind, CPAP in pneumonia with respiratory failure has been used in our area with good success. Technically, it may be said that it was the respiratory failure that was the trigger point in general, but the point remains it can, and has, been used in pneumonia patients. This is concurrently with IV fluids and often nebulizers CPAP'ed in so to speak. It has been very effective in turning the patient around in many cases., buying time for a more deliberate approach to total care in others, and some...unfortunately...get a tube anyway. Obviously it is not a universal treatment (i.e. every severe pneumonia ptient does not get it, only those in respiratory failure), but once our inversion gets here I can expect to use it every week or every other week until the flu/pnumonia/inversion/winter weather clears here in ID.

There is a big difference with SZ in a patient with KNOWN severe SZ history with a single continues SZ , who has multiple SZ a day (the patient you would typically expect on a neuro ward) and the patient who has no previous Hx, or who has a mild SZ history but who has been previously well controlled. Most of the patients /patients care givers whom I see with severe SZ history have a 20 minute and/or refractory to diastat rule. If the patient does not respond to diastat, or goes on for 20 minutes, then we (EMS) get called with the expectation we may intervene. This is based on guidance from one of our areas neurologist who specialized in pediatric neurology. It seems to be a common approach. Any patient who fits outside this demographic described above... I would be much more likely to intervene quickly, including the "unknown history" patients, the chronic alcoholics, drug involved patients, patients with multiple SZ who are previously well controlled, adult febrile patients, etc. Now a little bit of "street smatz": it is actually pretty rare to see a SZ in the field in an epileptic (meaning the high functioning well controlled patient, not the who is near bedridden with multiple medical issues). They tend to have resolved PTA of EMS in 90% of cases, so just seeing a SZ raises my index of suspicion simply because its outside the norm for even this class of patient. This is not evidence based, simply observation based, but it may keep you from overlooking something serious.

I admit that we would be hesitant, but not automatically a fail.. providing that: 1- It was not a felony 2- It was not an actual DUI 3- You had no other driving issues that would show a "pattern", Depending on the time frame, your other ticket may be a deal breaker...may not. 4- You had no issues with drugs, alcohol, etc Now, given the above, if...BIG if..you made it to the interview board with outstanding performance...and you clearly showed not only good interview skills AND a level of maturity that made it clear that this was a one time screw up and you had clearly learned from it..and you were accepting full responsibility... You could be hired. I am not convinced by your single post that you are there yet, but then again...that is the limitations of an online forum...no disrespect intended. Yes, those are a lot of "IFS" but keep in mind that which doesnt kill you ...makes you stronger. Also keep in mind, by the time you get through nursing school, your looking at another 2-4 years. That in it-self can go a long way to putting this behind you.

Hey all, upcoming are two of the deadliest days for law enforcement ...and by trickle down effect, two very dangerous days for us (EMS) as well. Auto Accidents and domestic violence are leading causes. Spread the word and stay safe this holiday season. http://blog.odmp.org...cement-are.html So, when you talk to the newbies, trainees, probees and rookees of your department, what are your tips and tricks for staying safe? (Please keep it nice everyone...)

Just point out to them that this practice is recommended in this tecxtbook (I have the 4th edition which I am referencing) http://www.amazon.com/Wilderness-Medicine-5th-Paul-Auerbach/dp/0323032281/ref=sr_1_1?ie=UTF8&qid=1324664695&sr=8-1 I believe 2 minutes/liter fluid, shaken (not stirred) prior to administration. Also, while designed for neonates, I have used this A LOT on potential hypothermic adults ( I place it on their chest). It works awesome, is consistent to 104-110 degrees for about 2 hours. We carry two per rig for deliveries, so they are readily available. http://www.progressivemed.com/estylez_item.aspx?item=515557

Which program are you enrolled in?

Many years ago on this or another site I had a informal contest to see who could get the origin of my name. It wasnt that hard, but it took people a while to get it. SO, here is the story... In my alternate life I am a geek. A serious sci fi, movie, book, and fantasy geek. I always have been since Jr High. I was during my service in the Army...you would be surprised how many geeks there are in the military..big hard core soldiers...who are indeed ...geeky... Anyway, I hid it for years because, quite frankly, it interfeered with people taking me seriously in my professional life. Especially in the south. About 13 years ago I simply "embraced the geek inside me" so everyone now has simply accepted it. Kind of. LOL Of course, working my ass off in my job and improving my profession and teaching a lot has helped a lot too. Anyway, I digress...my screen name .. which I use for a lot of things for many years......is a combination of a character ( a military physician of all things) from a book whose views I sympathize with, and my badge number that by pure coincidence I had at my first career service and I was assigned here at my current service when I was hired on 13 years ago. I think I first used it on a KY web site long ago and for years on the old EMSvillage website when it was active.

OK, thanks for the input on vasopressors, please take this in the spirit it is intended. Hypovolemia is a RELATIVE contraindication...refractory hypovolemia is not. In other words, it is perfectly appropriate to to do vasopressors and fluids simultaneously or after fluids or other efforts have failed. This is common practice in most any large IICU setting, especially in the treatment of DIC and septic shock. A good friend of mine recently had a young 20s female with DIC and septic shock on a CCT transport ...14 drips (3 pressors) and in excess of 8 liters of fluid.....in the first day. SO, I would do still do BOTH. 2- I am confused by the gurgling bloody airway...is this around my tube, or are you simply stating I have justification to intubate...because I had justification 30 seconds into this call ( "Anticipated clinical course"). RE: Septic Shock: Why do I think this is a possibility? Recent surgical procedure (D&C ) gone wrong leading to septic shock and peritonitis... OR micro emboli from the D&C showering the gut (i.e. intestines) and causing necrotic Bowell and peritonitis (this is my personal bet)... OR a previously undisclosed reason (Tampon in too long, Rough sex with a paramedic, who knows? Where is Dr. House when you need him)... To those who believe it is simple over medication and /or traumatic rupture....Yes Yes it could be simple bleeding but if it was a traumatic rupture it would have happened a long time ago....in the first week post MVC or after the D&C and either cause would have killed her quicker. In this stage, finding out the why is secondary to keeping her alive long enough to make use of the information . The rigid painful ABD in the absence of recent trauma with the DIC and the rash/SQ hemorrhagic discoloration strongly implies septic shock the other s/s and shock ---->DIC with SEPTIC SHOCK. Excellent comments man, really. Ketamine is not as common over here as it is over there for RSI... Dont ask why ..... there is no clear reason other than an abuse stigma. I agree it would be the better option than Etomidate. As for Etomidate in sepsis.. clearly it is dose dependent and to a lessor degree age dependent....but every time one study shows it is a big deal, another one shows something different. Lets agree its a consideration and a judgement call neither right nor wrong but depending on what else you have to work with.

I would look at alternatives over etomidate still. THe steroid "solution" has all sorts of problems too. If I had nothing else I would consider a benzo, she probably doesnt need much of a push to take her down anyway...though you are absolutely right on the hemodnamic concerns. Its really a choice of the lesser of two evils... Or ..as they said in Master and Commander.... The lesser of two weevils! 3 points for the obscure movie reference!

The background to this experiment is this. Our medical director(s) positions have recently evolved to a system wide medical directorate. This is usually a good thing for inter-agency cooperation, but there have been a few little details I am trying to iron out. This is one of them. With this change we went from running some infusions (like mag) in a bag to the more cumbersome buritrol. When we switched t the buritrol, the incidence of this medication being given dropped significant, go figure. We switched to the buritrol because one of the new docs was afraid of a run away line/infusion in a worse case scenario. I am trying to see if that the "worse case scenario" is still with in safety parameters. Does that make sense? And if you need a better reason to do this, because doing crap like this makes us better medics...and honestly...its fun!

You know, Im not saying its ligit (who buys Zoll charging stations?),but it has a ring of some truth to it. My bigger question, Have you talked to your counseler about " I want to get rid of the reminders"? I am just sensing that there may be more to this descision...and while I am not a counseler I generally go with my guton things. If your story is true, I hope you tlk to someone about this to be sure its a healthy expresson of your therapy, and not an unhealthy one. Eitherway.best of luck. ALso, for what its worth, my department trialed those griffin vests for TAC-MED...too bulky, heay as crap, and not modular enough for their needs. They went with a traditional ERT MOLLE type vest that our local swat wears.

VERY IMPORTANT POINT: Absense of fever does not preclude an infectious process or septicemia. Now I am going to ramble. If you want to skip ahead to treatment, feel fee to do so. If this was without the precceding history and if her mentation was more altered with neuropathic-encephalopathic s/s ...... I would think septic shock secondary to meningitis. She is the right age for that kind of silliness... HOWEVER, Since there is no suppotive history for meningitis, and SHE DOES HAVE the history of abdominal injury, miscariage, presumptively for a D&C, and abd rigidty, I am assuming probably some adverse sequala from the abrupted placenta/D&C, and related care. (I am assuming she isnt a closet alcoholic with end stage liver failure and coagulapathy, right? ) My guess is that she is currently in DIC, and probably secondary to septic shock, with exacerbating coagulopathy caused by her plavix/ASA a (distant) second in my mind. Regardless, the exact etiology is academic at this point At this point she is actively (strike that...AGRESSIVELY) dying. The cut on the arm probably saved her life because it prompted the call for help. So, to recap treatment and add some: BLS: O2, BVM, OPA, Suction PRN, Shock position, and the TQ on the arm lac is a good idea. If you are one of those agencies that carries hemostatic agents, use them. A special comment on the TQ: Use a B/P cuff not a CAT or similar TQ. In this case a narrower TQ (like the CAT) may actually precipitate severe bleeding at the site of the TQ due to micro-lacerations in an already coagulopathic patient. ALS: 1- ETT placement, va RSI/MAI if required, but do not use ETOMIDATE (mixed research on its adverse effects on adrenal response and survival in septic shock situations) 2- 2 large bore IV's, Start significant fluid resuscitation. I know there is a lot of information about permissive hypotension, but 99% of that is in traumatic cases. In SEPTIC shock, and in DIC, restoring perfusion to the gut and kidneys is paramount, and fluid resuscitation is key. Therefore, I would open the lines up and reassess Q 500-1000cc but probably wouldn’t slow down until I got past 2 liters. 3- Start the vasopressors now concurrently with your crystalloid infusions. Again I am presuming DIC secondary to septic shock, but in this case EPI drips (2-10 mcg/.min...mix 1 mg in 250 cc) is going to be a better than dopamine, though you may have to do both. if you carry levophed, that is probably your best choice. 4- When/if you get some breathing room...Since she is going to get multiple lines, start a third. YES a THIRD line. Use a twin cath (multi lumen) because many of the meds she needs to get NOW are not compatible with each other. Start it now while she has some vasculature left to hit. Yes she is probably getting a swan and a multi-lumen central line later...but only if she lives that long. Some thoughts: CHF is not an immediate concern, you have PPV in place which will stave off any pulmonary edema. In most other 20-something-year-olds their cardiovasculature can take 2-4 liters with no problem. Since we don’t have a lot of history on her non-specific cardiac issues, we cant assume that is the case with her, but we do KNOW she is dying right in front of us. If we dont start large volume resuscitation concurrently with vasopressors, she wont live long enough to die from CHF. One more thought: Yes this looks like DIC/MODS and possibly septic shock as I described above, but the only time I have seen septic shock try to kill someone this quick with (presumably) this sudden onset of DIC is bacterial meningitis, and I have heard that same thought repeated by several well respected docs in my area. THEREFORE: While none of the history points to this, It costs nothing to mask up all providers as well, and use the HEPA filters on the vent. Cover all your bases. One final thought: If she doesnt code, andshe doesnt respond to dopamine, epi, and volume rescusitation, I would get orders (or in my SWO's..invoke a clause that allows me todo this without calling due to her trying to die right in front of me... ) to increase her Dopamine beyond 20/mcg/min to about 30 mcg/kg/min...at this dose it mimics (kinda) Levophed. Unless I carry levophed, which most services do not. At this point, your pulling out all the "stops".

Thanks, much appreciated. NOW, WHY hasnt ANYONE else reproduced the same experiment? Hint Hint.....

Quick question...where do you get the exact pressure gradient of 75 cm H2O? Not doubting you , just trying to figure it out. Thanks.

Wow, this is really shaping up to be an informative thread.

I am curious as well. I found several references that state it should not be mixed in concentrations grater than X, but no the rational. Is it a clinical or a chemcial reason?

First, thanks for that PDF. Very useful. Second: The 16 G are quite short and I used the correct size. But yes, there is indeed something restricting flow,,, the size of the drip set You can have a 10 G in a vein but if you have a 60 gtt set on that, there is only so much volume that will flow through the needle in the drip chamber. Unless: (See point #3) Third: The main way to increase infusion rates beyond these parameters is to add pressure infusion either via a pressure bag or via an infusion device (i.e. pump or rapid infuser). Neither of which I did because we don’t use pressure bags on med infusions. You make excellent points regarding the equipment, etc. One thought though. RE; Trauma infusion rates- Most of that tubing (that we used back in the day of R Admas Cowley [R.I.P.] inspired trauma care) was 10 gtt tubing with oversized line (AKA repurposed blood tubing) and thus the laminar (sp) flow rates would be much higher. On final point, anectdotally I think our IV lines used to be much shorter back then....but who knows really. I was surprised to see about 7 feet of line when I did this! DWAYNE: Yes, I know, believe it or not I proof and MS word spell check usually, unfortunately I have issues typing, and further issues proofing on a computer screen. (This is why I print my charts to proof before I submit them, because I miss sooooooooo much when I try to proof on the computer screen). Its an issue I have struggled with for decades and short of multiple proofs, have never been able to completely lick. Ironically, I got straight A's in English, lit, journalism, and vocabulary, but this was before the age of computer screens in such common use in high schools and college. It is for simiar reasons I cant read (and I try to read a lot) on Kendles, Knooks, Xooms, or any of the other Ebook readers that are out there. Give me paper books any day! Perhaps I have some variant of deslexia (sp) ..who knows?

You are of course absolutely right, and I considered that as well. But I quickly came to two observations: 1- I have no equipment, nor accurate and useful parameters to simulate vascular resitance in this situation. 2- For this situation, vascular risistance is not a huge issue. I am trying to see what the maximum possible worst case scenario that could happen with a given combination of equipment if mag was left run at wide open, wich is one of the expressed concerns/reasons for our medical directorate wanting us to use a buretrol to give mag. So simulating vascular ristance is not that big of a concern. Incoperating vascular resstance would only make the estimate more conservative. The interesting part of this experiment is that it could be extrapolated to "run away" lines on other infusions too, like dopamine, lidocaine, etc. So therefore it would be useful to reproduce in or discuss in a paramedic program or other class as well. I am hoping someone will reproduce this with an 18 and or 20 gauge here soon though. (hint hint pretty please)

Just some of the random stuff I do at work when not running calls... I was researching some infusion protocols for Mag sulfate and I realized that there was no clear estimates on how fast wide open would be if someone accidentlaly ran in a bag of mag (or any other drug). so, I did this little experiment. Question: Can 5 GMS mag in 250 cc saline be safely run @ wide open and not exceed common safety parameters (i.e. < 1 gram/minute) in emergency situations? Methods: Using a stop watch, time the infusion of 250 cc saline and 10 cc mag using two prosposed infusion methods (noted below). Experiment #1: 250 cc saline + 10 cc (5 grams) mag elevated 30 inches above distal end, with 15 gtt set and saline extension set (93.5 inches total w/o cath) , run @ wide open, with 16 G 1 1/2 inch at distal end takes 5 minutes 26 seconds to run in. Estimated infusion rate 52 cc/minute Experiment #2 250 cc saline + 10 cc (5 grams) elevated 30 inches above distal end, with 60gtt set "STAT II PUMPETTE and saline extension set (91.5 inches total w/o cath), run @ "Full OPEN" , with 16 G 1 1/2 inch at distal end takes 15 minutes 03 seconds to run in. Estimated approx 17.3 cc/minute Conclusion: 5 GMS (10 cc) added to 250 cc saline run at the maximal possible infusion rate without a pressure infusion device (AKA wide open) at commonly accepted elevations and normal infusion equipment should not exceed safety parameters for emergency infusion using either commonly accepted infusion sets available in EMS. Secondary conclusion: I am an EMS GEEK. My challenge to you: Can you guys reproduce the same experiment with 18 G, 20 G and 14 G? And/or 10 gtt sets? (We dont use 10 gtt sets but some do...) I am sure if everyone takes one part and posts it, it would be very interesting. I am very interesting in the results with 18 and 20 G catheters.

OK , fair enough. Would appreciate it if you would vote in the "We give it in some other conposition (please describe below)" box or chose all the ones that apply. Helps the survey results. Also, of you could post the link or text of the order (and/or the service), it would help a lot in my refereces.