Protocols

[Kiwiology]

Our Intensive Care Paramedics use ketamine its wonderful stuff and I cannot recommend it highly enough.

Below is our drugs list if it helps, I think its very sensible.

Aspirin

Adrenaline

Atropine

Amiodarone

Entonox

Frusemide (probably going to be withdrawn in September)

GTN (nitrolingual)

Glucagon

Glucose 10%

Ketamine

Methoxyflurane

Morphine

Midazolam

Naloxone

Paracetamol

Salbutamol

Suxamethonium

Vecuronium

[fiznat]

I feel very strongly that in order for EMS to come into its own as a profession we MUST, absolutely MUST be the creators of our own destiny.

Okay, fair enough. Just don't lose sight of the fact that we are not independent practitioners. We will never, and nor should we, completely sever our connection with the physicians who direct and oversee our medicine. It is my opinion that you should view your medical directors as allies in this process rather than a hindrance. Utilize that resource!

Here is a link to our local protocols. I think they are pretty comprehensive, and organized in a thoughtful and accessible manner:

http://www.northcentralctems.org/documents/June%202%202009%20NCCEMS%20EMS%20Guidelines%20g.pdf

And a list of meds we use:

Acetaminophen

Activated Charcoal

Adenosine

Albuterol

Amiodarone

ASA

Atropine

Benzocaine Spray

Bumetanide

Calcium Chloride

Dextrose 50%

Diazepam

Diltiazem

Benadryl

Dopamine

Epinephrine 1:10k and 1:1k

Fentanyl

Lasix

Glucagon

Haldol

Atrovent

Toradol

Lidocane

Ativan

Magnesium Sulfate

Solu-Medrol

Reglan

Metoprolol

Versed

Morphine

Narcan

NTG

Zofran

Neo-Senephrine

Procanimide

Phenergan

Sodium Bicarbonate

Tetricane

Vasopressin

Edited February 13, 2011 by fiznat

[usalsfyre]

Reglan (and droperidol, for that matter) fell from popularity due to their respective black box warnings. Which may or may not have been fairly applied depending on who you talk to. Phenagren has some nasty side effects including phlebitis and a tendency to give older folks dystonic reactions (I've seen elderly patients pretty well flip their wig post phenagren, not sure why it seems to effect the elderly so badly).

Xopenex is an expensive drug that does basically what albuterol does. It is more beta 2 specific than albuterol, but it's still under patent so that specifity comes at a price.Used primarily to prevent long-term sympathetic stimulation in people who don't need it and in kids who have behavioral problems in Ventolin. Ipatropium on the other hand is a great addition to any drug box as it helps with acute broncospastic events from an entirely different angle.

Valium actually has the longest half life if all the agents listed. It's also the "weakest". I personally like midazolam simply because of the IN admin option and the tendency to induce anterograde amnesia, as usually when we're giving it something unpleasant is happening. Lorazapam is a perfectly ok agent and has less hemodynamic effects than midaz.

IV NTG is the bees knees IF you have a pump. It's not a drip you can eyeball. It's also about a hundred bucks a bottle, so it's not the cheapest stuff ever. I've personally probably hung a few gallons of the stuff and through urban, suburban, rural and HEMS have never had an issue with the glass bottle other than Minimed pumps throwing a fit over sucking minute amounts of air. If your really worried about it, get a Koozie, cut a hole in the bottom for the bottle neck and carry the NTG in there. Works like a charm.

Hopefully this was helpful.

Edited February 14, 2011 by usalsfyre

[Linuss]

We have Fentanyl for analgesia. Good thing about Fentanyl is the quick onset AND you can do it IN if need be. I've used Morphine but I don't like the slow onset, even if it last longer.

We use Zofran for antiemetic, though I have used Phenergan and liked it too. I think ODT Zofran, and an IV/ IM antiemetic, either Phenergan or Zofran, would be the best combo.

We have Ativan AND Versed as our Benzos, with our choice at when to use which. Can do both IV and IM, and can do the Versed IN as well.

We have Albuterol AND Atrovent, in separate vials for bronchospasm.

Our nitroglycerin is in both tablet and IV infusion. Yes, we carry the glass bottles, and I've yet to have one break on me. We leave it on the truck in the drug cabinet, so no real chance of it dropping and breaking unless YOU drop it.

[Kiwiology]

One other very important thing .....

Adrenaline drip for asthma, bradycardiac and anaphylaxis. We put 1mg in a 1 litre of bag of NS and run at 2gtt/sec (titrated).

It seems the US seems to think only IM adrenaline exists.

[chbare]

Does compelling evidence exist to support the use of IV adrenaline over IM adrenaline in the initial management of anaphylaxis?

Take care,

chbare.

Edited February 15, 2011 by chbare

[Kiwiology]

Does compelling evidence exist to support the use of IV adrenaline over IM adrenaline in the initial management of anaphylaxis?

Take care,

chbare.

I will get back to you on that but it makes better sense to us and to the Clinical Management Group.

If you are going to put a drip into somebody and infuse why bugger around giving IM adrenaline and IV fluid when a much smaller dose of IV adrenaline will have a faster onset and it gives you ready access to more adrenaline by just opening or closing the clamp on the drip bag.

Hook up a three way tap and have one bag of fluid, one of adrenaline and you can either run the adrenaline as an infusion or use it to draw up ten ml boluses out of.

I would rather use IV adrenaline over IM, esp if the pt. needs more than one dose

Now is any of this scientific? No, let me get back to you on that

Edited February 15, 2011 by kiwimedic

[Linuss]

One other very important thing .....

Adrenaline drip for asthma, bradycardiac and anaphylaxis. We put 1mg in a 1 litre of bag of NS and run at 2gtt/sec (titrated).

It seems the US seems to think only IM adrenaline exists.

We have Epi drips....

[fiznat]

We can do epi drips for bradycardia and hypotension, but they are way down towards the bottom of the guidelines. IM epinephrine works *extremely* well for anaphylaxis and severe asthma, and we will usually repeat those before we fiddle with a drip.

We also use racemic epinephrine for inhalation. Epi is a versatile drug!

Edited February 15, 2011 by fiznat

[medicgirl05]

Just wanted to share my thoughts.

Antiemetics- We carry phenergan, whcih works pretty well. However the local ER's don't like it because it causes tissue necrosis if the vein is not patent. We'd like to carry Zofran but our supervisor says its too expensive, though I dont know if that is true.

Pain Management- We carry Morphine, which is a great drug. However we find that lots of people are allergic to Morphine and we have no alternatives. We used to have Nubain, which works well, but the ER Dr.s don't like it because it causes narcotics to not work after the nubain wears off. So we quit using it.

Nitro- We use the spray. I've never used anything else but it seems to work.