Clinical Judgment and Protocols

[Johnboy]

un·con·scious (n-knshs)

adj.

1. Lacking awareness and the capacity for sensory perception; not conscious.

2. Temporarily lacking consciousness.

3. Occurring in the absence of conscious awareness or thought: unconscious resentment; unconscious fears.

4. Without conscious control; involuntary or unintended: an unconscious

Here ya go Ruff, In case you were not aware, Lidocaine is not indicated for unconscious persons. I have provided you with the definition of unconsciousness. I agree with you, Lidocaine IS, infact given to reduce pain. When your unconscious, guess what.... you feel no pain.

Lidocaine.....Here is what you just gave an unconscious pt.....

Adverse Reactions

Systemic

Adverse experiences following the administration of Lidocaine HCl are similar in nature to those observed with other amide local anesthetic agents. These adverse experiences are, in general, dose-related and may result from high plasma levels caused by excessive dosage, rapid absorption or inadvertent intravascular injection, or may result from a hypersensitivity, idiosyncrasy or diminished tolerance on the part of the patient. Serious adverse experiences are generally systemic in nature.

The following types are those most commonly reported:

Central Nervous System

CNS manifestations are excitatory and/or depressant and may be characterized by lightheadedness, nervousness, apprehension, euphoria, confusion, dizziness, drowsiness, tinnitus, blurred or double vision, vomiting, sensations of heat, cold or numbness, twitching, tremors, convulsions, unconsciousness, respiratory depression and arrest. The excitatory manifestations may be very brief or may not occur at all, in which case the first manifestation of toxicity may be drowsiness merging into unconsciousness and respiratory arrest.

Drowsiness following the administration of Lidocaine HCl is usually an early sign of a high blood level of the drug and may occur as a consequence of rapid absorption.

Cardiovascular System

Cardiovascular manifestations are usually depressant and are characterized by bradycardia, hypotension, and cardiovascular collapse, which may lead to cardiac arrest.

Allergic

Allergic reactions are characterized by cutaneous lesions, urticaria, edema or anaphylactoid reactions. Allergic reactions may occur as a result of sensitivity either to local anesthetic agents or to the methylparaben used as a preservative in the multiple dose vials. Allergic reactions as a result of sensitivity to Lidocaine HCl are extremely rare and, if they occur, should be managed by conventional means. The detection of sensitivity by skin testing is of doubtful value.

Neurologic

The incidences of adverse reactions associated with the use of local anesthetics may be related to the total dose of local anesthetic administered and are also dependent upon the particular drug used, the route of administration and the physical status of the patient. In a prospective review of 10,440 patients who received Lidocaine HCl for spinal anesthesia, the incidences of adverse reactions were reported to be about 3% each for positional headaches, hypotension and backache; 2% for shivering; and less than 1% each for peripheral nerve symptoms, nausea, respiratory inadequacy and double vision. Many of these observations may be related to local anesthetic techniques, with or without a contribution from the local anesthetic.

DO NO HARM, Fluids are indicated in stroke pts, IF THEY ARE HYPOTENSIVE !!!! Do I have to explain why Ruff?? Probably, but I'm not. You can do your research. I am not waisting my time on this any longer.

I have done plenty of IOs , WHEN THEY ARE WARRANTED!!!!

You two deserve each other!!!

[Just Plain Ruff]

No indicated for any unconscious patient? Vtach with a pulse but unresponsive you wouldn't give lido to after conversion?

Code situation - oh they are unconscious they don't get lido

I also have had plenty of patients who were unconscious who have said that they felt pain.

Why am I arguing with you? I sometimes wonder where we get some of these people.

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But you didn't show where with lidocaine that unconsciousness is a absolute or even relative contraindication.

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[Johnboy]

Blood glucose control

Recent data suggest that severe hyperglycemia is independently associated with poor outcome and reduced reperfusion in thrombolysis as well as extension of the infarcted territory.[45, 46, 47] Additionally, normoglycemic patients should not be given excessive glucose-containing intravenous fluids, as this may lead to hyperglycemia and may exacerbate ischemic cerebral injury. Blood sugar control should be tightly maintained with insulin therapy with the goal of establishing normoglycemia (90-140 mg/dL). Additionally, close monitoring of blood sugar level should continue throughout hospitalization to avoid hypoglycemia.[12]

Ruff- I am talking about the situation at hand ,not your most recent post........I am quite aware what the indications are for lidocaine, and it is NOT through an IO of an unconscious pt for PAIN .....

Nice try ..

If they said they felt pain then they were NOT unconscious, they were. RESPONSIVE TO PAINFUL STIMULI....

That is AVPU. ----- the P part, case you didn't know...

Recent studies have demonstrated that blood pressure typically drops in the first 24 hours after acute stroke whether or not antihypertensives are administered. Further, studies reveal poorer outcomes in patients with lower pressures, and these poorer outcomes correlated with the degree of pressure decline.[49] However, other data suggest that blood pressure control, particularly when systolic or diastolic pressures are extreme and when thrombolytics are planned, can be an important treatment intervention. As a result, the control of hypertension in the setting of acute stroke is controversial.[20] Because a systolic blood pressure greater than 185 mm Hg or a diastolic pressure of greater than 110 mm Hg is a contraindication to thrombolytics, emergency blood pressure control is indicated in order to allow for thrombolytic administration.

Because their BP was fine Dwayne , I could see why you placed the IO and gave them a medication that they didn't need ..( see above , unconsciousness, and Lidocaine) instead of giving them the medication that probably would have fixed the pathology (glucagon).....

[DwayneEMTP]

You are a moron, and your inability to debate in even a half way intelligent manner proves that. Your short sightedness in seeing that a likely hypoglycemic person is likely to become responsive easily within the useful life of the Lidocaine shows you to be either a child trying to play the grown up, or so clinically handicapped as to be a significant danger to your patients.

And, as Ruff mentioned, if you equate unresponsive with 'pain free' then again, you are a child trying to pretend that you have been doing this for a while. Why don't many medics have access to RSI? Because too many, like you, equate "I can't show pain" with "I don't feel pain" and neglect sedation before/during/after paralyzation.

Brother, after you get a little experience you will come to realize that you have made several significant mistakes here. How do I know that you have no experience? Because I don't know of anyone with it that is so completely sure of their ultimate rightness. You have been unable to hear a single argument because your ego is so delicate that you're terrified that you may have to reverse your stance. And that's a shame.

Do you want to know why none of the people in this thread are telling me I'm an arrogant asshole? After all they are down to a person smarter and more experienced than I am. First, because asshole is assumed and they're too smart to be redundant. Second because there is no one here that hasn't proved me wrong on points big and small. Shown my best logic to be completely off in the ditch...and in every instance I've thanked them for it. Nothing would have made me happier than for you to show me my errors using intelligent, logical, science based debate. I'm sorry that that is be beyond you at this point, but I wish it for you in the future.

Some day you'll get out of school, or get off of the volly dept you run with, or jump from fire and move to a transporting company...whatever it is that has protected you from the joys and tears of being both right AND terribly wrong in EMS and you will see things differently. Once you've grabbed the golden ring while your ass is chewing holes in the bench seat, and also become confident that real people have suffered because some of your very best decisions have been wrong, you will say fuck all to the certainties and enter the real world of EMS.

I'll tell you what though..I do like your passion! I do like your backbone! I hope you stay around until you grow up.

Good luck to you my friend... You're going to need it for a while...

Dwayne

Edited to adjust formatting. No contextual changes.

Edited April 5, 2011 by DwayneEMTP

[Johnboy]

September 2006 Annals of Epidemiology 

Advantages of Nasal Adminstration

     Nasal administration of medications for systemic effect offers several advantages. The rich vascular plexus of the nasal cavity provides a direct route into the bloodstream for medications that easily cross mucous membranes. Due to direct absorption into the bloodstream, rate and extent of absorption and plasma concentration versus time profiles are relatively comparable to those obtained by intravenous administration.

 This method of drug administration is essentially painless, does not require sterile technique, intravenous catheters or other invasive devices, and is immediately and readily available to most patients. Due to the close proximity of olfactory nasal mucosa to the central nervous system, CSF drug concentrations may exceed plasma concentrations, making this an attractive method of rapidly achieving adequate CSF drug concentrations for centrally acting medications (i.e., benzodiazepines for seizures and possibly for sedation). 4,7,8

What else do you want proof

You were WRONG in your treatment and exhibited POOR judgement. Again, kudos to your former boss!!!

JB- Enjoy your day!!

[Paramagic]

Johnboy, it is entirely possible for an unconscious patient to have an adverse physiological repsonse to painful stimuli, whether they are conscious of that stimuli or not. You may not be aware of this, but that is the reason that those of us who carry out RSI give not just sedation but also pain relief following intubation, regardless of why the RSI was carried out.

This is also why intensive care units have protocols for assessing and managing pain in the comatose/intubated patients. There is quite a significant volume of literature on this issue, not because pain relief is not warranted, but because it is a vital part of care of the unconscious patient, yet difficult to assess.

I think it is entirely appropriate to give lidocaine prior to other drugs via an IO irrespective of the conscious state. The only time I may forgoe this is in the cardiac arrest setting.

Might I recommend some texts to read regarding this? Wall's Textbook of Pain is always a good place to start for anything pain related. There is a good little book whose name escapes me at the moment that deals with this sort if thing in the ER. Analgesia and sedation in the emergency department? Something like that. It has a red cover. Damn. It will come to me later no doubt. Oh's Intensive Care Manual is a good resource also.

I hope these help. I would love to know if there are any updated references for IN glucagon that you could provide. I'm a big fan of the MAD, would love to hear of more uses for it.

Thanks.

Paramagic.

[Johnboy]

If you thnk for one minute that Lidocaine is short lived in the elderly they you are dumber then I thought!!!

[usalsfyre]

Unconscious and unresponsive are two different things bubba...

I've had an "unconscious" patient who damn near levitated off the cot when we flushed the IO to start a pressor infusion. As such anyone I place an IO in that had a pulse gets lido to treat the pain associated with the increased pressure in the meduleary cavity, which is what Vidacare recommends. Unless I'm mistaken, that was the reason for the lidocaine.

I'm not sure what blood pressure studies (which lido doesn't affect) and studies on poorer outcomes associated with HYPERglycemia have to do with this case. Still haven't seen a source for IN glucagon bring THE standard...

[Paramagic]

Oh sorry, I see there were some posts while I was typing. I'm a bit confused with the last reference you posted from the Annals of Epidemiology. This article is discussing the advantages of IN administration that need to cross into CSF and across the blood/brain barrier to be effective. Midazolam, naloxone and fentanyl are good examples of these drugs.

However, I don't see how this applies to glucagon, which of course needs to get to skeletal muscle and the liver to have an effect. Can you explain how this applies as I'm obviously missing something?

[usalsfyre]

1st semester medic students need to stay away from trying Google-Fu...