Pain managment techniques within the EMT-B and paramedic scope of practice

[chbare]

http://circ.ahajournals.org/content/122/18_suppl_3/S729.full#sec-1

One interpretation of the guidelines:

http://www.boundtreeuniversity.com/news/926416-AHA-Guidelines-2010-Implications-for-EMS

[Kiwiology]

If you ever do that I will be forced to hurt you badly. Get rid of obesity, stupidity, and alcohol and you take away about 90% of my business.

See, I told you that you should of become an Anaesthetist

Ahhh, but there is evidence that endotracheal intubation is beneficial.(Class IIb) according to AHA.

Class IIb evidence is evidence in which "usefulness/efficacy is less well established by evidence or opinion" and for endotracheal intubation is based upon level of evidence C which is "consensus opinion of experts, case studies, or standard of care"

Nobody in cardiac arrest ever died from not having an endotracheal tube shoved down their gob; there is one study acknowledged by the AHA from Victoria (Australia) from 2006 that claims endotracheal intubation increased the chance of ROSC but did not correlate to survival to neurologically intact hospital discharge.

There is no evidence endotracheal intubation has ever increased the rate of neurologically intact hospital discharge in patients who had a cardiac arrest; it therefore has no evidence and should be dismissed without evidence.

[BushyFromOz]

Maybe not intubation alone but intubation in the setting of ROSC opens doorways to other post ROSC management that certainly does improve survival to discharge and quality of life for those patients.

[Kiwiology]

Maybe not intubation alone but intubation in the setting of ROSC opens doorways to other post ROSC management that certainly does improve survival to discharge and quality of life for those patients.

Sure thing right there mate, if ROSC is achieved its totally appropriate to tube somebody and take them to the cath lab (providing you have anaesthetised and paralysed them first so they don't wake up halfway through angioplasty)

That's a whole different kettle of fish or barbie of shrimp than intubation for the patient in cardiac arrest

[ERDoc]

But is there any studies with good evidence that show it is harmful to be intubated? My thought process goes something like this, if I am going to get ROSC, I don't want to be behind the curve with vomit in the airway and an unsecured airway.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC300808/

[Kiwiology]

But is there any studies with good evidence that show it is harmful to be intubated?

http://www.ncbi.nlm....pubmed/20385694

http://www.ncbi.nlm.nih.gov/pubmed/20858132

http://www.ncbi.nlm....pubmed/11485508

http://www.ncbi.nlm....pubmed/11145768

http://www.ncbi.nlm....pubmed/12957980

My thought process goes something like this, if I am going to get ROSC, I don't want to be behind the curve with vomit in the airway and an unsecured airway.

I agree with you (hey maybe that means I should become an an Emergenthesiologist?)

I have no problem with intubating an unconscious patient who is post-ROSC so he can go straight to the cath lab after he's been plugged into whatever mix of sedation and paralysis the hospital is using because he's liable to wake up half way through angioplasty as the vecuronium the ambos gave him wore off.

http://www.ncbi.nlm....cles/PMC300808/

Touche mate, good point but still .....

Edited April 9, 2012 by Kiwiology

[ERDoc]

Some general comments first. I would like to talk about non-traumatic arrest. Traumatic arrest are a whole entity to themselves that can lead to days and days of discussion. Looking at the studies, I have the following comments:

Study #1:I don't have a subscription to the BMJ so I am basing my opinion on the abstract only. The number of pts that survived to hospital admission after being intubated was double the rate of those who were not intubated (No p-value available so we are not able to tell if it is statistically significant). They also don't compare the death rate between those who were and were not intubated. Do they include those with complications in the intubated or non-intubated cohort? If we take those numbers at face value, of the 794 cases identified, 573 were successfully intubated, leaving us with 221 nonintubated pts. They say that 55 pts who were not intubated survived, so it would seem that they have a 24.8% survival rate. Is this statistically significant? Too many questions to use this study to change my practice.

Study #2: Looks at trauma pts. Again, this is a whole other ball game that we won't discuss.

Study #3: Not really relevant to the discussion. It basically says the sicker you are before you code, the lower your chances of survival. The longer you go without being noticed to be in cardiac arrest, the less your chances are.

Study #4: This addresses a question I was going to ask. Is it the procedure itself or the provider that makes prehospital intubation lead to poorer outcomes. What would happen if you had a study looking at the outcomes of preshospitally intubated pts who suffer a medical cardiac arrest and are intubated by either a paramedic, ER attending or anesthesiology attending (translation for you Kiwi: ER consultant or aneasthesiology consultant)?

Study #5: Again, is it the procedure or the provider?

I don't think we have an adequate answer to the question of "Does intubation improve outcomes in medical cardiac arrests?" I think we have evidence leaning towards, "Prehospital intubations have a high rate of being placed in the esophagus which leads to poor outcomes."

[systemet]

My pt was in his 30's, about 6ft 4, and about 220 lbs. He is a non compliant perenoide schitzophrenic, that has been also an IV drug user in the past. He took himself to the hospital because he is hearing voices from the TV telling him to very violently kill his mother and then kill himself. Now really alot of read flags in this. This is what he had in a 2 hr time period. 2 mg of adivan and 5 mg of haldol IM, then an hr later they started an adivan regement a total of 6 mgs and 50 mg of gravol while I was there. This pt was still able to open his eyes and communicate. When he did become fussy on the stretcher I was able to settle him down and asked him simply to just go back to sleep. I seriously wanted one more dose of adivan but I didnt get my wish and this pt was almost returned, if he freaks in the plane the possiblity of an extra 4 people being killed is a big possiblity. I have been doing these types of medivacs for 15 years and I being a pt advocate have not been heard but I keep on trying, so RWN now you know you can ask but be aware you may not be heard and you will just have to carry on. In this you have to pick your battles.

Not wanting to distract from the exciting academic conversation that's going on (seeing pubmed on EMS sites makes me happy!), but this sounds like someone who might be a good candidate for RSI. He can't kill you if he's paralysed.

[Eydawn]

Is that ethical/legal? Can you intubate someone whose chief issue is agitation r/t mental illness? Very curious as to this line of thinking... to my thinking, RSI is a dangerous procedure with lots of potential sequelae involved with weaning them off the vent later, etc... can you justify it as a provider safety issue, based on those risks?

Wendy

CO EMT-B

[systemet]

Is that ethical/legal? Can you intubate someone whose chief issue is agitation r/t mental illness? Very curious as to this line of thinking... to my thinking, RSI is a dangerous procedure with lots of potential sequelae involved with weaning them off the vent later, etc... can you justify it as a provider safety issue, based on those risks?

Perhaps we should move this to it's own thread.

I'd argue that whether it's ethical depends on why you're doing it. If you're trying to punish the patient for being schizophrenic, and don't want to listen to him rant all the way to the receiving facility, then it's unethical. If you're doing it to facilitate his safe transport, and protect the airmedical crew from him, and protect him from himself, while avoiding the potential complications of giving large amounts of sedation in the air without a definitive airway, then I'd say it's ethically permissible. Others may disagree.

Weaning is more of an issue when you're intubating someone with pre-existing pulmonary disease, or you're going to have someone intubated for a long period of time. This isn't going to be the situation here. There's definitely some risk to intubation itself, especially in the hands of paramedics, but this has to be balanced against the risk to patient and crew of not having him intubated.

Just an opinion. Other's opinions may vary!