CPAP and administeration of oral medications

[Arctickat]

Excellent first post jkc, welcome to the City.

Edited November 14, 2012 by Arctickat

[J306]

So in cardiac scenarios today I was treating a patient for and acute MI with significant ST elevation in anterolateral leads with no relief of pain with rest of nitro. Gave him 3 mg Morphine SIVP and brought his pain from a 7/10 to a 4/10. This same instructor throws in that my patient has a 20 year history of asthma that he forgot to mention. Suddenly, the patient presents with a mild bronchospasm with audible wheezes. This increased his resp rate from 18-24 and drop his 02 sats from a 96 to a 92%...

The question was asked whether I would now treat with Ventolin... I first said I would switch my patient from a nasal at 3lpm to an NRB at 15 lpm and see how my patient tolerated it and whether the histamine relased by the morphine would resolve in a few minutes...My main reasons for not giving ventolin to an AMI patient was because I wanted the heart to have to work as little as possible, and the beta 1 properties of ventolin would increase peripheral vascular resistance and increase heart rate, potentially causing more damage to the myocardial tissues.

Thoughts? I'm still not sold on administering a drug with beta 1 agonist properties to a new onset, unresponsive to nitro, unstable chest pain.

[Arctickat]

Great question Jack. Have you checked your protocols? Specifically CP2.

[jkc]

Thanks Arctickat. I can't take credit, though, that tip was passed on by an excellent college instructor.

J306, as far as briefly removing CPAP and patient compliance with CPAP, all my recent CHF calls have required intensive efforts to get the patient to keep the mask ON. It's quite uncomfortable, and I can understand why patients feel the large CPAP arrangement (filter, ETCO2, Boussignac valve, facemask, headstraps) is even more smothering than an NRB can seem to some anxious, hypoxic patient. Not to mention the unaccustomed positive pressure itself.

[J306]

Great question Jack. Have you checked your protocols? Specifically CP2.

Sure did, even quoted it in my scenario, to which the response was that it was contraindicated in Pulmonary Edema not in AMI... Two intructors have now said that since it was under the Pulmonary Edema protocol it does not apply to the CP1 protocol... Interesting.. I'm still not convinced, but regardless, my thoughts are that we should be striving to "do no harm" so it all comes down to the greatest benefit to the patient.

[Arctickat]

I would agree, especially because the protocol indicates that, "Administer one dose of Salbutamol/ipratropium bromide if bronchospasm is present and the patient is not complaining of chest pain, which may be cardiac in origin."

Therefore, if the patient develops bronchospasm during an AMI then protocol CP2 trumps CP1 and we can't give ventolin.

Have I ever mentioned how I F---ing hate how our protocols have turned us into cookbook medics?

However, I am not your instructor...perhaps you should seek direction from the College, considering they're the ones who'll be raking you over the coals if they find an issue with it.

[J306]

Absolutley, that was my interpretation as well. It is very frusterating how we are graded and judged on how we can twist or change the protocols to the "greatest benefit of the patient." I am all for doing what's best for the patient, but administering a drug which even has a chance of causing that patient more harm then good really makes me check where my values are.. I'll send the college an email and post the response to benefit other SK medics on this site.

[J306]

Got a response from the college yesterday. They said that the protocols are currently being revised to become less standard procedures and more so guidelines. Within the next couple months they will be introducing a protocol deviation clause, which allows providers more freedom when challeneged with special circumstances in the field.

When I asked about the situation above, he said that since it was a relative contraindication that it was a cost/benefit situation and patient dependant, so we wouldn't get nailed to the cross for making an informed, intelligent decision given the situation and acting in the best interest of the patient.

In conclusion, another grey area. I was relieved to learn that the college is making steps in the right direction and empowering the providers to make those tough decisions in the field without having to worry about loosing their licence for it.