Respiratory arrest and Epi for BLS Providers

[kristo]

We can argue and talk all day about whether or not you should have epi (I would probably argue not since you are in a tiered system), should the system be tiered (I came from this type of system originally, so I tend to favor them), and

Doesn't sound like a very good tiered system, he did not get ALS when he needed it. He performed excellent patient care within his scope, realising, however, that what the patient needed was not within his scope. This means those guys need to find a better way to provide their patients with ALS - in this case, a patient in need did not receive it.

We've kicked the shit out of that dead horse, so I won't bother to stress the point, that BLS was not appropriate in this situation (although the OP seems to have done very good, considering his education/scope of practise). While, however, we have EMT-B's out there with patients who are falling into respiratory arrest due to asthma, I'd rather give them (the EMTs) epi, rather than letting the people die in the truck.

If you had a longer transport time of thirty to forty minutes in a more rural area, why not keep bagging, maintaining an airway as best possible and get to the hospital safe (good job slowing down on the unsafe roads)?

Because if the airway is constricted due to asthma, you will not be able to "maintain an airway" with OPAs, the combitube or King airway device you mentioned, or even an endotrachial tube, because the constriction is in the bronchioles, lower than even the ET goes. You need bronchodilators.

Epinephrine isn't the be all, end all and while it worked in this case, any experienced medic will tell you it dont always work and sometimes we have to get a little more aggresive with other medications that hospitals give and arent even on many rigs.

Epi is not the only thing, the corticosteroid solumedrol (methylprednisolone) IV works fast and lasts long, but has a potential for nasty side effects...a lot of other stuff exists. Epi, however, is easy to administer from the epi-pens, I'd think that would be the best choice for someone in respiratory arrest. Especially if you're going to give it to an EMT-B.

True, sometimes it doesn't work, there are examples of people using OTC pills that contain a little epinephrine for their asthma and hence need higher dosages for it to work, as they get "used to" the epi. The thing is, if it's a respiratory arrest due to asthma, and there's no help for 20 minutes, you don't have much to loose...

I don't know if it is available to you in your system but since she had no gag at one point, why not a Combitube or King Airway device. Again, you have an airway secured and you can monitor the patient's cardiovascular status from there. Just a thought, but please don't think we are any better. You were large and in charge on that call it sounds like and quite frankly got a "save."

See my comment above on the airway devices.

Nice work though, csuprun.

[AZCEP]

One correction kristo, solumedrol does not work quickly. It has an onset following an IV dose of 2-4 hours, patient depending of course.

The "tier" failed the OP in this case. He recognized the need for ALS early on, and tried to have them meet much sooner. Using the epi-pen probably would have been moderately to completely ineffective. This patient was shut down peripheraly. Unless they were able to put the standard dose deep into a large muscle group, the response would have been a bit haphazard.

Instead of having EMT's picking up extra skills, let's send them to school to better learn the why's and when's of using medications.

[EMSGeek]

As far as airway adjuncts go I only have OPAs and NPAs. We're a little behind in the times. Combitubes and King LTs are relatively new for medics here in New York and not that widely used. The medics in my area don't even carry them. I know a few agencies in northern New York which do carry them but most of the medics are more comfortable with standard intubation.

I agree completely with AZCEP...EMTs need better education not just more training. <rant> I see too many red neck fire monkeys who are unfortunately certified as EMTs who really don't give a damn about PT care other than the bare minimum. These are the guys who show up in sweat pants and have cars with 4 blue lights. I hate when I tell someone I'm an EMT and they have a look of surprise and explain that they think of someone with a large beer belly and a pickup as an EMT not a prehospital care provider as we should be. I want to see the day where there is much more education as well as training in the EMT and Paramedic program but unfortunately the public isn't willing to pay for quality care until they need it and then it's too late. </rant> Sorry about that.

Thanks for the great feed back and discussion.

[Kaisu]

Great job...

In Wisconsin, EMT-B's are allowed to administer EPI with medical control approval. Its in our protocols and within our scope of practice.

Now before you all get on me about how inadequate my training is to administer this I start paramedic school on the 20th of next month... Nevertheless, the situation as described is a save in my book.

[Dustdevil]

Nothing really to add here. It does sound like you did a good job, not only functionally, but in logically thinking through the scenario. Kudos on that. Sounds like you are ready for medic school, but I'm curious what other degree you are working on. If you aren't interested in EMS as a career, then I would cancel my recommendation for paramedic school. Your community doesn't just need ALS. Your community needs professionals.

I agree that -- medically speaking -- a call into MD for guidance and epi would have been appropriate in this case. No doubt. Yes, the Epi-Pen is SQ, which is a problem when your patient's circulation is seriously compromised like her's was. But your MD may believe it is worth a shot, and I would concur. Again, good job on thinking that through.

Now, notice I said that it was appropriate "medically speaking"? That does not mean it would have been appropriate operationally speaking. That's going to be specific to your particular system. Your medical control, supervisor, manager, chief, 3rd vice president and Grande Poobah may have had a real problem with it. You never know. Idiots abound in NYS volunteer organisations. Unfortunately, anytime you think outside the box in EMS, you are taking a risk.

I'm curious how big a girl this was. What was she weighing in at?

[vs-eh?]

As always I will critique based on things that I don't think "jive" with the scenario as you presented...

1) SOB for 8 hours, but had only taken her puffer twice total and only in the last 2 hours?

2) I assume progressing to profoundly hypoxic (pre respiratory arrest) but her vitals are "ok", she is till moving air and speaking and (it appears) is not obtunded or anything (takes a neb mask).

3) She took a "gasp" within "seconds" following IM epi administration and basically was now not tolerating an airway and breathing better? I don't think so...

I'm just wondering if she simply had a vaso-vagal response from this chronic vomiting, went unresponsive, and it appeared that she went into respiratory arrest. She might have had an asthma exacerbation as well, but that was not her main issue. Possiblity anyway...

A good time though to review ventilation strats for the critical asthmatic...You could end up causing more harm than good...

[kristo]

One correction kristo, solumedrol does not work quickly. It has an onset following an IV dose of 2-4 hours, patient depending of course.

That's what I thought, until I got it for my allergic asthma - worked withinin 2 minutes. They had some brand name like "Solu-med" or something like that, they were definately corticosteroids (they told me), so I'm assuming it's Solumedrol (methylprednisolone).

Anyway, I was just agreeing with the poster that there were other possibilites, but I still maintained that epi was the best one.

The "tier" failed the OP in this case. He recognized the need for ALS early on, and tried to have them meet much sooner. Using the epi-pen probably would have been moderately to completely ineffective. This patient was shut down peripheraly. Unless they were able to put the standard dose deep into a large muscle group, the response would have been a bit haphazard.

I'm assuming you mean his vessels were so constricted the epi wouldn't have made it to the systemic circulation system? Now, please bear in mind that my education here is only elementary (1 year down, 5 to go...), why do you think the patient was shut down peripherally, and how deep would he need to go? Deeper than the needle in an epi-pen could go in the shoulder or thigh?

Instead of having EMT's picking up extra skills, let's send them to school to better learn the why's and when's of using medications.

100% agreed. As I stated in my post, his system needs better EMS, as in better ALS availability. However, if/while they are stuck with EMT-B's transporting patients who could have a respiratory arrest for 20 minutes, I still think it's worth the risk to let them use epinephrine, as there is simply not a lot to loose - but everything to gain. In this case, even if the epi would have been ineffective, it would still be very unlikely to do any harm.

[AZCEP]

I'm assuming you mean his vessels were so constricted the epi wouldn't have made it to the systemic circulation system? Now, please bear in mind that my education here is only elementary (1 year down, 5 to go...), why do you think the patient was shut down peripherally, and how deep would he need to go? Deeper than the needle in an epi-pen could go in the shoulder or thigh?

I'm thinking the patient in this case is moving most of their circulatory volume away from the periphery due to the diaphoresis, and pale skin. This shows the patient's endogenous catecholamines are working as intended, but will make SQ medication administration challenging, and unreliable.

Epi-pens are designed to go SQ, which won't be very helpful here. Even deep IM might not be very effective.

[whit72]

I would agree with VS eh here. Within seconds of administration is unlikely. I have given it IM, and SQ with varying onset times. IM is much quicker.

AZCEP Epi pens are designed for IM injection. In one area I have worked in you can give it IM or sq, drawing it up with a syringe and injecting SQ. Where I work now we only have the ability to give it IM.

However the best treatment in a severe allergic reaction affecting the respiratory and cardiovascular system is IM. For less severe or early intervention SQ is fine. In later stages IM is definitely the preferred route.

[EMSGeek]

Sounds like you are ready for medic school, but I'm curious what other degree you are working on. If you aren't interested in EMS as a career, then I would cancel my recommendation for paramedic school. Your community doesn't just need ALS. Your community needs professionals.

Prior to attending college two years ago I had never been involved with EMS. I entered college pursuing a BA in Technical Theatre which is the degree program I am currently enrolled in. Since getting into EMS and becoming an EMT I have been struggling with the decision to seriously pursue EMS and the education which would go along with it. Now I am trying to figure out the best way for me to transfer schools and or get an associates in paramedicine. I've been looking at several colleges which offer degrees in emergency management or EMS management, etc which would allow me to get a BS which relates to EMS and become a paramedic. I'm going to start a new thread about some of those programs soon.

Idiots abound in NYS volunteer organisations.

Gosh you must know NYS pretty well. Hit that one on the head.

Unfortunately, anytime you think outside the box in EMS, you are taking a risk.

I've learned this to be a sad but true fact and there's no reason for it.

I'm curious how big a girl this was. What was she weighing in at?

Going against my expectations knowing I would have to carry the patient out of her home she was surprisingly skinny. I'd guess 130lbs perhaps. She wasn't malnourished or sickly but rather in decent shape and with a slim frame.

As I stated in my post, his system needs better EMS, as in better ALS availability.

I would say that 98% of the time when ALS is needed they are available. This happened to be a really bizare evening in which multiple emergencies occurred within minutes of one another. A series of severe thunder storms were part of the problem, those same thunderstorms slowed down our transport.

1) SOB for 8 hours, but had only taken her puffer twice total and only in the last 2 hours?

That's what she told me. We've all known patients to do dumber things, right?

2) I assume progressing to profoundly hypoxic (pre respiratory arrest) but her vitals are "ok", she is till moving air and speaking and (it appears) is not obtunded or anything (takes a neb mask).

She seemed to go down hill rather rapidly once we were in the ambulance. The vitals I had were shortly after arriving on scene. I did not get another set until after we were pulling into the ER. She was speaking in approx. 2 word blocks due to her SOB. She understood the neb might help and was able to take it.

3) She took a "gasp" within "seconds" following IM epi administration and basically was now not tolerating an airway and breathing better? I don't think so...

I think it was within 10 seconds or so because I don't remember using the BVM for very long after. It seemed like a switch was turned on because she gasped and started gagging immediately.

I'm just wondering if she simply had a vaso-vagal response from this chronic vomiting, went unresponsive, and it appeared that she went into respiratory arrest. She might have had an asthma exacerbation as well, but that was not her main issue. Possiblity anyway...

I'm going to keep an open mind and not rule anything out. I listened for lung sounds when I thought she stopped breathing and where I had heard sounds before there was nothing.

A good time though to review ventilation strats for the critical asthmatic...You could end up causing more harm than good...

I'm a big fan of on going education and I am certainly reviewing a lot of info about asthmatics.