Paramedic Systems of Wisconsin
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Transcript Paramedic Systems of Wisconsin
Paramedic Systems of
Wisconsin
Rick Barney MD
Beloit
UW Madison
Topics for Today
Pain Management-standing order and
drugs used
Cardiac Care- STEMI, NSTEMI
Latest on CHF care out of Hospital
RSI is now RSA
Capnography to guide ventilations
Use of Helicopters
Ketamine
Pain Management
Hot topic- patient comfort important
Use of pain scales important
Should have standing orders for RX
Morphine moving out of favor
Standing orders for pain
treatment
Decreases delays to treatment
Limits small meaningless doses.
Provides guidelines for safety.
Get Rid of Morphine
Morphine often under-dosed
Morphine is vasoactive and causes
hypotension and tachycardia’s
Morphine frequently causes nausea.
Specifically contra-indicated for nonSTEMI chest pain.
Slow onset, long half life.
Other drugs to consider
Fentanyl (Sublimaze)
80 times more potent than Morphine
Onset peak action 3-4 minutes
Rapidly metabolized- 45 minutes
No histamine release
No significant nausea
Recommended by many for cardiac pain.
Fentanyl
Dosed in micrograms
25-50 micrograms IV every 15 minutes
Still titrate to effect
Reversed with Nalaxone.
Hydromorphone
Trade name is Dilaudid
Commonly used in ED practice now
More potent, about 8 times of morphine
Less side effects, but still present.
Desired effect more quickly.
Dose is 0.5mg - 2 mg IVP.
Ketoralac
Toradol is trade name
Non-narcotic pain reliever.
Excellent for colic (GB,renal)
Often helps headaches
IV is 15-30mg IVP IM is 30-60mg
STEMI
Pre-hospital 12 lead with activation of a
hospital protocol is now standard per
AHA
Aspirin, Nitro for all unless contraindicated
Lopressor 5mg every 5 minutes X3
Pain med if needed
Plavix? Ativan?
NSTEMI
Cardiac chest pain without ST’s up
Two new issues
Morphine increases mortality
Beta blocker IV increases mortality
(Charles Pollack, Annals of EM April 2008)
Use Fentanyl, Lopressor for hyperdynamic
patients only.
CHF
Numerous studies, mostly critical care
based in past 2 years.
Best prehospital bang for buck, plus cost
effective
Nitroglycerine
CPAP
Morphine and lasix add mortality/morbidity
respectively.
RSI is now RSA
Much controversy about pre-hospital RSI
still exists.
Poor outcome studies always relate to
inadequate training, re-current training
Documented success frequent, but tight
medical control and small group.
Rapid Sequence Airway
Once paralytic drug is given with effect,
one shot to place an airway. If you see
cords, place ET tube and confirm.
No visualization, place non-visualized
airway. NO DELAY.
More education on who needs and more
importantly who DOES NOT need
emergent airway placed.
Anatomic concerns.
Capnography, Paramedics
best friend
Obvious use is to confirm ET Placement
Then to provide ventilations at rate
needed to provide eucapnea.
Quicker to show substandard ventilation
than waiting for pulse ox.
Hyperventilation generally bad.
HELICOPTERS
OVERUSED
EXPENSIVE
DANGEROUS
Usually add nothing to final outcome
Infrequently has value--then use by all
means.
We should try to decrease use by 50%
The time has come-KETAMINE
This drug has been around for a long
time and has received bad press and has
been plagued by evil spirits.
Numerous pre-hospital uses.
Effective and safe.
Enjoying wide-spread use in many areas.
KETAMINE
Provides Dissociative State
Chemical disconnect of limbic system
from the rest of the brain
May have vivid hallucinations, colors.
Plenty to see, but not aware of normal
sensory inputs.
Has been used in Veterinary Medicine for
years.
KETAMINE
Frequently employed in ED’s for
procedural sedation, often in children.
Slight increase in HR and BP.
Moderate increase in ICP.
Ventilation and oxygenation remain
unchanged.
Quick on and off.
Helicopter use of Ketamine
Severe burns
Painful devices or extrications
RSA for Asthma as sedative, induction
Excited Delirium
IV 1mg/Kg
IM 2-3mg/Kg
VASOPRESSIN
Keep watching
Numerous studies showing no benefit
over, or with, Epinephrine.
No surprise here. Adopted by us too
quickly.
Latest article NEJM July 2003
Questions??
Other Issues??