Download 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
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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)
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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
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Dosed in micrograms
25-50 micrograms IV every 15 minutes
Still titrate to effect
Reversed with Nalaxone.
Hydromorphone
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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
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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
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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%
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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
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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??