Paramedic Systems of Wisconsin

Rick Barney MDBeloit

UW Madison

Rick Barney MDBeloit

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 non-

STEMI 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 contra-indicated

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??