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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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Paramedic Systems of Wisconsin

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  1. Paramedic Systems of Wisconsin Rick Barney MD Beloit UW Madison

  2. 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

  3. Pain Management • Hot topic- patient comfort important • Use of pain scales important • Should have standing orders for RX • Morphine moving out of favor

  4. Standing orders for pain treatment • Decreases delays to treatment • Limits small meaningless doses. • Provides guidelines for safety.

  5. 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.

  6. 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.

  7. Fentanyl • Dosed in micrograms • 25-50 micrograms IV every 15 minutes • Still titrate to effect • Reversed with Nalaxone.

  8. 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.

  9. 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

  10. 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?

  11. 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.

  12. 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.

  13. 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.

  14. 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.

  15. 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.

  16. 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%

  17. 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.

  18. 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.

  19. 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.

  20. 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

  21. 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

  22. Questions?? • Other Issues??

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