1 / 22

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.

kipling
Download Presentation

Paramedic Systems of Wisconsin

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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??

More Related