Paramedic Systems of Wisconsin Rick Barney MD Beloit UW Madison 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 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  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??