Author Archives: SWORBHP

Synergy!

Synergy!

Posted on: July 8th, 2020

Synergy!

When utilizing the analgesia Medical Directive: Remember, “Whenever possible, consider co-administration of acetaminophen and ibuprofen.” The reason being that both act in different ways to produce analgesia.  Using both agents has been proven to have a synergistic effect: The combined effect of these two medications is greater than the effect of the two medications administered alone (i.e. 1 + 1 = greater than 2).

Beaudoin FL.  Combination of ibuprofen and acetaminophen is no different than low-dose opioid analgesic preparations in relieving short-term acute extremity pain.  BMJ Evid Based Med.  2018;23(5):197-198.

Derry CJ, Derry S, Moore RA.  Single dose oral ibuprofen plus paracetamol (acetaminophen) for acute postoperative pain.  Cochrane Database Syst Rev. 2013;24(6)

  • Was this Helpful?
  • Yes   No

Dextrose “Titration”

Dextrose “Titration”

Posted on: June 24th, 2020

Tricyclic antidepressants (TCAs)

Titration = adjustment of drug until the desired clinical effect is achieved.

Some drugs we administer to effect: i.e. Oxygen for target Sp02, IV Naloxone for target RR, Dopamine for target SBP.  An initial starting dose is administered and further dosing altered based upon response.

However, some medications are “titrated” with repeated set dosages. For example, under the Hypoglycemia Medical Directive, D10W is given 0.2g/kg (2mL/kg), every 10minutes (to a maximum of 2 dosages), to correct symptomatic hypoglycemia.  The dose given each time (2mL/kg) is not altered and the entire dosage should be completed in its entirety, not stopped early (i.e. after 1mL/kg) if the patient regains normal LOA.  This is to ensure adequate glucose replacement to overcome the threshold of hypoglycemia which varies from patient to patient.

  • Was this Helpful?
  • Yes   No

Tricyclic antidepressants (TCAs)

Tricyclic antidepressants (TCAs)

Posted on: June 19th, 2020

Tricyclic antidepressants (TCAs)

Tricyclic antidepressants are among the earliest antidepressants developed and utilized in health care.  Although used less for their antidepressant function, they have seen a resurgence as they are increasingly being used to treat other conditions (e.g. neuropathic pain management, restless leg syndrome etc).  TCAs improve mood by creating a functional increase in the levels of serotonin and norepinephrine, however they also affect histamine and acetylcholine levels causing unwanted side effects.   In general, TCAs have a narrow therapeutic window making appropriate dosing difficult.  Compounded upon this is the high rate of drug-drug interactions due to TCA’s impairment of hepatic metabolism: which can cause increased TCA side effects as well as increased serum concentration and toxicity of other medications.

However, the most concerning feature of this drug class is the potential for rapid and lethal overdose, when taken in large amounts.  The combined effects of TCA on various receptors and ion channels (including the cardiac myocyte sodium-channels) lead to depressed level of consciousness, seizures, hypotension and, wide-complex cardiac arrhythmias.

Be on the lookout for these medications in overdose calls.  If suspected, initiate expedient transport to hospital and be prepared for rapid deterioration.  As mentioned in the ACP 2018 MCME Precourse, history of TCA overdose and a QRS of >100 is a consideration for patching for Sodium Bicarbonate, to treat the sodium-channel blocking mechanism of the lethal arrhythmias.  If the patient seizes, it is safe to follow your Seizure Medical Directive and administer Midazolam.

Brand Name Generic/Chemical Name MedScape Reference
Elavil amitriptyline http://reference.medscape.com/drug/levate-amitriptyline-342936
Pamelor, Aventyl nortriptyline http://search.medscape.com/search/?q=nortriptyline
Vivactil protriptyline http://reference.medscape.com/drug/vivactil-protriptyline-342945
Surmontil, Trimip, Tripramine trimipramine http://reference.medscape.com/drug/surmontil-trimipramine-342947
Anafranil Clomipramine http://reference.medscape.com/drug/anafranil-clomipramine-342938
Silenor Doxepin http://reference.medscape.com/drug/silenor-doxepin-342940
Tofranil Imipramine http://reference.medscape.com/drug/tofranil-pm-imipramine-342941

References

Mayo Clinic Staff (2017).  Tricyclic antidepressants and tetracyclic antidepressants. Retrieved from http://www.mayoclinic.org/diseases-conditions/depression/in-depth/antidepressants/art-20046983

Nickson, C. (2009). Tricyclic antidepressant toxicity.  Retrieved from https://lifeinthefastlane.com/toxicology-conundrum-022/

  • Was this Helpful?
  • Yes   No

Scope of Practice – IV Certification

Scope of Practice – IV Certification

Posted on: June 10th, 2020

Closing the Circuit: Taping the King LT Suction Port

Can a non-IV certified paramedic assume care of a patient once an IV has been established by their IV certified partner?

The short answer is no.  If the IV has been initiated because the patient requires or is anticipated to require an intervention requiring IV access (which is why the IV would be placed) then the patient should be cared for by the paramedic who is capable of utilizing this access.

The longer explanation can be found in the latest SWORBHP PCP vs PCP Expanded Scope Crew Configuration – Division of Responsibilities Policy (June 2019)  and SWORBHP PCP/ACP Crew Configuration – Division of Responsibilities Policy (June 2019).  The following are the pertinent sections of each:

  • 0 The PCP with expanded scope and certified in auxiliary medical directives MUST attend any patient when the patient has received, requires, or is anticipated to require an intervention or treatment requiring the expanded scope of the auxiliary medical directives.
  • 1 The PCP with expanded scope and certified in auxiliary directives will not perform auxiliary medical directives of expanded scope and then transfer care to a PCP crew for transportation to hospital unless there are extenuating circumstances. These must be reported through the SWORBHP Communication Line
  • 0 The ACP MUST attend any patient when the patient has received, required, or is anticipated to require an intervention or treatment beyond the PCP scope of practice.
  • An ACP crew will not perform ACP medical directives and then transfer care to a PCP crew for transportation to hospital unless there are extenuating circumstances. These must be reported through the SWORBHP Communication Line/
  • In cases where an ACP is attending, transfer of care to a PCP crew can occur in hospital offload delay as long as treatment beyond PCP scope of practice has not occurred.

 

 

  • Was this Helpful?
  • Yes   No

Unusual Critical Circumstances: When to call for help

Unusual Critical Circumstances:  When to call for help

Posted on: June 4th, 2020

Closing the Circuit: Taping the King LT Suction Port

Unfortunately, not every call is straightforward, nor fits nicely into our Medical Directives.

For example,

You arrive on scene to find an adult patient trapped under a large grain bin.  The only visible portion of the patient’s body is their head and left arm.  The bin is covering their chest up to the clavicle area.  Therefore, your assessment abilities are limited.

C – You palpate no carotid pulse.  You are unable apply the defib pads to the patient and therefore cannot analyze the rhythm nor determine a “Monitored HR” for TOR assessment.

A – The airway is filled with blood and tissue, requiring suctioning.

B – Once the airway is cleared, you attempt to ventilate and are unable to do so.

D – Altered LOA (GCS 3)

What do you do now? 

Does this patient meet TOR criteria? They are ≥ 16, with altered LOA, no detectable HR nor RR and you are unable to obtain an SBP.  They have no palpable pulses.  However, you are unable to obtain a “Monitored HR”, determine their underlying rhythm, nor able to deliver defibrillation.

Do you continue the resuscitation?  How?  Time to call for direction!

In cases where the directives are not clear, as in this situation, patching to the BHP is designed to: Address situations that fall outside of the Medical Directives, help direct management and provide advice for your individual call circumstance.

  • Was this Helpful?
  • Yes   No

Hello, I was wondering if SWORBHP can offer out some assistance in obtaining CMEs for this year. Since there are no conferences to attend to, the hosting/posting of webinars doesn’t seem to happen anymore and online courses are fairly expensive. Could you link in some approved resources that we could utilize? I would love to see SWORB return to posting webinars more frequently.

Due to known patching issues inhibited by the currently required PPE can the OBHG look at omitting mandatory patch points specifically surrounding Midazolam and Ketamine administration for combative and excited delirium patients. I have never been denied an order for either of these medications and the time required to call for an order increases the risk of injury to everyone involved with the extra time required to complete the call delaying treatment. Second question, can we also look at increasing the maximum dose of Midazolam to 10 mg for combative patients as I have found that often times 5mg is insufficient especially when used on patients with known drug abuse. Or, is it possible for the OBHG to considering opening up Ketamine to be used on combative patients, as its my understanding Ketamine is a safer drug with less side effects?

*Updated* I wanted to clarify, which drugs/treatments are contraindicated after the patient is found to be hypotensive, even if the BP normalizes either with or without IV bolus therapy?

I was just reviewing a 2012 webinar regarding DNR confirmation forms. It was said that a DNR confirmation form is a contraindication for transcutaneous pacing but not for synchronized cardioversion. Is this the case? And if so then why? Also, what about the administration of other ALS drugs such as Atropine, Dopamine, and Adenosine?

If a dentist administers nitroglycerin to a patient who has no previous-prescribed use; does this constitute prescribed use at this point?

1 2 3 58