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Ambulance: Naloxone in Cardiac Arrest

Written by RSS Poster Medic Scribe

 

Case # 1

You find the fifty year old man supine on the floor with the fire department doing CPR. Their AED announces, “No shock advised. Continue CPR.”

You set your monitor by the man’s head and connect the fire department’s pads to your monitor, while your paramedic student quickly places an IO in the man’s tibia. As you approach the two minute mark, you charge the monitor, and then order stop CPR. The patient is in asystole. “Continue CPR,” you say, as you harmlessly dump the charge by hitting the joule button.

Just then the man’s wife announces, “Oh, my God! He was using heroin.” She holds the empty bags she has just found in the trash can. “He used to use. He’s been clean for five years.”

What drug do you give?

***

Epinephrine.

According to the 2010 AHA Guidelines

There is no data to support the use of specific antidotes in the setting of cardiac arrest due to opioid overdose.

Resuscitation from cardiac arrest should follow standard BLS and ACLS algorithms

Naloxone has no role in the...

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Ambulance: Surviving Post Naloxone

Written by RSS Poster Medic Scribe

You find the patient – a young man – in respiratory arrest in a Honda with tinted windows behind a service station.  His head is back, his mouth is open, and he is deeply cyanotic.  His skin is warm and despite having no respirations, he has a pounding carotid pulse.  On the floor board you see an orange capped syringe.  On his lap are crumpled heroin bags that say “Soul Survivor.”  The Fire Department has already squirted some naloxone up his nose and while your partner resumes bagging the man, you get the stretcher next to the car and then carefully extricate the man.  Slowly he begins breathing again on his own.  His ETCO2, which initially was 94, has come down to the 50s and then hits 35.  His SAT is 100.  You stop bagging and monitor him.

A minute later he opens his eyes with a start and tries to sit up.  You tell him he overdosed.  He says “What?  I don’t use drugs.”  You carefully explain that he was found not breathing in his car behind the service station.  He had a syringe in the car and empty heroin...

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Ambulance: Wild Wild West

Written by RSS Poster Medic Scribe

There is an anxious crowd on the corner of Hungerford as we come lights and sirens down Park Street.  A woman with tattooed arms waves for us to hurry.   A man is on the ground with a crowd clustered around him.   I can see another man kneeling over his chest. His arms together like he is doing  CPR.  “They hit him twice,”  a bystander says to me.  “Lot of people packing it on this corner.”

“He was just walking along and down he went,” another says.

“He gave him four in the right,” the first man says, and then nodding toward a shorter man wearing a Pittsburgh Pirates hat, “and he gave him two in the left.”  

The man on the ground has his eyes open now and starts looking around as the crowd cheers.

“You oded, man,” a man says to him, still holding the syringe with the atomizer on it.

“I did not,” he says.  “What are you all looking?”

“Man, you were out.  I did CPR on you, man.”

“No, I fine,” he says.  “I just fell out.”

“No, man,” a man with the 4 mg nasal spray in his hand says.  “You...

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Ambulance: Call of Duty

Written by RSS Poster Medic Scribe

“I’m a shit bag,” he says to me.  “I’m supposed to be taking my boy trick or treating tonight.  I can’t fucking believe I did this.  You said I wasn’t breathing?  After all I’ve been through to die like this.  Fuck me.  I’ve got shit for brains.”

The young man got out of jail an hour before.  Thirty days for failure to appear.  He got picked up by some acquaintances, who as a present gave him a bag of heroin to snort (“Just one bag,” he says, “and I snorted it.  I’ve never oded before.  And on top of that I’ve been clean for two months.”

They were going to drop him off at his girlfriend’s house who was going to drive him to his ex-wife’s house, who was going to let him take his son trick or treating.  Instead, when he turned blue and stopped breathing, they dumped him on the sidewalk in front of a hospital – only it wasn’t a hospital with an ED – and took off.  A security guard found him, called 911 and alerted the medical staff inside.

When he came around, I saw the panic in his eyes.  I was...

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Ambulance: Grade A

Written by RSS Poster Medic Scribe

The man kneels in the grass next the pickup truck that has its door open. He vomits.  The fire department is standing over him.  “Citizen Narcan found him in the truck passed out, squirted him with two doses and then took off when we got here,” a firefighter tells me. I see the two 4 mg nasal devices in the grass.

“Thank goodness for community narcan,” I say.

The vomiting man, who looks to be in his early fifties, rouses enough that my partner and our paramedic student are able to get him on our stretcher. I do a quick check of the truck to look for bags, but don’t find any. I do find a used syringe under the center fold down console. I find that odd as the fire department told me they also found a syringe. I do another look in the grass and then I see the bags – three fresh white bags sitting on top of the grass. The brand is a new one. “Grade A” stamped in blue.

On the way to the hospital I learn the man is a house painter. He hurt his back a few years ago when he fell off a ladder. He got hooked on the pain pills. Now he...

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Ambulance: Fentanyl Safety

Written by RSS Poster Medic Scribe

Finally!

The Federal Government has listened to the experts and released sensible evidenced-based recommendations on safety for first responders when encountering fentanyl and fentanyl analogues, including carfentanil.

Fentanyl Safety for First Responders

The document issued yesterday by the White House National Security Council is the product of their Federal Interagency Working group with collaborative support of groups such as the American College of Emergency Physicians, the American College of Medical Toxicologists and many other reputable organizations.

Gone are the scare tactics that declared that just touching fentanyl can kill you.  There is no more nonsense about delaying care to search for packages from China.  And the recommendation now is to give narcan for opioid toxidrome symptoms, not merely for exposure.  

The document acknowledges that “misinformation and inconsistent recommendations regarding fentanyl have resulted in confusion in the first responder community.”

Here are the key points:

Inhalation of airborne...

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Ambulance: Hope

Written by RSS Poster Medic Scribe

The call is for an overdose in the stairwell of the apartment building. Fire has arrived just before us – they have propped the front door open. I enter with my house bag over my shoulder and carrying the cardiac monitor in my right hand. There is no one in the dim lobby to direct me. I go through the door to the ground floor hallway. I see a stairwell to the far right and one to the far left. I take the one to the right. I don’t hear anyone in the stairwell, so I take the stairs two at a time (I am six eight so this is not too hard for me). I get to the top without encountering fire or an overdose. I come out on the fourth floor, and the go down the hall all the way to the far stairwell, and head down taking them only one at a time (I am 59 and my balance is not the best). I am back down on the ground floor with no patient. I have at least caught up with two firefighters who are trying to radio their fellow crew members to see if they have found anything. I head back up the stairs, stopping on each floor to look and listen. Finally, on...

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Ambulance: Controversies and Carfentanil

Written by RSS Poster Medic Scribe

Great article in the November 2017 edition of the  American Journal of Emergency Medicine about the  controversies surrounding the dangers of carfentanil, fentanyl and other fentanyl analogues.  The physician authors, John B. Cole and Lewis S. Nelson, take the Drug Enforcement Agency (DEA) and the media to task for sensationalizing the dangers to responders of these synthetic opioids.

They write that the DEA guidance that mucosal or dermal absorption of fentanyl can rapidly kill and the DEA video of two officers suffering symptoms following accidental exposure should, based on “real world and foundational” evidence, “be treated with healthy skepticism.”  They note that the officers’ symptoms are “inconsistent with opioid poisoning.”  They also note that “it is unquestionable that both drug user and sellers contact the product on a regular basis without apparent harm.”

Last month in Connecticut, the acting head of the DEA, Chuck Rosenberg, speaking at a Yale Law School Opioid Conference, continued to repeat the DEA’s...

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Ambulance: Endocarditis

Written by RSS Poster Medic Scribe

The patient is “a skin popper.”  She injects heroin into her skin rather than snorting it or injecting it directly into her veins.  Her arms are covered with sores in various stages of ulceration from old scars to open weeping sores. 

example of skin popper
The ambulance crew is there not for an overdose, but for chest pain and confusion.  The medic puts  electrodes on the woman’s chest and does a rapid 12-lead ECG.  The ECG shows huge anterior ST-segment elevations.    The 12-lead is transmitted and then a STEMI ALERT is made to the receiving hospital.  The cath team meets the patient at the ED door, but the doctor is concerned that the patient is having difficulty comprehending the consent instructions and is unable to write her name.  She is sent to the CT scan before being rushed up to the cath lab.  A Stroke Alert is called and as soon as the cath lab team has pulled several emboli out of her occluded left anterior descending artery, the neurology team takes over.  The CT scan revealed multiple septic emboli in the brain as...

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Ambulance: Non-Opioid Pain Management

Written by RSS Poster Medic Scribe

The state of Massachusetts just passed an emergency protocol change requiring all paramedic ambulances to carry non opioid pain management alternatives, including Ibuprofen PO, Acetaminophen PO and Ketorolac IV or IM.  Acetaminophen IV is optional.  The changes are to take place January 1, 2018.

Massachusetts Pain Management Protocol

Emergency Non-Opioid Pain Treatment Options Update

Here is the dosing regime:

Adult

Acetaminophen 1000 mg IV or PO

Ibuprofen 600 mg PO

Ketorolac  15 mg IV or 30 mg IM

Pediatric

Acetaminophen 15 mg/kg IV or PO to max 1000 mg.

Ibuprofen 10 mg/kg PO to max 600 mg.

Ketorolac 0.5 mg/kg IV or IM to max 15 mg.

The Massachusetts protocol includes the following note:

All pain medications have contraindications-do not administer medications in

such circumstances. These contraindications include but are not limited to:

Ketorolac and ibuprofen are contraindicated in head injury, chest pain, abdominal pain,

or in any patient with potential for bleeding, ulcer, or renal injury; likely to need...

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