I have a patient who has undergone a shoulder injection by another provider and ended up in the ER on pressors due to elevated blood pressure. He used betamethasone. She had another experience with iontophoresis with dexamethasone and again needed pressors. She has signs and symptoms of sacroiliac dysfunction and the next step after PT and manipulation is an injection which of course we cannot do due to the steroid issue. Does anyone have any ideas?
Steroid Allergy?
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might be a good idea to hold the pressors for patients with elevated BP. i assume you meant low blood pressure after cortisone injection
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Use a different steroid.
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What about sacral RF?
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Stress from an illness or injury can trigger an adrenal crisis on someone with low cortisol levels. Does the patient have a history of exogenous steroid use? Sounds like an internist and allergist mystery to be solved.
If the purpose of the injection is diagnostic, then no steroid is required. I have used ketorolac successfully in joints in the past with patients that insist on no steroids.
If the purpose of the injection is diagnostic, then no steroid is required. I have used ketorolac successfully in joints in the past with patients that insist on no steroids.
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Can you be allergic to a steroid? Probably more likely the preservative in the steroid. Ketorolac into the joint. Now there's an idea. As others have said, just do a diagnostic with local only and then SIJ RF if positive.
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I find that patients who have an "allergy" to steroids often have the same "allergy" to bendryl. They also have allergies to epinephrine ("makes my heart race"), NSAID's ("upsets my stomach"), morphine ("makes me itch") and codeine ("makes me drowsy").
Yeah, I know, people can have allergies to additives, dyes, etc. I think most of these people just experienced an unpleasant side effect and thought it was an allergy. E.g. face turned red, retained water, glucose went up.
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Allergies to steroids exist.
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i had a lady go into full-blow anaphylaxis after applying chlorhexidine swab to the back ...
1) within about 30 seconds of applying the chlorhexidine her heart goes up to 120bts/min... i attribute it to anxiety and the fact the chlorhexidine is cold
2) just as put the local anesthesia into the skin/subq she says her throat is closing up.
i flip her on her back... she is looking crappy... can't feel a pulse... heart rate is 140... BP cuff can't measure anything --- she is staring into the sky whispering that she can't breathe..
get O2 bag valve mask
get epi from code cart... no IV access --- nurse trying to find a vein... there are none
i give full stick of epi IM
tilt her trendelenburg (my nurse and x-ray tech lift foot end of table and shove several boxes underneath)... get an EJ... put in a 16g
get the intubation stuff ready
give 300mcg epi through EJ... BP now 60 systolic... still complaining of not being able to breathe (sats at 90%)...
pouring fluid into her, nurses now lifting her legs up and another 500mcg of epi...
about to intubate, just as she says I don't want to that thing in my mouth... i keep O2 w/ positive pressure on her...
her vitals recover... she looks like crap... transfer to ICU on low dose epi drip...
1) i didn't know people could anaphylax to prep (!)... her only history is of bee sting allergy... we use latex-free gloves all the time... so it ain't latex exposure
2) thank god for my anesthesia training
3) thank god I run a mock-code in the procedure room twice a year w/ nurses, aides and x-ray techs... they were all cool as cucumbers
4) that REALLY screwed up my schedule for the day because i spent about an hour w/ her before i could get on w/ my day...
1) within about 30 seconds of applying the chlorhexidine her heart goes up to 120bts/min... i attribute it to anxiety and the fact the chlorhexidine is cold
2) just as put the local anesthesia into the skin/subq she says her throat is closing up.
i flip her on her back... she is looking crappy... can't feel a pulse... heart rate is 140... BP cuff can't measure anything --- she is staring into the sky whispering that she can't breathe..
get O2 bag valve mask
get epi from code cart... no IV access --- nurse trying to find a vein... there are none
i give full stick of epi IM
tilt her trendelenburg (my nurse and x-ray tech lift foot end of table and shove several boxes underneath)... get an EJ... put in a 16g
get the intubation stuff ready
give 300mcg epi through EJ... BP now 60 systolic... still complaining of not being able to breathe (sats at 90%)...
pouring fluid into her, nurses now lifting her legs up and another 500mcg of epi...
about to intubate, just as she says I don't want to that thing in my mouth... i keep O2 w/ positive pressure on her...
her vitals recover... she looks like crap... transfer to ICU on low dose epi drip...
1) i didn't know people could anaphylax to prep (!)... her only history is of bee sting allergy... we use latex-free gloves all the time... so it ain't latex exposure
2) thank god for my anesthesia training
3) thank god I run a mock-code in the procedure room twice a year w/ nurses, aides and x-ray techs... they were all cool as cucumbers
4) that REALLY screwed up my schedule for the day because i spent about an hour w/ her before i could get on w/ my day...
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same lady gets allergy eval .... allergist recommends that she avoid beta-blockers... i point out that since she was able to increase her heart rate to 140, beta blockers obviously didn't affect her anaphylaxis... allergist recommends avoiding chlorhexidine prep... great, that was a worthwhile consult...
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wow..I've heard about allergies to contrast this bad, but not to chlro.
See this is the issue I have when non-anesthesia trained individuals do interventional techniques say at a ASC or anywhere. Do you really think a PMR, psych or neuro trained person could resuscitate the pt in the manner you did? I highly doubt it..it simply cant be taught in a 1 year fellowship in Pain Medicine.
This stuff was second nature to YOU since you had anesthesia training...This isnt meant to 'flame' the others. But seriously I know several residents in neuro,psych, pmr...they've even told me they havent started an IV ever! They havent picked up a needle in years! Yes, they may have the muscoskeletal and other skills. But let's be honest. The money is in the interventions. If you do these interventions, you need to be trained in how to manage things when pt's code.
Imagine now starting an IV in a pt in your case where the BP was likely 40/palp.
Not an indeal situation to just start learning how to resuscitate...
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wow..I've heard about allergies to contrast this bad, but not to chlro.
See this is the issue I have when non-anesthesia trained individuals do interventional techniques say at a ASC or anywhere. Do you really think a PMR, psych or neuro trained person could resuscitate the pt in the manner you did? I highly doubt it..it simply cant be taught in a 1 year fellowship in Pain Medicine.
This stuff was second nature to YOU since you had anesthesia training...This isnt meant to 'flame' the others. But seriously I know several residents in neuro,psych, pmr...they've even told me they havent started an IV ever! They havent picked up a needle in years! Yes, they may have the muscoskeletal and other skills. But let's be honest. The money is in the interventions. If you do these interventions, you need to be trained in how to manage things when pt's code.
Imagine now starting an IV in a pt in your case where the BP was likely 40/palp.
Not an indeal situation to just start learning how to resuscitate...
Same situation could happen to a GI doc or interventional radiologist or even the dermatologist doing a procedure with chloroprep. Do you have an issue with these non-anesthesia people doing interventional procedures?
Don't get me wrong, Anesthesiology training is invaluable in these crash situations, nobody can argue that. I'm grateful for my airway management training.
It simply is impossible to limit all interventional techniques to only anesthesiologists.
Cases like this also make good argument for intraosseous access as well...
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I'm only pointing out that these 'simple spinal injections' can be turned into something quite diastrous. I mention this because I've been on the trail very recently. I've sat next to non-anesthesia folks who for whatever reason seemed to be more defensive. For example, I met one guy that was like "psych is a clear extension for pain management. And let's be real it's just about putting a needle under fluro into a patient and injecting some meds'.
While I believe pain management should be a multi-faceted approach. I dont think these are 'simple injections and needle placement'. Tenesma illustrated above what exactly COULD happen.
In terms of IO lines. I'm not sure how many people actually keep those IO drills in their offices
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I'm only pointing out that these 'simple spinal injections' can be turned into something quite diastrous. I mention this because I've been on the trail very recently. I've sat next to non-anesthesia folks who for whatever reason seemed to be more defensive. For example, I met one guy that was like "psych is a clear extension for pain management. And let's be real it's just about putting a needle under fluro into a patient and injecting some meds'.
While I believe pain management should be a multi-faceted approach. I dont think these are 'simple injections and needle placement'. Tenesma illustrated above what exactly COULD happen.
In terms of IO lines. I'm not sure how many people actually keep those IO drills in their offices
I think you picked an especially bad example for your "anesthesologists reign supreme" schitck. Chloroprep is used by everyone at my institution. PM&R, rheum, you name it. Its why code teams, rapid response, etc. exist in part. What percentage of pts does this happen to?
If someone is doing procedres in their office w/o anesthesia training, away from a hospital, then yes the pt is at more risk for that rare issue. Thats why informed consent and prepartion are important. If I were a physician like that I'd find out how long the local ambulance takes to respond and drill with my staff as someone rec'd above. I would also have an IV in every pt with a funny allergy history, and hire a RN who used to work in an ICU and get started an IV faster than whistlers mother.
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Not meant to be a 'flame war'. The point is not just related to steroid allergies, it could have been related to cntrast (more common).
These things maybe 'rare' but they are the ones that are fatal It just tkes one case that goes south to ruin your career my friend. Just one. It could happen to anyone. It's about how you manage the situation. Not sure how many times you've give 300 mcg of epi. I've done it in code situations in the OR. On top of that he had gven 1mg IM. That's huge. This means this lady was in really bad shape before he resuscitated her.
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argh... i didn't mean to post something about anesthesia vs other specialties...
the reality is that bad stuff can happen to any one...
reactions likes these are extremely rare and can happen to anybody...
to go through anesthesia training for an event that may happen once every three years is a bit overkill...
what is KEY is for interventionalists to have a system in place to address these issues
1) the correct equipment available within a few seconds... you don't want to be hunting for an IV bag and an angio cath for 5 minutes
2) clearly defined roles in the event of an emergency - ie: somebody who calls 911/calls for more help...
3) take certain precautions - when i used to do office based procedures, all the patients had IVs in place prior to the procedure.
4) practicing mock-codes on a semi-regular basis ...
figures sleepisgood would distort this...
the reality is that bad stuff can happen to any one...
reactions likes these are extremely rare and can happen to anybody...
to go through anesthesia training for an event that may happen once every three years is a bit overkill...
what is KEY is for interventionalists to have a system in place to address these issues
1) the correct equipment available within a few seconds... you don't want to be hunting for an IV bag and an angio cath for 5 minutes
2) clearly defined roles in the event of an emergency - ie: somebody who calls 911/calls for more help...
3) take certain precautions - when i used to do office based procedures, all the patients had IVs in place prior to the procedure.
4) practicing mock-codes on a semi-regular basis ...
figures sleepisgood would distort this...
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First off Dude, chill out!
Step back and forget about your preconceived reservations about me and look to see what is safer for the patient.
I did say that this could happen to ANYONE. If you are doing these sorts of procedures in the office you need to 1)be well versed/skilled in advanced resuscitory methods 2) have a well oiled machine to address these issues PERIOD.
All I was saying is that people shouldnt just think, hey these are 'benign procedures'
Step back and forget about your preconceived reservations about me and look to see what is safer for the patient.
I did say that this could happen to ANYONE. If you are doing these sorts of procedures in the office you need to 1)be well versed/skilled in advanced resuscitory methods 2) have a well oiled machine to address these issues PERIOD.
All I was saying is that people shouldnt just think, hey these are 'benign procedures'
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what i learned also is it's also important to know how to react and interact with the patient and his/her family after an adverse event. Too many times, our first instinct is to get upset or frustrated about the situation, then try to figure out why it happened, then perhaps get scared that there may be a lawsuit. Some physicians ignore the family or try not to talk to them too much from fear that whatever they say will be used against them.
i learned through experience, both as a physician and as a family member, that the most important thing is to make sure the patient and family know that the priority is taking care of the complication/situation first - then figuring out the cause. communicating with the patient and family constantly and updating continuously , explaining tests, treatment options, etc. going over imaging, etc. and physically showing up as much as possible - is the best way to establish and maintain rapport with the family. When you avoid their phone calls and you don't show up physically, that's when they start wondering if there is something you are trying to hide. Most patients know that complications are possible and they know that they are taking a risk when going through a procedure. They may not expect it, but it shouldn't be a total surprise.
All of the above requires a certain level of emotional maturity and getting over the annoyance factor of having to shut down clinic, waking up in the middle of the night to go to the ER, or seeing an inpatient every day until they are discharged. I think that medical training will give you the tools you need to medically handle the situation (i.e. run codes, etc.) but knowing how to communicate and handling the repercussions of a complication takes more than technical/medical training.
To the patient, it really doesn't matter if you are anesthesia/PM&R/Psych/Neuro background, or what prestigious institution you trained, or how many procedures you have done. All of those things don't really matter if you are an a**hole that doesn't know how to communicate, or if you are working at a mill and don't have much history or rapport with the patients, or you just don't care enough to handle the complications yourself (delegate to ER, mid-level, etc.).
and honestly, until you have been in that situation, you really don't know how it feels
i learned through experience, both as a physician and as a family member, that the most important thing is to make sure the patient and family know that the priority is taking care of the complication/situation first - then figuring out the cause. communicating with the patient and family constantly and updating continuously , explaining tests, treatment options, etc. going over imaging, etc. and physically showing up as much as possible - is the best way to establish and maintain rapport with the family. When you avoid their phone calls and you don't show up physically, that's when they start wondering if there is something you are trying to hide. Most patients know that complications are possible and they know that they are taking a risk when going through a procedure. They may not expect it, but it shouldn't be a total surprise.
All of the above requires a certain level of emotional maturity and getting over the annoyance factor of having to shut down clinic, waking up in the middle of the night to go to the ER, or seeing an inpatient every day until they are discharged. I think that medical training will give you the tools you need to medically handle the situation (i.e. run codes, etc.) but knowing how to communicate and handling the repercussions of a complication takes more than technical/medical training.
To the patient, it really doesn't matter if you are anesthesia/PM&R/Psych/Neuro background, or what prestigious institution you trained, or how many procedures you have done. All of those things don't really matter if you are an a**hole that doesn't know how to communicate, or if you are working at a mill and don't have much history or rapport with the patients, or you just don't care enough to handle the complications yourself (delegate to ER, mid-level, etc.).
and honestly, until you have been in that situation, you really don't know how it feels
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wow..I've heard about allergies to contrast this bad, but not to chlro.
See this is the issue I have when non-anesthesia trained individuals do interventional techniques say at a ASC or anywhere. Do you really think a PMR, psych or neuro trained person could resuscitate the pt in the manner you did? I highly doubt it..it simply cant be taught in a 1 year fellowship in Pain Medicine.
This stuff was second nature to YOU since you had anesthesia training...This isnt meant to 'flame' the others. But seriously I know several residents in neuro,psych, pmr...they've even told me they havent started an IV ever! They havent picked up a needle in years! Yes, they may have the muscoskeletal and other skills. But let's be honest. The money is in the interventions. If you do these interventions, you need to be trained in how to manage things when pt's code.
Imagine now starting an IV in a pt in your case where the BP was likely 40/palp.
Not an indeal situation to just start learning how to resuscitate...
You're right. We'll all stop exposing patients to any chemicals that could potentially cause anaphlaxis or any other potenitally life-threatening reaction, until we have an anesthesiologist on stand-by. Which pretty much rules out doing anything except seeing the patient from a distance and offering advice about exercise. I shudder at the thought of all those patients I've chloroprepped before joint injections. I coulda killed them all!!!
Pardon me while I go bury all those patient's I was not sufficiently trained enough to save their lives from lack of an anesthesiologist 10 feet away.
Couldn't help but laugh at SleepIsGood stirring the pot again. But he does bring up an interesting point which I've discussed with other PMR docs who did ACGME fellowships. Should people who don't have extensive experience running codes, in particular intubations, only perform these procedures in ASC/Hospitals? In which case practically speaking only Anesthesiologists would get to do them in office settings. Some physiatrists have admitted off the record that they wouldn't be able to handle an emergency situation by themselves yet they still do procedures in their office for financial reasons.
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Well If wanted a comprehensive pain doctor, I would choose with fellowship training in pain Mgmt, extensive musculoskeletal experience, neuro experience, someone who could perform and interpret EMG/NCS- but that is just me.
i agree with everything except the emg thing. They are a HUGE waste IMHO. Rarely do I see their utility, and I often seeing them being done primarily because they know how, or to "confirm the diagnosis"
I rarely order them. I thought about learning how to do them, in case I needed to, but its just not worth it to me.
But thats just me...
maybe people are defensive around you because you are an a-hole.
EMGs are over-ordered, poorly interpreted, and often lead to improper treatment. however, when ordered on the right patients, for the right reasons, and performed well, they can be very valuable.
clearly, anesthesiologists bring a lot to the table when it comes to the nightmare scenario that tenesma posted (i think i had allergic reaction to just reading that post). however i have yet to meet one who really had a good grasp of when they should be used, which ones are crap, and how to interpret them. this in and of itself takes years to master.
dont let the bonehead neurologists looking for some easy procedural cash completely sway your opinion on the value of an appropriately performed EMG.
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1) I do not believe that office-based procedures should be done by anybody who is not comfortable with advanced resuscitation.... i have reviewed enough legal cases of patients w/ problems in the office during/after the procedure and the interventionalists (who weren't anesth) basically waited, leaning against the wall while 911 took 8 minutes to arrive... so for all those non-anesth folk doing office-based procedures, do yourself a favor and A) make sure you have current ACLS training B) you feel very, very comfortable managing a code with the knowledge that 911/ambulance ain't gonna show up for up to 10-15 minutes.... in fact, in my state there are VERY few non-anesth doing procedures in their own office, most prefer ASC/hospitals... which i think is quite appropriate
2) while being a lowly-anesth, i believe any pain doctor should not order tests without understanding the way they are done, what it feels like and what to do with the results... I primarily use EMGs to document that a weakness is not neurologic... for example, a lot of my personal injury/work comp patients have all kinds of weaknesses that are non-neurologic on exam (ie: have almost complete loss of strength handgrasp/intrinsics and yet have no problem holding their flavored coffee in that hand and have no problem picking up their HUGE handbag) ... those patients/and their creepy lawyers tend to not come back after the EMG
2) while being a lowly-anesth, i believe any pain doctor should not order tests without understanding the way they are done, what it feels like and what to do with the results... I primarily use EMGs to document that a weakness is not neurologic... for example, a lot of my personal injury/work comp patients have all kinds of weaknesses that are non-neurologic on exam (ie: have almost complete loss of strength handgrasp/intrinsics and yet have no problem holding their flavored coffee in that hand and have no problem picking up their HUGE handbag) ... those patients/and their creepy lawyers tend to not come back after the EMG
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and the above points out the weakness of the anesth based pain doctor...
i have had to do a LOT of learning, shadowing, CMEs, etc to catch up on my MSK skills, neurologic issues....
another reason why we need a pain residency or a 2 year pain fellowship...
gosh... i am still learning new things...
i have had to do a LOT of learning, shadowing, CMEs, etc to catch up on my MSK skills, neurologic issues....
another reason why we need a pain residency or a 2 year pain fellowship...
gosh... i am still learning new things...
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This is all I'm saying.
Again, I think some guys like SSdoc and others get a little riled up for no reason.
Look, if you arent comfortable or competent in resuscitation, you shouldnt be doing office based procedures at your office. If you are somewhere (hosp based) where a code team or something can come quickly...totally different story.
Bottom line is safety for patient. Mock all you want about chloraprep or steroids. I agree they are benign. I'm not saying Anesthesiologists should always be around. But if they arent, you better make sure you are competent in resuscitation. Or else, there are going to be plenty of people ready to nail you.
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Hands down disasters are better handled by anesthesiologists but fortunately disasters are few and far between. However it goes w/o saying that all nonanesthesia pain practitioners should be well trained and equipped to handle these types of situations, at least until the medic or anesthesiologist arrives. I've been told time and again that intubation isn't necessarily the key, rather good bagging is what's needed. True?
I'd like to take a poll. What would most people give (doses) and do in the following situations and in what order:
1) You inject dye to confirm adequate epidural spread. Few minutes later man says he's starting to itch, can't breath and bps 100/60 and dropping....
2) You inject dye and few minutes later guy breaks out in hives and starts itching all over but no anyphylaxis or airway edema.
3) You do a cervical TFESI and guy becomes unresponsive and starts seizing...
4) You do a cervical ILESI with local and guy becomes unresponsive (clinical picture c/w high spinal) ...
Just thought I'd be a fun little exercise since I'm sure people give somewhat different meds at somewhat variable doses (i.e. subq vs IV epi)
I'd like to take a poll. What would most people give (doses) and do in the following situations and in what order:
1) You inject dye to confirm adequate epidural spread. Few minutes later man says he's starting to itch, can't breath and bps 100/60 and dropping....
2) You inject dye and few minutes later guy breaks out in hives and starts itching all over but no anyphylaxis or airway edema.
3) You do a cervical TFESI and guy becomes unresponsive and starts seizing...
4) You do a cervical ILESI with local and guy becomes unresponsive (clinical picture c/w high spinal) ...
Just thought I'd be a fun little exercise since I'm sure people give somewhat different meds at somewhat variable doses (i.e. subq vs IV epi)
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1) get help, epi, benadryl, solumedrol
2) benadryl, solumedrol
3) ABC (airway, breathing, circulation) if seizures persist or limit intubation would give propofol then some ativan
4) ABCs....
i do not include local with thoracic or epidural ESIs... specifically because of scenario #4.
2) benadryl, solumedrol
3) ABC (airway, breathing, circulation) if seizures persist or limit intubation would give propofol then some ativan
4) ABCs....
i do not include local with thoracic or epidural ESIs... specifically because of scenario #4.
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Of course for all these the patient first thing is get help (possibly 911) and ABC.
1) get help, legs up, start IV , give diphenhydramine, solumedrol. Would hold on epi until reasses breathing and BPs. Would have someone listen to breath sounds. If really bad and BP bad then would give EPI.
2) benadryl, solumedrol
3) ABC (airway, breathing, circulation). Put patient on the side so he doesnt aspirate. If sz continues, I would give pentothal or propofol, sux, tube. At the bare minimum would try to VENTILATE the patient. As someone stated, intubation may not be as important as VENTILATING..however, when szing, aspiration is a real possibility and a secure a/w is ideal.
4) same as 3. Ventilate until spinal wears off....I'm assuming there's no ventilator available in the office, so one would have to support BP,HR, and essentially 'bag' until patient can be transferred to a hosp.
1) get help, legs up, start IV , give diphenhydramine, solumedrol. Would hold on epi until reasses breathing and BPs. Would have someone listen to breath sounds. If really bad and BP bad then would give EPI.
2) benadryl, solumedrol
3) ABC (airway, breathing, circulation). Put patient on the side so he doesnt aspirate. If sz continues, I would give pentothal or propofol, sux, tube. At the bare minimum would try to VENTILATE the patient. As someone stated, intubation may not be as important as VENTILATING..however, when szing, aspiration is a real possibility and a secure a/w is ideal.
4) same as 3. Ventilate until spinal wears off....I'm assuming there's no ventilator available in the office, so one would have to support BP,HR, and essentially 'bag' until patient can be transferred to a hosp.
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Everybody on the board will be subject to an emergent medical case or issue as some point (especially if you are busy) in their practice. I have my own stories that were independent of the injection process but secondary to medical conditions. I am well equipped and trained to handle these issues. Just as I am trained in multidisciplinary approaches, both interventional, medical, and in the CAM realm.
Why argue whether a neurologist, anesthesia, or PMR is the better physician, when in the end your outcomes, referral base, and reputation will determine how effective you are in a competitive market/community. There are some amazing physiatrist/neurologists in my regeon subscribing to huge doses of opioids for everybody, with occasional diagnostic EMGs/NCV every 2 years. This is their philosophy and training, not mine.
Furthermore, I cannot even recall if an EMG/NCV has ever really made a significant difference in a patient's outcome or management. Maybe I should be relying on this test more often, and ignoring clinical acumen.
Why argue whether a neurologist, anesthesia, or PMR is the better physician, when in the end your outcomes, referral base, and reputation will determine how effective you are in a competitive market/community. There are some amazing physiatrist/neurologists in my regeon subscribing to huge doses of opioids for everybody, with occasional diagnostic EMGs/NCV every 2 years. This is their philosophy and training, not mine.
Furthermore, I cannot even recall if an EMG/NCV has ever really made a significant difference in a patient's outcome or management. Maybe I should be relying on this test more often, and ignoring clinical acumen.
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I'm just a physiatrist, so I would lean against the wall and wait for the paramedics to arrive, wishing to God I had become an anesthesiologist instead...
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1. Call 911, open fluids, SQ epi, remove needle, flip patient, O2, benadryl.
2. Benadryl, monitor
3. Don't do TFESI in the neck.
4. High spinal? I use 2cc Celestone and 2cc NSS. Spinal that.
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Alright so everyone's saying epi. You go subq or IV? 1:10,000 or 1:100,000? How many cc's? And what about ephedrine (5mg/cc) Save that for other hypotensive emergencies, not anaphylaxis? And for the guy seizing, is it cool just to give a few cc's of midaz since it's already out for your sedation cases? And for the high spinal, would you typically see hypotension and brady? Never seen one so trying to remember. In that case do you pull the epi or something like phenylephrine or ephedrine? Just curious what guys who've experienced more acute situations would recommend. How obvious is the physiatry background now?
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any anaphylactic reaction you have to use epi. epi stabilizes mast cell membranes along with treating the blood pressure issue.
guy seizing - priority is airway. secure airway. use thiopental or valium to calm seizures before intubating
high spinal - you have complete sympathectomy with causes brady/hypotension. use epi again. atropine is a muscarinic antagonist, causing unopposed sympathetics, but if u have no sympathetic flow, i believe epi would be a better choice because atropine would not be as effective. but pour in fluids (increase preload/venous side) and epi and any pressor available until you can give epi. secure airway first if they can't breath. yes you are PMR
guy seizing - priority is airway. secure airway. use thiopental or valium to calm seizures before intubating
high spinal - you have complete sympathectomy with causes brady/hypotension. use epi again. atropine is a muscarinic antagonist, causing unopposed sympathetics, but if u have no sympathetic flow, i believe epi would be a better choice because atropine would not be as effective. but pour in fluids (increase preload/venous side) and epi and any pressor available until you can give epi. secure airway first if they can't breath. yes you are PMR
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Alright so everyone's saying epi. You go subq or IV? 1:10,000 or 1:100,000? How many cc's? And what about ephedrine (5mg/cc) Save that for other hypotensive emergencies, not anaphylaxis? And for the guy seizing, is it cool just to give a few cc's of midaz since it's already out for your sedation cases? And for the high spinal, would you typically see hypotension and brady? Never seen one so trying to remember. In that case do you pull the epi or something like phenylephrine or ephedrine? Just curious what guys who've experienced more acute situations would recommend. How obvious is the physiatry background now?
Not sure which one of us you took a swipe at.
Epi. I just read the sheet on the inside of the cabinet.
Absorption and subsequent achievement of maximum plasma concentration after subcutaneous administration is slower and may be significantly delayed with shock.10,11 Thus, intramuscular (IM) administration is favored.
* Administer epinephrine by IM injection early to all patients with signs of a systemic reaction, especially hypotension, airway swelling, or definite difficulty breathing.
* Use an IM dose of 0.3 to 0.5 mg (1:1000) repeated every 15 to 20 minutes if there is no clinical improvement.
Administer IV epinephrine if anaphylaxis appears to be severe with immediate life-threatening manifestations.12
* Use epinephrine (1:10 000) 0.1 mg IV slowly over 5 minutes. Epinephrine may be diluted to a 1:10 000 solution before infusion.
* An IV infusion at rates of 1 to 4 µg/min may prevent the need to repeat epinephrine injections frequently.13
If it's about the high spinal: Show me benefit from dumping bupi or lido into the epidural space and weigh it against the risks. Then tell me why would a a high spinal ever occur in Pain Medicine?
Its interesting to hear so many people say they never or rarely order or use EMGs. I think you are missing a potentially helpful tool. I do perform them and when done well on the right patients as an extension of the physical exam I feel like they can add a good amount of objective diagnostic and potentially prognostic information. I do wind up changing or at least adjusting my plan based on the results frequently.
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For similar reasons it is said to use Ephedrine whn you get a 'vasovagal' s/p cervical epidurals.
i thought he was being sincere, saying he has a PMR background, am i missing something?
ironically i had a new one...
going into hyoplycemic shock on the table today during an RF in my office...
started bradying into the 40s...diaphretic, BP was in 80s...
guess what i did?
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Yeah, Steve I wasn't taking a swipe. I was referring to my own PMR background. It didn't quite prepare me for these emergent situations. Had to learn this in my fellowship but fortunately (or unfortunately) I never had to use this info so I was curious about some of the specifics that become oh so important during these "think on your toes" situations.
And DocShark, lemme guess, you gave 1mg glucagon. My question is, how did you know that it was a hypoglycemic episode initially and not vasovagal, anaphylactic shock or sympathectomy from your procedure (assuming you were doing something around the sympathetics..)
gave her some glucose tabs she carries with, flipped her over, smacked her around, and waited a minute. All was fine when the glucose hit...
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If the rule is don't do the procedure if you can't handle the complications, then we are all out of luck when an epidural hematoma comes around.
We all need each other's help, and anyone who says they can handle all the potential complications of what we do doesn't have enough experience to be making such overly broad pronouncements.
We all need each other's help, and anyone who says they can handle all the potential complications of what we do doesn't have enough experience to be making such overly broad pronouncements.
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i agree w/ ampa but it is crucial that we have back-up plans in place...
for example, if you are doing spine procedures you should have at least 2 competent spine surgeons who are willing to decompress your patients within 12 hours and help co-manage bad situations that have now become surgical situations...
for example, if you are doing spine procedures you should have at least 2 competent spine surgeons who are willing to decompress your patients within 12 hours and help co-manage bad situations that have now become surgical situations...
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I don't know what backwoods state your from, but where I live all peanut salesmen at the ball park are required to be anesthesia trained
