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acute pain management

Discussion in 'Pre-Hospital [ EMS ]' started by joeDO2, 12.28.11.

  1. joeDO2

    joeDO2

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    one of the things that always frustrated me as a medic was the inability to achieve adequate pain control for the patient in acute distress. in the systems i have worked in, prehospital protocols typically max out at 10mg morphine / 150mcg fentanyl with the option to request more if necessary (which many medics do not take advantage of because calling the hospital could prove time consuming). quite frequently i've seen these doses only mildly effective for severe pain (esp in pelvic fx, femur fx, sickle cell, etc). i am wondering if anyone has seen such as repeating doses of opioids without a hard maximum or perhaps using something like ketamine?
  2. Altruist

    Altruist Hoodledooer

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    First off, I doubt most medical directors would be big fans of letting paramedics push ketamine without calling them.

    In my old system, we had the 10 mg limit for morphine under standing orders, but could pretty easily reach medical control for additional meds. I rarely ran into situations where I needed more.

    The times I did, the docs at the receiving hospital told me that if somebody coming in required several doses of pain meds, they wanted a heads-up about that patient. That sentiment among docs is the biggest reason I don't think you'll find many systems with higher limits than the ones you've worked under.

    Related anecdote: Even in a system with a standing order limit of 10 mg of morphine, I had members of the local opiod aficionado club quote my standing orders to me on calls. ("The last crew gave me 10 of morphine before they tried to move me!") With more liberal pain med protocols, god knows what that last crew would have given...
  3. Dzerzhinsky

    Dzerzhinsky Chekist It Out Lifetime Donor

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    My system allows up to 20 mg initial/10 mg repeat on standing orders alone. Our transport times are short (average 10-15 min), though; rarely do I see one of our medics actually pop the locks on the case, given that fact. Honestly, of greater concern than the dosing is getting BLS providers to call for a medic just for pain control in cases where it would be appropriate to do so; the resource is available, but it never gets used.
  4. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    I think there is some emerging literature, some of it coming from the military, about using low dose ketamine for analgesia in the field. I'll have to try to find it when I have some time. But it's not a radical suggestion. It is probably too cutting edge for the majority of agencies to consider at this point.
  5. psychbender

    psychbender Cynical Member

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    Are you talking about "Ketamine for Procedural Sedation and Analgesia by Nonanesthesiologists in the Field - A Review for Military Health Care Providers" ? Unfortunately, I cannot remember my log-in for that journal, and am not at work right now, so cannot attach the full article.
  6. joeDO2

    joeDO2

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    i agree, although there is evidence of efficacy, cutting edge and ems are not usually in the same sentence. maybe combining an opiate with nsaid would be more palatable? i know there is some good evidence out there with toradol and morphine having a good effect.
  7. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    Toradol has some problems, the main ones are that it has a greater degree of nephrotoxicity associated with it than with other NSAIDs and that it's no more effective than PO ibuprofen. NSAIDs also call increased bleeding so they are avoided in possibly surgical patients.

    We would probably do better with a combo of opiates and benzos. They are both already on the rigs and in the protocols. Adding some benzo to morphine can really help.
  8. proman

    proman Member Moderator

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    To be honest, ketamine in analgesic doses (ie 10mg q 15-20 min) would be a much safer choice compared to any other drug out there. I'm most concerned about respiratory depression with opiates, something that low dose ketamine does not cause. Obviously, I would not give ketamine in any dose to a patient with altered mental status. IV acetaminophen would be a useful adjunct. NSAIDs, in particular ketorolac, also impair bone healing.
  9. joeDO2

    joeDO2

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    interesting point with the acetaminophen...i had not thought of that. i know there have been a few studies demonstrating hypotension with it however (one of them showing 16% of patients in a small study required intervention to correct BP:
    Paracetamol for intravenous use in medium--and intensive care patients: pharmacokinetics and tolerance.
    de Maat MM, Tijssen TA, Brüggemann RJ, Ponssen HH
    Eur J Clin Pharmacol. 2010;66(7):713.

    although I suppose you could say the same about morphine (which is why i strongly prefer fentanyl in most cases)

    as for the respiratory depression with opiates- that is always cited as the highest concern but- I think the risk is actually much lower than it is made out to be...i've rarely seen significant respiratory depression with slow careful titration and in the few cases it does develop, it is easily reversed with naloxone. i would imagine this would be more of a concern in a setting that is less monitored. it is fairly easy to detect early respiratory changes in the ems 1 on 1 setting, esp with the advent of continuous waveform capnography.

    i'd be interested to know if anyone has tried the iv acetaminophen in the field or know of any pertinent studies
  10. Lawsonc

    Lawsonc Career Student

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    In my current system we are allowed to also give a benzo for pain management. We carry Valium, Ativan, and Versed, our primary choice is 2.5 of Valium (offline) with the option of more with a phone call. I have found the Valium + Morphine mixture works well for long bone fractures, isolated hip and femur fractures, etc.

    We also carry Nitrous Oxide (Nitronox) which works well and is easy to "dosage" as the patient holds the mouth piece.

    When it comes to pain management I often wonder if it is an issue of culture rather then the medication. When I was a basic, I worked in a system where just touching the box was a big deal, and medics rarely did unless they had to. Where I am now, narcotic usage is more liberal, and it is expected that field personnel treat and manage pain.
  11. proman

    proman Member Moderator

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    Benzodiazepines have no analgesic properties and are synergistic with opioids. The analgesic effect of opioid is increased, so are the adverse effects, including apnea. I've made patients apneic with 2mg of midazolam and 100 mcg of fentanyl. Morphine is a lousy drug. Its analgesic properties are average at best. It's sedating and pruritic because of histamine release (which also causes hypotension). Hydromorphone is really the drug that people should be trying to use. It causes much less histamine release and produces effective analgesia and is a familiar drug.

    BTW, the more paperwork that's involved in something the less likely someone is to do it. It applies to almost everything in life, including cracking the drug box.
  12. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    I've got to disagree on the Dilaudid. I think it's a horrible drug, a scourge really. It is euphoric so it is highly sough after by seekers and just by existing leads to scores of unnecessary ED visits in my area alone. It has a high incidence of apnea and I hope we soon banish it from EDs the way we have with Demerol. I'm on my health system's Pharmacy committee and all of the CNOs want it gone altogether from all the apnea incidents on the floors. We found that in our system when Narcan is used on inpatients it was for Dilaudid 90% of the time. I also would expect that Ambulance break ins would increase greatly if it became known there was Dilaudid in the boxes.
  13. proman

    proman Member Moderator

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    I'm not sure how to respond to your post. Dilaudid isn't a scourge when used properly in the right patient. I think the ED has lead to much of the abuse of the drug, it seems it's the only painkiller prescribed. Hydromorphone causes less dysphoria than a drug like morphine and is less sedating. The druggies like to get it with diphenhydramine and promethazine because of the sedating effects of those drugs. Meperidine is a whole other story where the toxic metabolites legitimately caused harm.

    What percentage of total patients received hydromorphone as inpatients? I'd guess almost all of them, so it's no surprise that the majority of complications happen with the drug used the most. As for break ins, I doubt there would be a spike if hydromorphone gets stocked. The IV street drugs are much more accessible and potent.
  14. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    I agree that it has its place when used very selectively. However putting it on ambulances and in acute pain protocols will cause it to be used very widely, i.e. in all acute pain patients transported by EMS.

    You note that the ED is responsible for Dilaudid abuse by overprescribing but you then say that almost all inpatients are on it as well. So it overprescribed on the inpatient side as well?

    I have many days where up to 30% of my patient load revolves around Dilaudid seeking. I'd just hate to see that overuse and abuse extended to EMS as well.
  15. proman

    proman Member Moderator

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    I've been answering in the context of an acute musculoskeletal pain protocol. It's much harder to be concerned about drug seeking behavior when there's a bone sticking out at you. Not impossible, but harder.

    My current hospital has a tremendously high rate of IVDA and other drug seekers. When the pain is legit, you still should treat it. Morphine isn't a good drug. Fentanyl is effective but I only recommend it in patients who are at risk of pulmonary complications (like OSA, COPD, etc). Hydromorphone is effective when used appropriately. As another issue, if you stop giving hydromorphone in the ED what are you going to use? Morphine? Fentanyl? Whatever you switch to will get the same abuse down the road, just like meperidine. There's no opioid currently available without side effects and abuse potential.
  16. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    I just don't see the rabid seeking of morphine to anywhere near the same degree as I see it for Dilaudid. Dilaudid closely mirrors Demerol in that respect. I think using morphine instead of Dilaudid is very viable, it's how I practice.

    I certainly believe your position and I do agree that for ortho issues in particular using Dilaudid in EMS settings could be valuable (although I do think the boxes would get jacked a lot). I just have such a high volume of Dilaudid specific seeking in my area I can't advocate for increasing its use.
  17. Lawsonc

    Lawsonc Career Student

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    Morphine = probably cheaper.


    I think the bigger crime is a medic truck with only 1 benzo on board.
  18. jwk

    jwk AA-C ASA-PAC Contributor

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    20mg of Morphine IVP? That's scary. You can start lower and give more after you actually take the time to assess your patient and the drug's effect. I would ream my anesthesia students a new one if they pushed that much on any patient.

    :thumbup: This is the difference with an anesthesia/pain management perspective. Right drug, right indication, right patient.
  19. Lawsonc

    Lawsonc Career Student

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    20mg IVP is really not all that uncommon when dealing with certain populations. Try a femur fracture on the way to your methadone clinic. I am pretty sure that was "up to 20mg" titrate.
  20. Lawsonc

    Lawsonc Career Student

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    Forgot to respond to this post, what was the purpose of 100mcg fentanyl and 2 of midazolam? Conscious sedation? I'm assuming you really wanted them out. I only like to use midazolam for RSI procedures, given the choice of other Benzos. I would think Valium or even Ativan would be a better "pain management" choice (of course as you have stated for synergistic properties). Given that my current service carries all three there is some liberal protocols to provider preference.

    The drug box issue was more cultural than paperwork in my opinion. All of the services I have worked, interned and then worked with had similar if not identical processes for narcotic usage, after all it is regulated by the same agency.

    I also wanted to bring up that in EMS we are limited in storage space and economics, It does not make sense to carry multiples of each class of drugs. Morphine probably won't ever go away because of its multiple uses. None of the mentioned drugs can be used for pain management and drop pressure in a fluid filled CHFer. I have worked in some services that carry only morphine, others that primarily use fentanyl, but I must say I am very happy in the current service that has both morphine and fentanyl with the option of benzos and nitrous oxide.
  21. leviathan

    leviathan Drinking from the hydrant Moderator Emeritus

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    Why do you think that?
  22. Lawsonc

    Lawsonc Career Student

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    All of the services I've seen that carry only one, carry versed. It has a short duration, has amnesic properties, and is useless for seizures. On the flip side, if you only had valium, you'd better have a hypnotic agent for intubation (such as etomidate) and figure out how your going to "comfortably" cardiovert someone. I can think of so many different indications for a benzo, but not one benzo that could cover them all.

    I don't think you need all three, and I know with the refrigeration issues some services are hesitant to use Ativan. Personally I think we all need another option, be it a Ativan/Versed combo, or Valium/Versed.

    There have been lots of pre-hospital research into the "ideal" benzo, and in most cases it includes Ativan. I will look for some sources and peer reviewed articles when I have some time.
  23. joeDO2

    joeDO2

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    -I would not say at all that versed is "useless" for seizures. There is some very good evidence suggesting its efficacy and I have used versed via nasal atomizer in patients without IV access with success in the past for status. It also has very minimal vascular effects compared to other agents making it a decent choice. For more info check out this study:
    Intravenous midazolam for the treatment of refractory status epilepticus.
    Kumar A, Bleck TP
    Crit Care Med. 1992;20(4):483.
  24. Lawsonc

    Lawsonc Career Student

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    I have seen it done with the nasal atomizer (both in the field and hospital), and unless im confused, its the only benzo of the three I've mentioned that can be done this way due to its water solubility. Since becoming a Paramedic I have not encountered any counties through my internship, or where I've been working that use the nasal route for any medication. I am going to look up that article, and then I will throw some more recent pre-hospital articles your way. It seems there is this divide, be it time (that article was in 1992) or be it which side of the spectrum you are on. Recent studies have really made versed out to be not that great. I don't not like it, but from personal experiences I have had better luck with Ativan and Valium.
  25. joeDO2

    joeDO2

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    I do find it interesting that some areas are not embracing this form of drug delivery. It appears well suited for the prehospital environment. I did a quick search for some more recent stuff to look at this more closely....here are some articles you may find interesting....

    Intranasal versus intravenous lorazepam for control of acute seizures in children: a randomized open-label study.
    Arya R, Gulati S, Kabra M, Sahu JK, Kalra V
    Epilepsia. 2011;52(4):788.
    Authors find no difference in seizure control between the intranasal and IV routes for ativan

    Intranasal midazolam vs rectal diazepam in acute childhood seizures.
    Bhattacharyya M, Kalra V, Gulati S
    Pediatr Neurol. 2006;34(5):355.
    Authors find intranasal midazolam preferable over rectal diazepam

    Intranasal midazolam vs rectal diazepam for the home treatment of acute seizures in pediatric patients with epilepsy.
    Holsti M, Dudley N, Schunk J, Adelgais K, Greenberg R, Olsen C, Healy A, Firth S, Filloux Arch Pediatr Adolesc Med. 2010;164(8):747.
    Authors find no difference between intranasal midazolam and rectal diazepam
  26. Lawsonc

    Lawsonc Career Student

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    I will check these out, I am actually enrolled in two classes that require personal research and review of current topics in EMS (research/articles) You might have helped me with some homework. :)
  27. joeDO2

    joeDO2

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    anything i can do to help! ;)
  28. tremulousNeedle

    tremulousNeedle

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    Anecdote alert: A couple months ago I had a chronic pain patient who developed a hematoma after a hip replacement. I had given Dilaudid 36mg IV by the time I transferred him. We were giving 5mg IV per dose by the end. He said it helped, but I really doubt I was making a dent in his pain. That’s equivalent to about 35-40mg of morphine IV per dose depending on the conversion factor you’re using.
  29. Dzerzhinsky

    Dzerzhinsky Chekist It Out Lifetime Donor

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    Thanks, Lawsonc; you are entirely correct. Yes, we don't blindly push 20 mg on a 100-pound 20-year-old with a bruise. That would be stupid. Fortunately we're not stupid. (Most of the time.)
  30. Lawsonc

    Lawsonc Career Student

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    Most I've had to give is 15mg Morphine and 2 of Valium during a rather short transport. I've heard about patients getting up to 50, but I wouldn't be surprised if I never run into one of those in the field (never say never in this game). During my internship I was fortunate enough to rotate through different agencies, and I never ran into an agency that carries that much. My current agency only carries 30 and then 300 of fentanyl.
  31. Lawsonc

    Lawsonc Career Student

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    In relations to the original posters question, and someones mention of ketamine, here is an article.

    Someone in a current class I am taking presented this article, and I thought if you hadn't seen it, you might be interested.

    Morphine and Ketamine Is Superior to Morphine Alone for Out-of-Hospital Trauma Analgesia: A Randomized Controlled Trial
    Annals of Emergency Medicine; 2011;xx:xxx.

  32. Rotors

    Rotors Medevac airborne ...

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    I know I'm a bit late to this one but,

    Intensive Care Paramedics have had ketamine for five years; it's great stuff, absolutely love it to bits. It is the bees knees! Australia also has it although they are a bit more conservative than we; i.e. in Queensland it can only be used for fractures whereas here the indication is simply "severe pain" so it can be pain of any aetiology.

    As with all our drugs we are limited only by professional judgement and the physical amounts we carry (400mg)

    We used to have morphine + midazolam from 2001-2007 and that was pretty good too but ketamine is far superior.

    Why would you want to call a Doctor? The days of a Doctor on scene ended here thirty years ago.
  33. AlmostJesus

    AlmostJesus

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    The Iowa state protocols that I work under define the pain management doses as a guideline, thus if we document reasoning correctly, we can give any amount. The recommended doses in the protocol are Morphine 2-4mg followed by another 2-4mg after 5 minutes or Fentanyl 25-50mcg every 5 minutes up to 100mcg. (We also carry toradol) The area where I like it is we can give benzos as a adjunct for severe pain. We carry valium and versed and we can give 2.5mg of either. We carry 20mg of morphine, 100mcg of Fentanyl (I would like to see more), 20mg Valium, and 20mg of Versed.
    I do wish it was standardized to a weight based dose of 0.1mg/kg morphine and 0.05mg/kg for those over 65 or 1mcg/kg of fentanyl that we can repeat. It would also be nice if we could give benedryl with our morphine for the synergistic, antihistamine, and antiemetic effects.
    When dealing with a patient in pain, generally I ask the patient if they would like something for pain.If yes, I will give them something based on my gestalt, if no, I wont give them anything. I had a hip patient a couple weeks ago that was still in pretty severe pain after 50mcg fentanyl and I did offer him some valium too while I was waiting to give more fentanyl. While my offer may get me scammed by a drug seeker at some point, the amount that I am giving them is not that much if they are opioid dependent, and Id rather treat pain then withhold it from someone who needs it.
    Id be interested in exploring ketamine for analgesia. I think it is a drug that we do not use enough for a lot of things.
  34. EMS5

    EMS5

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    Ok...late question...with the increase in the usage of benzos as an adjunct for acute pain management, obviously the possibility of the pt becoming apneic increases. Is there any specific reason flumazenil isn't carried in the field? I took a quick look around and there were a couple articles vaguely citing controversy, but they didn't really go into detail.

    Couple that with the exponential growth in prescription drug abuse over the past 10 years, and I could justify carrying flumazenil for benzo OD's in the field. Narcan won't achieve the desired effect b/c it comes down to opioid vs GABA receptors...so what say the docs?
  35. Dwindlin

    Dwindlin SDN Gold Donor Gold Donor

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    Acute benzo withdrawl is life threatening, generally not a god idea to reverse an overdose.
  36. Daiphon

    Daiphon Semper Ubi Sub Ubi SDN Advisor

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    Concur. Reversal with flumazenil will cause withdrawal; and in the habituated user, due to downregulation of GABA receptors, intractable seizures...

    ...that you can't tx with benzos, as you've blocked the receptor binding site.

    Mountains & molehills. d=|

    If they're that sick, just tube em.

    Cheers!
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    Sent from my DROID BIONIC using Tapatalk
  37. jwk

    jwk AA-C ASA-PAC Contributor

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    Here's the hard truth - if you feel the need to use have flumazenil available just in case you might have issues when you give benzo's, you probably shouldn't be giving them. Flumazenil is a crutch, and it's used by people who get themselves in trouble - either they use too much midaz/diazepam, and/or they can't adequately manage an airway.

    I can see it's use for an accidental overdose in a non-habitual user, but significant caution is warranted. It is NOT a commonly used drug.
  38. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    There is no role for flumazenil in prehospital medicine. There is no role for it in the ER either. It's only role in in a patient who has had a detailed and believable pre anesthesia evaluation. By definition no ER or EMS patient will have had this. If you give it and someone turn out to be a habitual user they have a very good chance of dying. It is much safer to intubate and manage the patient while they metabolize their OD than to risk the withdrawals.
  39. COMedic2Doc

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    A couple of things that I think would benefit some systems, those with a >10 minute transport time. First, combination analgesia. This proves especially useful in management of orthopedic injuries, and an agency that I worked for prior to my deployment to Iraq had protocols for us to start it in the ambulance. We used the midazolam and fentanyl combination (both short half-life, and required that we start capnography). This proved to be extremely useful. Regarding the comments about one benzo, I can only imagine how this would be. Colorado is pretty much standard to carry both Diazepam and Midazolam. Regarding the discussion on Toradol: Based on personal experience while working in Iraq, it would be a huge benefit for pre-hospital use especially in management of certain etiologies (migraine HAs and kidney stones come to mind) would benefit imho. Yes we face an increased risk of internal bleeding complications, but at the same time we're using an NSAID instead of using a narcotic. This would perhaps be another specific use of general transport time >10 minutes. Just my .02.
  40. proman

    proman Member Moderator

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    You do understand that benzodiazepines have no analgesic properties, right? I'm not saying that they have no role in pain management, especially for long bone fractures, but they are purely anxiolytic/sedatives.
  41. COMedic2Doc

    COMedic2Doc

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    Yes. I was trying to emphasize the combination part of the analgesia. Using a benzo and a narcotic synergistically helps with better reception and management of injuries, especially for longer transports over mountain highways. I apologize for any confusion.
  42. AlmostJesus

    AlmostJesus

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    The Iowa state protocols includes flumenazil, and we carry it where I work. We do not have it specifically written in our protocols so it would require medical control. We are only supposed to use it for benzos administered by us in the ambulance.
    http://www.idph.state.ia.us/ems/common/pdf/ems_protocols.pdf
    Generally, when I am sedating someone, I have good luck when I just tell them to breathe for me :). If it gets any worse, that is what we keep our airway equipment handy for.
  43. proman

    proman Member Moderator

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    I know it's frustrating not being able to appropriately treat patients. I treat patients in pain every day. I never think "If I give a benzo it'll be easier to treat this pain". You don't really get better pain relief with the synergy from benzos + opioids. You do definitely get a higher risk of complications, such as apnea. What's really needed is opioids or non-opioid analgesics in appropriate doses.
  44. jwk

    jwk AA-C ASA-PAC Contributor

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    If you carry flumazenil to specifically treat your own overdoses, then you shouldn't be giving any benzos in the first place.
  45. jwk

    jwk AA-C ASA-PAC Contributor

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    Unfortunately, this falls under the "a little knowledge is a dangerous thing" concept as far as paramedics trying to play with multi-modal pain control.
  46. proman

    proman Member Moderator

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    :laugh: Tell that to my cardiologists in the cath lab.
  47. AlmostJesus

    AlmostJesus

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    Tell that to the Iowa bureau of EMS. We carry flumenazil but oddly enough, we dont have a protocol for it.
  48. COMedic2Doc

    COMedic2Doc

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    Ok, allow me to clarify. This is a standing protocol for a county where I served. This means that this was approved and designed by Physicians (specifically Medical Directors) not Paramedics. I agree that Paramedics are essentially dangerous with a little bit of knowledge (trust me serving in Remote Duty Medicine you learn this quite quickly). I was purely attempting to offer a point of discussion, and personally I wish that we would design some sort of non-opioid based pain treatment in the field (which may come along in the future, only time will tell).
  49. leviathan

    leviathan Drinking from the hydrant Moderator Emeritus

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    Versed is not useless for seizures. The EMS group I worked for uses versed with great success. There was actually just a paper in the new england showing superiority of IM versed over IV ativan for terminating status seizures.
    http://www.nejm.org/doi/full/10.1056/NEJMoa1107494
  50. COMedic2Doc

    COMedic2Doc

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    I personally prefer Versed in my personal practice as well, especially for seizure patients and combative patients. If administered properly with a good Paramedic who is attentive to the needs of the patient, Versed proves extremely useful in pre-hospital EMS.

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