EMS patches into your ED

[fiznat]

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I thought this might be interesting to ask you guys who are already working in an ED.

I guess it is very often nurses that recieve incoming EMS patches, but in case it is you guys-- I would like to hear about what kind of information you specifically look for in a patch. Is the consensus that "short and sweet" is better than "lengthy and detailed?" Anything specific that ED people like to hear besides the basic ETA/Age/Sex/CC/Vitals/Treatment?

I work in EMS in a very busy city system, and I've done countless patches by this point, but often it seems like people have different opinions on what is a "good" patch. What say you guys?

 

[docB]

I only care if the pt is sick. I don't need to hear that your transporting grandma and she was weak and dizzy but her vitals are nl. That just wastes my time or the nurse's time. If you are tubing or coding let us know so we can clear a room or you'll be doing CPR in the hallway for awhile. And on those we don't need much "Old guy. Chest pain. CPR in progress." will do.

 

[southerndoc]

Where I worked as a paramedic, we didn't even patch routine returns. Only STAT returns were patched in. Often it was something to the effect of "41 year old male, inferior MI; vitals are stable; has received ASA, NTG, morphine, metoprolol, and Retavase. ETA in 5."

I can't believe some of the crap that is patched into my hospital. If it's not a STAT return, involving multiple patients, or a paramedic requesting authorization for a med, then I don't want to hear about it. It just takes up too many resources -- the paramedic treating the patient, the nurse receiving the report, and the poor paramedic with the guy spinnin' the drain who is waiting for the radio to clear so he can do his priority patch.

 

[DropkickMurphy]

My now (in)famous call-in: "It's bad, it's real bad, there's blood everywhere. Get ready."

To my defense, this was the first trauma code I ever worked (1997) and I was alone in the back.

 

[USCDiver]

At my residency, there are two 'ambulance' services. One is the local EMS run by the county that brings patients directly to our hospital. They have no calls in to the ED unless it is a possible Trauma team activation, a no transport request, or a request for medication orders etc beyond their protocols. All calls are taken by a resident.
The other service is a hospital run, interfacility transport service with ambulances and helicopters that goes and gets patients from other surrounding hospitals (our catchment area is 29 counties and probably 20+ hospitals). They are required to give report to an MD for every transport they make.
Guess who takes those calls...yep, the residents. The good calls are the short and sweet "we got a guy going directly to the cardiac unit with an NSTEMI, stable vitals, nitro drip, be there in 45minutes." The bad ones tell you the guy's family history and ****. Usually on my end of the call you hear "uh huh, uh huh, ok, have a safe trip" while I'm doing charting on the patients I'm seeing.

Once I took a call and the guy was going on and on, and I wasn't really listening very closely and then at the end he says "so we want to put him on a Cardizem drip, is that ok?" and I had to have him repeat the whole story again.

 

[fiznat]

hahaha, I know what you guys are saying. Where I work we mostly use one of two hospitals: Hartford Hospital (a levl 1 trauma ctr) or St. Francis (lvl 2). St Frans requires patches for every single thing that comes into the ED, while Hartford will yell at you if you try to patch anything other than priority ALS calls.

Exceptions tend to be trauma/medical activations ("get the team together and clear a room"), maternity (direct to L+D or no?), or security updates warning the hospital to make sure they have people ready to help restrain a patient.

So you guys seem to be leaning towards short + sweet? What about a trauma where there potentially might be more things to say? Pertanent negatives from a trauma exam? Extent of damage in an MVA, or +/- airbags and seatbelts? Its tough to decide, because often there is much more that could be said, but you never know how well the doc/resident/nurse on the other line is listening.



by the way, Merry Christmas everyone! Hope nobody is working long hours today.

 

[Apollyon]

Where I worked as a paramedic, we didn't even patch routine returns. Only STAT returns were patched in. Often it was something to the effect of "41 year old male, inferior MI; vitals are stable; has received ASA, NTG, morphine, metoprolol, and Retavase. ETA in 5."

I can't believe some of the crap that is patched into my hospital. If it's not a STAT return, involving multiple patients, or a paramedic requesting authorization for a med, then I don't want to hear about it. It just takes up too many resources -- the paramedic treating the patient, the nurse receiving the report, and the poor paramedic with the guy spinnin' the drain who is waiting for the radio to clear so he can do his priority patch.

Well, two states to the north of where you worked, EMS SUCKS on the radio. 3-5 minutes of talking (with the radio cutting out after a minute even not clicking in their minds), and you still don't know what the problem is. Moreover, no one - and I mean NO ONE - not even flight nurses who have been doing it for years, can estimate an ETA. Not even close - like, "ETA 10 minutes" being - I kid you not - 35 minutes, with a "Level I trauma" - who was conscious, breathing, and ended up with NO identified injuries. Our surgeons think that EMS in and around our county are a bunch of idiots. I've tried to encourage them (with some success) to tell me "vehicle, location, mechanism, belted, airbag, extricated, ambulatory", as in "pickup truck off road while on interstate into tree airbag deployed belted extricated by fire" instead of "this patient here was in a car accident, we got him on the backboard, he has a bloody nose, the vehicle was smashed, I got an IV, a 22 in his left thumb". Another thing is "bronchospasm" - I ask them why don't they say "asthma", and I don't try to explain how the spasm is only a small part of the RAD. Simple is better - don't try to be "paragod".

 

[docB]

My now (in)famous call-in: "It's bad, it's real bad, there's blood everywhere. Get ready."

To my defense, this was the first trauma code I ever worked (1997) and I was alone in the back.

All the nurses thought I was crazy when I read this and busted up. They think it's funny too.

The best call in I ever got was "This is Medic 5. There's going to be a CPR in progress pulling up to your door in a private car in about 2 minutes."

Turns out that they got called to a full arrest and the bystanders got impatient and tossed the guy in a car and headed in our direction. Even weirder is that when they did pull up (I swear I'm not making this up) it was 1 dead guy and 4 transvestite hookers. By the end of it all we had cops, medics, transvestite hookers, security and 1 very pissed off, formerly dead guy withdrawing from heroin from all the narcan I shot under his tongue.

 

[pm2do]

. Moreover, no one - and I mean NO ONE - not even flight nurses who have been doing it for years, can estimate an ETA. Not even close - like, "ETA 10 minutes" being - - ".

I gave up on exact times a long time ago...though we were always asked so my standard response ...see you in 5 minutes..depends on traffic , if I hit the traintracks and stop due to train or my patient decides to take a dump so I light up.....understandably working on the ER side its nice to know that you might be coming in a certain time frame but hey at least you got warning...its worse when you look up and realize you are there because you are w/ a rookie driver who forgot to give you a heads up that you were 5-10 out while working the code....that tends to make people slightly unhappy... 😱

 

[deleted6669]

I work at a very busy trauma ctr and we often get reports like this:
pediatric code 199, 1 minute(click) or
stemi protocol, arriving now or
please activate interventional stroke team, we are 1 min out.....
or my favorite...the drive up code.....code 199, parking lot, NOW

 

[DropkickMurphy]

One of my coworkers holds the record for the best call in ever. Bear in mind that this EMT grew up in a very very sheltered household. He blushed whenever he had to strip a woman during trauma resusciations, so this call was hysterical to listen to. I was standing at the nurses station in the ER when it came in.
EMT: "Uh, -------- Medic 112 to U----- ER"
ER: "Go ahead Medic 112, this is U----- ER"
EMT: "Yes, we are coming to you with a, uh, um, patient from a motor vehicle accident. Unrestrained driver of a small car, extricated by fire, intubated, unable to obtain IV access. Vitals unstable, hypotensive. Requesting trauma alert."
ER: "Medic 112, what is the age and sex of the patient?"
*10-15 sec pause*
EMT: "Um, looks to be about 25 years of age. Not sure of sex."
ER: "What do you mean not sure?"
EMT: "Well she has breasts, but has wedding tackle." (His exact words)
*ER doc turns around and walks away laughing hysterically. Nurse nearly pisses herself*

Apparently Greg had never seen a tranny before.

 

[DropkickMurphy]

Well, two states to the north of where you worked, EMS SUCKS on the radio. 3-5 minutes of talking (with the radio cutting out after a minute even not clicking in their minds), and you still don't know what the problem is. Moreover, no one - and I mean NO ONE - not even flight nurses who have been doing it for years, can estimate an ETA. Not even close - like, "ETA 10 minutes" being - I kid you not - 35 minutes, with a "Level I trauma" - who was conscious, breathing, and ended up with NO identified injuries. Our surgeons think that EMS in and around our county are a bunch of idiots. I've tried to encourage them (with some success) to tell me "vehicle, location, mechanism, belted, airbag, extricated, ambulatory", as in "pickup truck off road while on interstate into tree airbag deployed belted extricated by fire" instead of "this patient here was in a car accident, we got him on the backboard, he has a bloody nose, the vehicle was smashed, I got an IV, a 22 in his left thumb". Another thing is "bronchospasm" - I ask them why don't they say "asthma", and I don't try to explain how the spasm is only a small part of the RAD. Simple is better - don't try to be "paragod".

Sounds like Missouri.

 

[Paramedic1]

Penner MS. Cone DC. MacMillan D. A time-motion study of ambulance-to-emergency department radio communications. Prehospital Emergency Care. 7(2):204-8, 2003 Apr-Jun.

 

[southerndoc]

Penner MS. Cone DC. MacMillan D. A time-motion study of ambulance-to-emergency department radio communications. Prehospital Emergency Care. 7(2):204-8, 2003 Apr-Jun.

Haha, funny you quote a study done by one of this forum's members. I'll refrain from identifying him. He can identify himself if he wishes.

This study was done at my facility, and unfortunately, has not changed the way paramedics communicate by radio. ALL patients are still patched in, and it's a huge waste of triage resources. I find the percentage quoted for in-person patient reports as very low. In my experience, all patients arriving via ambulance have an in-patient report given to the triage nurse. Perhaps they were assessing in-person reports to the treatment nurse?

Maybe our SDN member can comment on it.

 

[Flopotomist]

Where I worked as a paramedic, we didn't even patch routine returns. Only STAT returns were patched in. Often it was something to the effect of "41 year old male, inferior MI; vitals are stable; has received ASA, NTG, morphine, metoprolol, and Retavase. ETA in 5."

I can't believe some of the crap that is patched into my hospital. If it's not a STAT return, involving multiple patients, or a paramedic requesting authorization for a med, then I don't want to hear about it. It just takes up too many resources -- the paramedic treating the patient, the nurse receiving the report, and the poor paramedic with the guy spinnin' the drain who is waiting for the radio to clear so he can do his priority patch.

You worked in a system that had metoprolol and retavase in the prehospital setting???

 

[margaritaboy]

I thought this might be interesting to ask you guys who are already working in an ED.

I guess it is very often nurses that recieve incoming EMS patches, but in case it is you guys-- I would like to hear about what kind of information you specifically look for in a patch. Is the consensus that "short and sweet" is better than "lengthy and detailed?" Anything specific that ED people like to hear besides the basic ETA/Age/Sex/CC/Vitals/Treatment?

I work in EMS in a very busy city system, and I've done countless patches by this point, but often it seems like people have different opinions on what is a "good" patch. What say you guys?

In my opinion, a 'good' patch is one that is short, and only includes information that will potentially change what services we activate prior to the patient's arrival (trauma, stroke, radiology, cardiology etc.).

Basically, chief complaint with minimal HPI and vital signs are sufficient. I really really don't want to sit through a patient's medication list, medical and family histories etc. As far as vitals, just give it to me straight. Our EMS has been consistently adding the '5th and 6th' vitals signs of, "skin is warm and dry, pupils are PERRL." Unless the patient's skin is on fire, there is nothing you can tell me about the skin that will change what we do to prepare for them.

Although other aspects of the patient's history are important, we don't need to hash out everything on the patch phone. We'll have the opportunity to hear about all the details when the patient arrives. The "ETA/Age/Sex/CC/Vitals/Treatment" you mention is a pretty good template.

 

[basementbeastie]

enunciation is key too....

 

[southerndoc]

You worked in a system that had metoprolol and retavase in the prehospital setting???

This is actually very common in Georgia. There are about 25 services that carry thrombolytics and even more that carry either metoprolol (usually) or labetalol.

 

[DropkickMurphy]

Why wouldn't they as a paramedic service carry metoprolol? AHA still recommend beta-blockers as an adjunctive therapy for AMI, unless I missed something.

As for thrombolytics, I'm not a big advocate of it unless you have really good medical control oversight (not a normal status in EMS in most places sadly), long transport times to a cath or CABG capable facility, and no aeromedical coverage. The stars sort of have to align for this one to be of any benefit to the patient in the prehospital setting.

 

[spyderdoc]

Penner MS. Cone DC. MacMillan D. A time-motion study of ambulance-to-emergency department radio communications. Prehospital Emergency Care. 7(2):204-8, 2003 Apr-Jun.

Ah shucks, my first quote.

Point of it all: Keep it short and sweet. On anything other than an emergent condition, EMS patches are pretty useless.

 

[DropkickMurphy]

Ah shucks, my first quote.

Point of it all: Keep it short and sweet. On anything other than an emergent condition, EMS patches are pretty useless.

Unless you're requesting orders 😉

 

[FoughtFyr]

My now (in)famous call-in: "It's bad, it's real bad, there's blood everywhere. Get ready."

To my defense, this was the first trauma code I ever worked (1997) and I was alone in the back.

My worst patch ever....

"Call E******* fire (we were going to E******* Hospital) and have them meet us in the bay. We've been in an accident but are still inbound to your facility with the 25 yo full arrest s/p a different MVC. Now my partner is out on the floor with severe back pain, I can't move my right arm but another firefighter with us is maintaining CPR. Original patient is intubated and has large bore access. We are self-diverting from the trauma center (would be an additional 10 mins) ETA 5 mins."

- H

 

[DropkickMurphy]

My worst patch ever....

"Call E******* fire (we were going to E******* Hospital) and have them meet us in the bay. We've been in an accident but are still inbound to your facility with the 25 yo full arrest s/p a different MVC. Now my partner is out on the floor with severe back pain, I can't move my right arm but another firefighter with us is maintaining CPR. Original patient is intubated and has large bore access. We are self-diverting from the trauma center (would be an additional 10 mins) ETA 5 mins."

- H

Oops. Bet they were thrilled to hear that one.

 

[emtp6811]

CHART:

Chief complaint
Hx
Assessment (LOC, mental status, pertinant +)
Rx ("tx per ACLS", intubated, etc.)
ETE

Most of the time, even that is too much. I usually stick with just my field diagnosis, pertinent treatments and whether the pt is hemodynamically stable. Really, do you need to know anything else before I get there? Usually not...but I have seriously heard full on head to toe assessments given over the radio. Nobody cares if your thumb laceration pts pupils are PERRLA! 🙄

 

[Flopotomist]

Why wouldn't they as a paramedic service carry metoprolol? AHA still recommend beta-blockers as an adjunctive therapy for AMI, unless I missed something.

As for thrombolytics, I'm not a big advocate of it unless you have really good medical control oversight (not a normal status in EMS in most places sadly), long transport times to a cath or CABG capable facility, and no aeromedical coverage. The stars sort of have to align for this one to be of any benefit to the patient in the prehospital setting.

I just haven't read any literature that indicate that a risk-benefit analysis has been done suggesting that a beta blocker needs to be given so rapidly that it can not be delayed 10 minutes until the patient arrives in the hospital. In fact, with metoprolol, isn't there literature suggesting that the benefit exceeds the risk if this therapy is initiated several days after the event? I recall reading that somewhere... WRT the thrombolytics, I share your opinion and also wonder if it is cost effective to keep a thrombolytic on every ambulance in a system - aren't lytics wicked expensive?

 

[BKN]

I thought this might be interesting to ask you guys who are already working in an ED.

I guess it is very often nurses that recieve incoming EMS patches, but in case it is you guys-- I would like to hear about what kind of information you specifically look for in a patch. Is the consensus that "short and sweet" is better than "lengthy and detailed?" Anything specific that ED people like to hear besides the basic ETA/Age/Sex/CC/Vitals/Treatment?

I work in EMS in a very busy city system, and I've done countless patches by this point, but often it seems like people have different opinions on what is a "good" patch. What say you guys?

Years ago in the AF, I had a Basic service staffed by the ER techs. The calls were mostly in the base housing area 2 minutes away and emergencies were rare. One of the techs was the son of two doctors (he said). He would give an entire history and physical taking about 10 minutes to describe an ankle sprain. We made a habit of walking off and doing whatever until he finally paused, then we said "Sorry, you were broken up, can you repeat that?"
And he did. You could do it as many times as you liked and he never got it.

Then one night he called in a pelvic exam on a stable vag bleeder and the hammer came down.

 

[DropkickMurphy]

Then one night he called in a pelvic exam on a stable vag bleeder and the hammer came down.

Oh, I bet it did. What did the AF do to him?

 

[DropkickMurphy]

I just haven't read any literature that indicate that a risk-benefit analysis has been done suggesting that a beta blocker needs to be given so rapidly that it can not be delayed 10 minutes until the patient arrives in the hospital. In fact, with metoprolol, isn't there literature suggesting that the benefit exceeds the risk if this therapy is initiated several days after the event? I recall reading that somewhere... WRT the thrombolytics, I share your opinion and also wonder if it is cost effective to keep a thrombolytic on every ambulance in a system - aren't lytics wicked expensive?

Yes, they are very expensive, but really are not useful prehospital except in a few select circumstances (long transport times being the major factor).

As for metoprolol, given the at times sketchy benefits data for some of the medications we use prehospitally, and that metoprolol and other beta blockers are effective and generally safe why delay giving them?

 

[Flopotomist]

As for metoprolol, given the at times sketchy benefits data for some of the medications we use prehospitally, and that metoprolol and other beta blockers are effective and generally safe why delay giving them?

The evidence is just not there suggesting that this drug is safe to use in a prehospital setting, and there is no evidence suggesting that there is any harm in waiting the 10 minutes or so it takes MOST ambulances to get to a hospital. Yes, beta-blockers are generally safe, but they are not without risks, and do have contraindications that the prehospital provider may not be able to identify. (Cocaine ingestion comes to mind).

 

[Reg]

So sorry for my ignorance...
....what is a "patch?" By deductive reasoning I assume they are "runs" - short H&Ps that are relayed from the field to the receiving hospital. But I've never heard this term 'patch.'

 

[blotto geltaco]

So sorry for my ignorance...
....what is a "patch?" By deductive reasoning I assume they are "runs" - short H&Ps that are relayed from the field to the receiving hospital. But I've never heard this term 'patch.'

Patch is a (sometimes) brief report to the receiving facility. Refers to creating a "patch" between your radio and the hospitals radio, whether it be on a dedicated frequency or simply a channel. On some of the dispatch consoles operators had to manually press a button to "patch" the two radios together, but now is done w/computers in CAD systems. Patch is also known as an encode.

 

[DropkickMurphy]

Granted, the 10 minute transport times in the city might not lend themselves to full out aggressive therapy in these cases, but what about the longer transports associated with rural settings?

And correct me if I am wrong, but doesn't the recommended management of cocaine toxicity (or cocaine induced MI) involve beta-blockade to help alleviate the issues stemming from the drug use?

 

[12R34Y]

Granted, the 10 minute transport times in the city might not lend themselves to full out aggressive therapy in these cases, but what about the longer transports associated with rural settings?

And correct me if I am wrong, but doesn't the recommended management of cocaine toxicity (or cocaine induced MI) involve beta-blockade to help alleviate the issues stemming from the drug use?

The answer to your second question is an emphatic NO.

You never give a beta blocker to a cocaine intoxicated person. You then have unopposed alpha stiimulation and a potential for a HUGE rise in blood pressure. Thus it is contraindicated.

You generally give ativan if they are having chest pain for instance.

later

 

[DropkickMurphy]

D'oh! Well seeing as I don't give beta blockers in any of my medical roles (RT or EMT-I) I just learned something new.

 

[Flopotomist]

The answer to your second question is an emphatic NO.

You never give a beta blocker to a cocaine intoxicated person. You then have unopposed alpha stiimulation and a potential for a HUGE rise in blood pressure. Thus it is contraindicated.



later

Hence my argument that beta-blockers are best delayed until a thorough eval can be done in a hospital (possibly including a u-tox if cocaine is suspected.)

 

[12R34Y]

Hence my argument that beta-blockers are best delayed until a thorough eval can be done in a hospital (possibly including a u-tox if cocaine is suspected.)

I mostly agree that metoprolol can be delayed until the ED, but for places that have greater than 1 hour transport times there may be some times it would help ie. afib with rapid ventricular respone and patient decompensating over the transport etc.....

However, I don't think having a possible cocaine overdose makes anymore difference. I mean in the ED do you ask the 83 year old lady from a nursing home if she has taken crack before you give her a beta blocker? i doubt it. Most people would have a fairly decent idea if cocaine was an issue.

later

 

[DropkickMurphy]

Most people would have a fairly decent idea if cocaine was an issue

That's an excellent point, since I can't think of a single cocaine user I've encountered that it wasn't somewhat obvious they were on a stimulant (unless they had chased the cocaine with some form of sedative or narcotic).

 

[12R34Y]

That's an excellent point, since I can't think of a single cocaine user I've encountered that it wasn't somewhat obvious they were on a stimulant (unless they had chased the cocaine with some form of sedative or narcotic).

exactly.

later

 

[southerndoc]

However, I don't think having a possible cocaine overdose makes anymore difference. I mean in the ED do you ask the 83 year old lady from a nursing home if she has taken crack before you give her a beta blocker? i doubt it. Most people would have a fairly decent idea if cocaine was an issue.

I generally don't ask ECF patients if they've used cocaine, but I routinely ask 60-65 year olds if they've used cocaine. I've had a few that have admitted to recent cocaine use. I was shocked to say the least!

 

[DropkickMurphy]

We had a 72 year old cokehead around here a few years back, so it does happen.....

 

[a_ditchdoc]

Or...ummm, we could....uhh......just teach the paramedics to ask about cocaine use?

Nahhh...way too simple...!

 

[Seaglass]

Actually I've had plenty of times where the cocaine use wasn't obvious.

 

[DropkickMurphy]

Or...ummm, we could....uhh......just teach the paramedics to ask about cocaine use?

Nahhh...way too simple...!

Exactly.....

 

[docB]

I mostly agree that metoprolol can be delayed until the ED, but for places that have greater than 1 hour transport times there may be some times it would help ie. afib with rapid ventricular respone and patient decompensating over the transport etc.....

However, I don't think having a possible cocaine overdose makes anymore difference. I mean in the ED do you ask the 83 year old lady from a nursing home if she has taken crack before you give her a beta blocker? i doubt it. Most people would have a fairly decent idea if cocaine was an issue.

later

Beta Blockers don't need to be given during a transport. The CMS core measures want them given within the first 24 hours of hospitalization. This is an instance of something that can cause more trouble than benefit in the field.

If a patient has Afib with RVR and is decompensating they get shocked. They don't get PO (or IV) Lopressor.

Training EMS to ask about coke is useless because patients lie. They lie to the ER staff too but the consequences of giving it to the wrong pt are much more easily delt with in the ED.

You also can't give it to CHFers, COPDers or anyone who is bradycardic or almost bradycardic or hypotensive or almost hypotensive. And that's after you've given the nitro.

Too many problems and not enough benefit.

 

[12R34Y]

Beta Blockers don't need to be given during a transport. The CMS core measures want them given within the first 24 hours of hospitalization. This is an instance of something that can cause more trouble than benefit in the field.

If a patient has Afib with RVR and is decompensating they get shocked. They don't get PO (or IV) Lopressor.

Training EMS to ask about coke is useless because patients lie. They lie to the ER staff too but the consequences of giving it to the wrong pt are much more easily delt with in the ED.

You also can't give it to CHFers, COPDers or anyone who is bradycardic or almost bradycardic or hypotensive or almost hypotensive. And that's after you've given the nitro.

Too many problems and not enough benefit.

Just had this on cardiology rounds yesterday. For so many years and still people are hesitant to give cardioselective B-blockers (metoprolol, atenolol etc..) due to reactive airway disease or COPD.

A cochrane metanalysis review was done on both and revealed that there is NO reason why cardioselective beta blockers should be witheld even in severe underlying COPD. The benefit of beta blockers CHF (not acute), AMI, rate control etc....outweighs it.

It's finally changing at my institution and last year I can still remember people saying on rounds......"we held the beta blocker because she has a history of asthma." No longer........just food for thought.

Again......like I said I don't think beta blockers need to be given in the field except in a rare circumstance. I didn't mean true decompensation in the sense that they need to be urgently cardioverted.

Meaning that if you have an 1 or 2 transport (some do) to a hospital and you have a guy who can't tolerate a heart rate of 150 due to his new onset A-fib then metoprolol would be sweet and relatively safe.

later

 

[mikecwru]

There is no reason to give beta blockade prehospital just as there is very little reason to give adenosine pre-hospital. If they're unstable, they need electricity. You can safely give Bblockers to COPDers, asthmatics, but everyone reacts differently. There are people who will not tolerate them and will have more bronchospasm but chronically (popping in and out of the hospital with wheezing since their MI) and acutely decompensating in front of your eyes.

mike

Just had this on cardiology rounds yesterday. For so many years and still people are hesitant to give cardioselective B-blockers (metoprolol, atenolol etc..) due to reactive airway disease or COPD.

A cochrane metanalysis review was done on both and revealed that there is NO reason why cardioselective beta blockers should be witheld even in severe underlying COPD. The benefit of beta blockers CHF (not acute), AMI, rate control etc....outweighs it.

It's finally changing at my institution and last year I can still remember people saying on rounds......"we held the beta blocker because she has a history of asthma." No longer........just food for thought.

Again......like I said I don't think beta blockers need to be given in the field except in a rare circumstance. I didn't mean true decompensation in the sense that they need to be urgently cardioverted.

Meaning that if you have an 1 or 2 transport (some do) to a hospital and you have a guy who can't tolerate a heart rate of 150 due to his new onset A-fib then metoprolol would be sweet and relatively safe.

later

 

[Arch Guillotti]

In the OR I routinely push lots of beta blockers on patients w/lung dz. Only really withhold them when the pt. is actively wheezing/bronchospasm. There is no evidence-based data to guide dosing of any beta1 blockers in severe asthmatics.

 

[a_ditchdoc]

There is no reason to give beta blockade prehospital just as there is very little reason to give adenosine pre-hospital. If they're unstable, they need electricity.
mike

I am hoping I missed some sort of subtle sarcasm here? Surely you are not advocating the free use of electricity over adenosine. Popping someone with 100 joules is not nearly as comfortable or benign as giving an injection or two of adenosine. The last thing I want to see if I ever go into SVT is some excited guy standing over me with a pair of paddles... "This is going to hurt a little bit...!"

 

[southerndoc]

I am hoping I missed some sort of subtle sarcasm here? Surely you are not advocating the free use of electricity over adenosine. Popping someone with 100 joules is not nearly as comfortable or benign as giving an injection or two of adenosine. The last thing I want to see if I ever go into SVT is some excited guy standing over me with a pair of paddles... "This is going to hurt a little bit...!"

Actually electricity is safer than adenosine. There have been several case reports of adenosine-induced, aminophylline-resistant asystolic cardiac arrests.

 

[12R34Y]

The beta blockers in lung dz is not really an argument. If you have somebody who is ACTIVELY wheezing then no beta blocker. If you have someone who just had an AMI or is htn/new-onset afib etc.....and they have COPd or asthma and that currently isn't their problem you GIVE a beta blocker. The evidence is overwhelming that short term giving cardioselective beta blockers does NOT cause any harm. It's one of those dinosaurs that keeps getting passed on through medicine like atelectasis casues a fever? no it doesn't. But, you still hear attendings spouting it as a cause of a WBC etc...

I really disagree with the adenosine thing. You will find a "case report" on just about anything. If we heeded them too much you'd never give most drugs or do anything b/c there is always a "risk".

Adenosine is usually very benign and works extremely well (as you all know) in reentrant supraventricular tachyarrythmias.

I think I'd rather have a 20 y/o paramedic in the field giving someone 6 of adenosine rather than sedating them with versed, giving narcs (now you have a potential airway problem as well) and then cardioverting them!

This is all just my personal opinion. Having been working with an electrophysiologist for the last 2 weeks in the CCU I've had many ephiphanies in the care of certain CV diseases.

Again all my personal opinion/experiences. Not meant to be antagonistic.

good discussion though.

later