Speaking of airway meds....

[ffspo0k]

How many of you out there have Atrovent and solu-medrol in your arsenal?

We are allowed to give atrovent in our second nebulizer or in the initial nebulizer provided the pt attempted their own nebulizer or MDI prior to our arrival without relief.

In addition, we can give solu-medrol to our more severe COPD/Asthma patients, and while it is somewhat up to us, I tend to like to administer that early on as it takes approx 15-20 mins to act.

My personal preference is to give continuous albuterol/atrovent mixed aerosols, and while the patient is puffing on that, I'll start a line and push the solu-medrol. I have had some great success with this combo, just curious as to everyones experience..

[RoryEl]

A/A updrafts are a good combo and tend to work well,as does Xopenex. We are looking at adding Xopenex at present. Breathine is part of our second line treatments and we may RSI on a prn basis, esp refractory decompensated COPD. Solu-medrol does not act quickly as you stated and is a adjunct treatment. Becareful of those who have previously have any steroids (recently), are immuniocompromised, or have DM. Also fluids should be infused if not contraindicated.

[ 01-04-2002: Message edited by: rory ]</p>

[KYMEDIC]

The only neb med we use is Albuterol.

Solu-Medrol is available for use at the medic's option, especially if the "estimated" time with patient will be greater than 30 minutes. That was written into the protocol to ease fighting with our state's EMS Board, who have shown an anti-steroid sentiment for 10-15 years (although they're starting to come out of it).

Officially steroids may take a couple of hours to kick in and take effect, which is often the arguement docs use against it. My two arguements are:

1) If it takes that long, that means all the more reason to get it started early, especially with the lack of side effects with the one time dose we'll be giving.

2) I have seen it take effect MUCH more shortly than what the book says. In our department we have 1 medic with a history of asthma and 2 with history of severe allergic reactions, and all three report onset of action within "several minutes after administartion where all else has failed. Since I don't know if my patient will be helped in 2 hours or 10 minutes, I'll take the leap of faith just in case, for their sake.

P.S. Steroids are not in our anaphylaxis standing orders, although they are a medical control option.

[panther]

We carry both Solu-Medrol and Dex. Personally, I like the Dex. Faster acting time with minimal contraindications (TB, ulcers, infection). I also go for Dex with closed head injuries. Just my personal preference.

As always, stay safe and well! <img src="cool.gif" border="0">

[Medic162]

Just the other day I ran a respitory distress with the classic Hx... She had been puffing her Albuterol inhaler all evening with no success. Atrovent was her "wonder drug". I'm a fan of any med that can turn the patient around so quickly with minimal side effects!

[ffspo0k]

In a job where thank you's are rare, my last one was a lady we picked up from a church getting no relief from her inhaler, after albuterol/atrovent nebulizers x2 and IV solu-medrol (I know I know, it wasn't working yet) she was breathing fine, and thanked us for keeping her off the respirator.

[N2DFire]

For Field Use we are still "stuck" with Albuterol while in the E.R. (depending on the Doc & Respiratory Tech. working) xopenex is fast becoming the drug of choice.

As far as Protocols go - here's what our book says. (Any comments or notes from myself are in italics)<br />COPD / Diff Breathing

02 Therapy as indicated.<br />Albuterol 2.5mg Nebulized X2 q10 Min.<br />125mg Methylprednisolone (Solu-medrol) IV if continued wheezing after second Albuterol treatment.

Allergic Reaction/Anaphylaxix

O2 Therapy as indicated<br />Administer Pt's own Epi Auto Injector if available and Indicated (regardless of Pt. Age)Provided injector is in date, etc. - Standard Medication Precautions<br />If Pt. 35yrs or younger AND no cardiac Hx - administer 0.3 - 0.5 mg Ep1 1:1000 IM<br />If Pt. >35yrs and/or Cardiac Hx - MUST have Online Orders for Epi Dosed & Delivered as above<br />Establish IV NS KVO w/ Macro Drip Set<br />500ml Fluid Bolus if Hypotensive<br />25 mg Diphenhydramine (Benadryl) IV<br />125 mg Methylprednisolone (Solu-medrol) IV<br />50 mg Ranitidine( Zantac) Diluted in NS to 20 ml, over 2 minutes IV<br />if If Wheezing, administer Albuterol 2.5mg Nebulized.<br />If needed, repeate Epi (0.3 - 0.5 mg 1:1000 IM)<br />If no response to Epi - administer 1mg glucagon IM<br />BY ORDERS ONLY - If no response to Epi & IV bolus and Pt. remains Hypotensive - consider use of Dopamine

End of Protocols.

If anyone is interested - our Protocol book has recently been published online in PDF format and is available at <a href="http://western.vaems.org" target="_blank">http://western.vaems.org</a> Just click the link that says Protocols on the left hand menu.

It's pretty cool because each drug name is a hyperlink that pops up a card with all the information about the drug, as well as a picture of how it's supplied in our boxes.

Take Care - Stay Safe - God Bless<br />Stephen<br />FF/Paramedic

[Medic162]

Just wanted to drop a link to one of my services online protocols in case anyone is researching anything. Take care & be Safe... Brian<br />Click on!!!<br /><a href="http://www.flinthills.com/~mcems/Protocol%20Index.htm" target="_blank">http://www.flinthills.com/~mcems/Protocol%20Index.htm</a><br /> <img src="wink.gif" border="0">

[nfd4611]

Our resp distress protocol alows us to use Atrovent mixed with Albuterol as the first neb treatment, subsequent treatments are Albuterol only. Also at medical control's discretion we can give .3-.5 epi 1:1,000 SQ

[firemedic110]

Atrovent is a good med, but is usually not given continuously. Some protocols recommend q6-8hrs between dosing.

[Paramark14]

We use a mix of 2.5 albuterol and .5 of atrovent for the first tx, all subsequent nebs are albuterol only. We have a SO for 125 of Solu-Medrol for COPD and asthmatics with wheezes present. We just started using the atrovent last year and I think it works very well. For peds we use the same dose only we dilute it with an additional 3cc of NS.

Mark<br />Indiana

[medic3401]

We use albuterol/atrovent as the second dose if needed. We also have solu-medrol and agree with the post about getting it in asap due to the long onset. One med noone has mentioned is Mag Sulfate. We use it also as an infusion and I know the dept I am going to in March also uses it. Have heard good things about it. Anyone else use it? If so, what do you think?

<a href="http://www.co.wake.nc.us/EMS/website.nsf/d8afe96f1b9e5a4d852568dc005fc2 27/d1479962af636171852569b40068e1 5a/$FILE/Protocols%20Effective%20Novemb er%202001.pdf" target="_blank">http://www.co.wake.nc.us/EMS/website.nsf/d8afe96f1b9e5a4d852568dc005fc2 27/d1479962af636171852569b40068e1 5a/$FILE/Protocols%20Effective%20Novemb er%202001.pdf</a>

[jniehus]

anyone else using CPAP? It sometimes helps the pt. "dodge the tube" for us.

[ffspo0k]

CPAP in the field.. nice.. Closest thing we have is the portable vent deal.. which no one uses <br />a) because we are only 3-5 mins from the hospital<br />and<br />b) our o2 cylindars can't handle the volume requirements..

[ajbrnmed1]

To "panther" and anyone else who does the same. There is NO indication for using steroids in head injury. Zip, zero, zilch, nada. Go to <a href="http://www.braintrauma.org" target="_blank">www.braintrauma.org</a> and you will find the 2000 Guidelines for management of acute head injury. Steroids are NOT recommended. I know this is off the original topic but when panther said he/she uses it for CHI, I had to rebut. <img src="eek.gif" border="0">

[Canmedic]

For our service, we give continous Ventolin/Atrovent nebulizers...I know when Atrovent first came out, the dose was 500mcg q4-6h...but that seems to have gone by the wayside, I'm surprised some services still go by that. Seems they've come out with research indicating that it has less cardiac effects than once thought.

As for Solu-Medrol, the onset also seems to be a helluva lot quicker than once thought, all the more reason to get it on board for refractory SOB pts. Our dose is 125mg SIVP

Mike Kesthely
FF/Paramedic
Lethbridge Fire Dept.

[gordon112]

Our department has been using CPAP for over a year with great success!More department's need to use CPAP.

[panther]

ajbrnmed1

I would HIGHLY recommend you go back and read the guidelines.

The authors did not look at Dex, only Mannitol (and the study they refer to only contained 41 pts over a 2 hr period).

Moreover, under Brain Specific Treatment you will find the following:


CONCLUSIONS

A. Standards

There are insufficient data to support the creation of brain specific treatment standards.

B. Guidelines

There are insufficient data to support the creation of brain specific treatment guidelines.


Something else should be mentioned, they were focusing on cerebral herniation (ie. Level Three ICP). When treating pts my goal is not to allow them to progress to that point. And with transport times that can exceed 60 min you need all the help you can get.

For the record, I have used Dex in conjuction with ABC management and it has worked VERY WELL! Maybe its time you thought outside the box!

As always, stay safe and well!;)

[NCFiremedic]

Albuterol/Atrovent and solu-medrol has been the norm. Just started using CPAP this month and it seems very promising from the training but have yet to use it on a pt. We did try it out o each other during class and WOW what a feeling!
Hey Matt how is Denver? Hope you do well at the academy.

[ALSfirefighter]

We also use albuterol 2.5mg/atrovent 0.5 for initial neb w/ straight albuterol nebs every 10 mins after. Our medical control opitions are:
Breathine 0.25mg SQ; w/ repeat prn
Epi 1:1,000 0.3mg SQ; repeat asdir
Mag Sulfate 1-2 gm IV over 5 mins (which is becoming more common and works great!)
Solu-medrol 125mg/50ml NS over 2 mins. (we also had some of the docs who were anti-solu-medrol, but most have begun giving it)
The solu medrol in my opinion onsets faster then what is written, also in my opinion we have an overall responsibility for overall patient care, and I've argued in the past that why wait till they arrive to get it on board if I can get it in 10-20 mins before that and reduce the door to door time.

Ajbrnmed1, he is right, dex is still used by some doctors for CHI, it is controversial, but I do beleive there are trials still ongoing. I have seen it still used for spinal cord injury and with some good effects. I believe, Decadron is what they used on Dennis Byrd, who was a NY Jet with a spinal cord injury and he now walks.

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The above is my opinion/thoughts only and doesn't reflect that of any dept/agency I work for, deal with, or am a member of. :D

[PHMEDIC93]

I've used Atrovent quite a few times in the field. Our protocol says we can use it first line with an Albuterol neb. I've seen it work well at times and other times not work real great. It is nice to have. In pediatrics I'll usually give them the albuterol to get them dilated then give the atrovent (steroid). I also don't like to hesitate giving people a SC brethine 0.25 mg about the same time we give the neb. It has almost no cardiac affect and seems to work better after a while like 10 -15 minutes when I'm dropping them off. We have etomidate and versed for medicated airway management as well...hope that helps.