Ideal Drug Box

[redcrossemt]

If you were redesigning your agency or system drug box, what would you put in it? I think we can assume the ACLS drugs (epi, vasopressin, atropine, amiodarone/lidocaine, adenosine, dopamine) are there. ? on procainamide...

I would argue for:

zofran
aspirin
nitro SL + IV
cardizem
narcan
albuterol
ipatroprium
diphenhydramine
pepcid
solumedrol
terbutaline
oxytocin
furosemide
fentanyl
morphine
toradol
versed
haldol
etomidate
rocuronium
magnesium sulfate
sodium bicarbonate
calcium chloride
sodium nitrate
sodium thiosulfate
glucagon
D50
acetaminophen
thiamine
labetalol

 

[Shishkabob]

Everything you said and:

Bretylium

I heard it was fantastic when we could actually get it.

 

[reaper]

Everything you listed. Minus the Bretylium!!!!!!!!!

 

[Smash]

Everything you said and:

Bretylium

I heard it was fantastic when we could actually get it.

Fantastic at having utterly no effect on survival you mean? Or fantastic at having lots of adverse effects?

There is a reason why we can't get it anymore you know.

 

[MrBrown]

Adenosine
Adrenaline
Amiodarone
Aspirin
Atropine
Clopidogrel
Dextrose 10%
Diphenhydramine
Fentanyl
Glucagon
GTN
Heparin
Hydrocortisone
Ketamine
Methoxyflurane
Midazolam
Naloxone
Oxycotin
Ondansetron
Rocuronium
Salbutamol
Streptase
Suxamethonium

 

[triemal04]

If you were redesigning your agency or system drug box, what would you put in it? I think we can assume the ACLS drugs (epi, vasopressin, atropine, amiodarone/lidocaine, adenosine, dopamine) are there. ? on procainamide...

I would argue for:

zofran
aspirin
nitro SL + IV
cardizem
narcan
albuterol
ipatroprium
diphenhydramine
pepcid
solumedrol
terbutaline
oxytocin
furosemide
fentanyl
morphine
toradol
versed
haldol
etomidate
rocuronium
magnesium sulfate
sodium bicarbonate
calcium chloride
sodium nitrate
sodium thiosulfate
glucagon
D50
acetaminophen
thiamine
labetalol

Add in D25, reglan, phenergan, nitrous oxide, proparacaine, replace calcium chloride with calcium gluconate, and, unless you have a different use for them, replace the sodium nitrate and thiosulfate with a cyanokit.

 

[redcrossemt]

Add in D25, reglan, phenergan, nitrous oxide, proparacaine, replace calcium chloride with calcium gluconate, and, unless you have a different use for them, replace the sodium nitrate and thiosulfate with a cyanokit.

Fair enough.

Do you use reglan a lot? Or phenergan preferentially over ondansetron?

 

[redcrossemt]

Adenosine
Adrenaline
Amiodarone
Aspirin
Atropine
Clopidogrel
Dextrose 10%
Diphenhydramine
Fentanyl
Glucagon
GTN
Heparin
Hydrocortisone
Ketamine
Methoxyflurane
Midazolam
Naloxone
Oxycotin
Ondansetron
Rocuronium
Salbutamol
Streptase
Suxamethonium

Why sux and roc?

Does anyone use streptase or another thrombolytic a lot for STEMI? Can they still do PCI after that (I'm thinking risk of bleeding - but I don't know much about it)?

Forgot about clopidogrel. +1 there.

 

[Bloom-IUEMT]

If you were redesigning your agency or system drug box, what would you put in it? I think we can assume the ACLS drugs (epi, vasopressin, atropine, amiodarone/lidocaine, adenosine, dopamine) are there. ? on procainamide...

I would argue for:

zofran
aspirin
nitro SL + IV
cardizem
narcan
albuterol
ipatroprium
diphenhydramine
pepcid
solumedrol
terbutaline
oxytocin
furosemide
fentanyl
morphine
toradol
versed
haldol
etomidate
rocuronium
magnesium sulfate
sodium bicarbonate
calcium chloride
sodium nitrate
sodium thiosulfate
glucagon
D50
acetaminophen
thiamine
labetalol

Just curious: are medics trained in all these drugs or is this idealistic wish list? Not very much familiar with oxytocin other than its role in inducing labor....so would there be an instance where you'd want to induce labor on a patient??

 

[redcrossemt]

Just curious: are medics trained in all these drugs or is this idealistic wish list? Not very much familiar with oxytocin other than its role in inducing labor....so would there be an instance where you'd want to induce labor on a patient??

All of these drugs are utilized by paramedics in different parts of the world working for different services.

Oxytocin increases uterine tone and can be used to control post-partum hemorrhage.

 

[triemal04]

Fair enough.

Do you use reglan a lot? Or phenergan preferentially over ondansetron?

I actually don't carry phenergan currently; my only option is zofran, which, much as I like it, is much less effective after the pt has already begun to vomit. Phenergan on the other hand seems to be effective regardless. Of course it's harder on the veins and has some interactions that aren't always the best, so having multiple options would be better.

Same with reglan; I don't carry it, but have had multiple interactions with MD's and PA's who swear by it for treating nausea caused by migraines. And based on my own experiences in treating that type of nausea with zofan...it doesn't always work.

 

[MrBrown]

Why sux and roc?

For RSI

 

[redcrossemt]

For RSI

Hehe, good one!

I was asking, why carry both?

The one thought I have is the duration of rocuronium is scary! You have 20-60 minutes depending on dose that you can't do a neuro exam.

 

[Melclin]

Interesting that no one has mentioned ceftriaxone. Prehospital sepsis management seems to be pretty low down the list of priorities in the US. Mortality from sepsic shock increases 7.6% for every hour antibiotics are delayed (1). Have a look at this article (2) for an good argument for enhanced prehospital sepsis management. We carry ceft here for sepsis, although our sepsis education and guidelines remain in their infancy.

(1) Kumar A, Roberts D, Wood K, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the determinant of survival in human septic shock. Crit Care Med 2006;34:589–96.

(2) Robson W, Nutbeam T, Daniels R. Sepsis: a need for prehospital intervention? Emerg Med J. 2009;26:535–538.

 

[Melclin]

Hehe, good one!

I was asking, why carry both?

The one thought I have is the duration of rocuronium is scary! You have 20-60 minutes depending on dose that you can't do a neuro exam.

Our MICA trucks carry both sux and pancuronium. Sux as an induction agent and panc for continuing paralysis should you need it. Panc also for continuing paralysis in therapeutic hypothermia.

 

[redcrossemt]

Our MICA trucks carry both sux and pancuronium. Sux as an induction agent and panc for continuing paralysis should you need it. Panc also for continuing paralysis in therapeutic hypothermia.

Any reason, other than what I mentioned, for not carrying just rocuronium? From the research I can find, the onset is about the same. Some say the intubating conditions are better with sux, but some say not... I think the data there is pretty subjective.

 

[redcrossemt]

Interesting that no one has mentioned ceftriaxone.

Ceftriaxone is a great choice to add! Totally forgot about this, but it is becoming a bigger thing, at least in CCT. Ceft is a great start, but also may also want quinolones, macrolides, and/or aminoglycosides for broad spectrum coverage since many of our patients are from nursing homes and have complicated infections of multiple or unknown source/system.

Any thoughts on carrying multiple antibiotics and administering for sepsis from an unknown organism?

Are you drawing cultures before administration??

 

[Smash]

Any reason, other than what I mentioned, for not carrying just rocuronium? From the research I can find, the onset is about the same. Some say the intubating conditions are better with sux, but some say not... I think the data there is pretty subjective.

Safety. Sux has a duration of about 5 minutes, which is shorter than the safe period of apnoea a well de-nitrogenated, healthy adult can sustain. If you use the rocuronium for your initial paralytic and you find yourself in a can't intubate/can't ventilate situation, you are faced with the very real prospect of having to cut the patients throat if you don't have any luck with a backup airway device. With sux you just have to wait a few minutes, let them breathe on their own and off to hospital.

My service carries sux and panc also. Aside from the refridgeration issues (not a big deal with new rigs having fridges; that or throwing out the drugs each week) panc is good because it does not require any reconstitution, is easy to administer and has (for our purposes) an acceptable duration of action.

As for antibiotics, cefazoin, cefataxine, ceftriaxone, something along those lines is good (we carry ceftriaxone). A third gen cephalosporin should provide adequate cover initially, and ceftriaxone is good because it can get into the CSF without too much trouble.
We aren't aiming for killing off the bugs, just bacteriostasis to slow things down before we can work out the targeted regimine of antibiotics, and 1 gram of ceftriaxone is acceptable for this (although there is some suggestion that 2gm might be better) Cultures will then be grown to work out exactly what we need so I don't know that a scattershot approach without knowing what to use is the best approach.
Whether we give the AB's or not depends on an awful lot of factors, not least of which is the time to hospital. We don't want to mess up any labs, but nor do we want to leave the patient without baceriostasis, particularly if they are unlucky enough to have got themselves some neisseria meningitidis on board. If we suspect an aggressive micoorganism like N. Meningitidis we will get straight on to the ABs + fluid + inotropes + intubation and ventilation.

I still haven't figured out why we want bretylium yet...

 

[Melclin]

Any reason, other than what I mentioned, for not carrying just rocuronium? From the research I can find, the onset is about the same. Some say the intubating conditions are better with sux, but some say not... I think the data there is pretty subjective.

I couldn't say with any authority. Sux is whats used in EDs all over the country. It may just be that its the status quo and they extended it to MICA when RSI came in.

Ceftriaxone is a great choice to add! Totally forgot about this, but it is becoming a bigger thing, at least in CCT. Ceft is a great start, but also may also want quinolones, macrolides, and/or aminoglycosides for broad spectrum coverage since many of our patients are from nursing homes and have complicated infections of multiple or unknown source/system.

Any thoughts on carrying multiple antibiotics and administering for sepsis from an unknown organism?

Are you drawing cultures before administration??

I would suggest a respiratory quinolone like levofloxacin seeing as though community acquired pneumonia (CAP) constitutes the majority of sepsis case seen in the prehospital environment. But to be honest I don't know a great deal about this. Its my understanding that the particular drug used would be tailored to the local florae.

Perhaps also doxycylcine given its potential in both resp and urinary tract infections (septic nursing home patients with CAP or UTIs would constitute the bulk of sepsis case I would think).

Although, I'm not sure of the necessity of utility of carrying such drugs on the average 000 truck. What I am more interested in is the idea of starting the management of the 'sepsis six' in the prehospital environment, in the hopes of expediting the process of the first 6 hours of evaluation and resuscitation, which in turn will expedite their ICU care should they need it.

1) ~100% O2 (currently we actually don't carry NRBMs, which I would like changed, personally).

2) Blood cultures (we don't currently draw blood cultures. I believe we should for two reasons. Firstly, it expedites a diagnosis if we can roll in the ED door with a bag ready to run off to the lab even while we're still waiting for a bed. Secondly, a blood culture taken before the ceftriaxone prevents the ED from encountering problems identifying the type of infection from sterile blood samples taken soon after the initial cef).

3) IV antibiotics (we have cef, for now I feel this is adequate, but the culture of not using it in the ambulance service needs to be addressed, Ambulance paramedics here, still do not appear to understand the way sepsis can creep up on you).

4)Fluid resuscitate (MICA can fluid resus a septic patient, basics cannot, although, you could easily argue dyhydration, or just plain step outside the guidelines - as long as you can back it up then that's fine. 2-3 rounds of 20mls/kg of a crystaloid appears to be the go in sepsis, and basics here are experienced in this modality for other conditions).

5)Serum Lactate and haemoglobbin. (obviously difficult in the prehospital environment. Although, there are relatively cheap, reliable portable lactate measuring tools apparently, and the suggest algorithm for sepsis triage (bellow) requires a lactate level).

6)Urinary cath + urin output (perhaps in rural mega transport time areas but otherwise I'd say this one can be left out [thoughts?], given that its a sterile and sometimes time consuming procedure).

 

[redcrossemt]

I couldn't say with any authority. Sux is whats used in EDs all over the country. It may just be that its the status quo and they extended it to MICA when RSI came in.

I think safety is one part - as Smash described. The other is continuing assessment. I would recommend, with this in mind, carrying sux as the primary paralytic for RSI, with an intermediate duration agent (like rocuronium or vecuronium) as an alternate (sux contraindicated) and for maintaining paralysis.

Would stay away from pancuronium outside of the hospital ICU... Duration is about 2 hours! Roc or vec, you can just bolus every 20-40 minutes as needed, which shouldn't be too many doses even for rural transports.

As far as sepsis, good talk here. I would really like to see us drawing the cultures before starting antibiotics, and a clear evidence-based approach to what antibiotics to start based on the likely source of infection. I think it's reasonable for us to carry 2-3 antibiotics used alone or in concert with each other depending on the case. At the same time, there has to be some consideration to not going overboard due to the toxic effects of some of these antibiotics, and the risk of resistance, until the organism is identified.