the 100% directionless thread

[DesertMedic66]

One would assume from the scenario given that there will be an imminent respiratory arrest. RR of 3? One would also assume that the PT is already getting BVM, so intubation would be the next step. We have intubated pts in the ED with bradypnea and given Narcan which sometimes worked, sometimes didn't. And yes, when it did work, they were extubated.

Intubation really should not be the immediate next step. Bag the patient to get them back to normal oxygen levels then give some narcan. If the narcan works then you just saved yourself from doing a 100% unnecessary procedure on that patient.

EMS providers daily are bagging patients and giving narcan which completely reverses the apnea and a lot of these patients sign out AMA all without a tube ever being touched.

I would hope there is a QA/QI process that would catch providers who are intubating this patients just to push narcan and then extubate them.

 

[NomadicMedic]

One would assume from the scenario given that there will be an imminent respiratory arrest. RR of 3? One would also assume that the PT is already getting BVM, so intubation would be the next step. We have intubated pts in the ED with bradypnea and given Narcan which sometimes worked, sometimes didn't. And yes, when it did work, they were extubated.

when was the last time you worked an acute opiate OD in the field?

 

[VentMonkey]

Blessing (Monkey) No. 4. Family’s pulled me further and further away from identifying with my job as my identity. Gotta love it. Peace.

 

[CCCSD]

View attachment 5476
Blessing (Monkey) No. 4. Family’s pulled me further and further away from identifying with my job as my identity. Gotta love it. Peace.

 

[Old Tracker]

View attachment 5476
Blessing (Monkey) No. 4. Family’s pulled me further and further away from identifying with my job as my identity. Gotta love it. Peace.

Congrates. Daughter #4 just had her 3rd (husband is deployed foreign) the night before last. I've been in S. Carolina for about 2 months now and will be able to go back to my wonderful Texas as soon as my wife gets here to take over helping out with the other 2. Hang tough VM, it all counts on 20.

 

[Tigger]

Tigger, I appreciate your new person/patient, per se. However, the scenario you provided utilized BVM, RR of 3 and a Pulse Ox of 50%? That should of required intubation and Narcan immediately. I realize you are a new medic, from your posts, but seriously? Narcan effects the MU-2 receptors immediately affecting respiratory factors with respect to respiratory effort

Definitely not a new medic. Not really sure what it is that you do.

Also not sure why you would be intubating someone you plan to give narcan to. Recall most patients EMS arrives to are not receiving any care considering where they are located. I don’t know how to make this clearer. If you walk into a bedroom and find someone with a respiratory rate of three and sats in the toilet, the BVM is the first and only thing you should be reaching for. Not narcan, not a tube, not something else. That is the only the point being made here.

 

[CALEMT]

Diesel has a check engine light along with a service DEF system message so I elect to take the Toyota into work today. Don’t want to be limited to 5MPH on the interstate in the event something happens with the emissions on my diesel. While filing up my tacoma my starter decided to die effectively leaving my in the scenario that I was trying to avoid. The irony is thick this morning and I don’t want to be an adult anymore.

Plus I’m late for my shift… and I’m getting forced this week too…

 

[Jim37F]

Of course when I agreed to pick up the OT shift yesterday to cover a guy taking it off, it was the annual hose testing day for our Engine. Every bit of hose pulled off, pressurized... not too bad. Repacking it all is the fun bit. They did pair us up with another Engine, so that helped in repacking...of course also means instead of just our truck we repacked the entire hose beds of two trucks now. So yay...

And now I get a normal 2 day weekend off before work again, so yay again ahahaha

I was half expecting someone to have called off today for the game and there to be another OT opportunity... or maybe it'll be guys calling off tomorrow instead...

 

[Tigger]

I was half expecting someone to have called off today for the game and there to be another OT opportunity... or maybe it'll be guys calling off tomorrow instead...

I remember coming to work one day when I was still a part time EMT and the guy I was relieving looks at me as I come up the stairs and says “goddamn it it’s the first isn’t it, I’m calling out and you can have the hours.”

I was bewildered until I remembered we had three ambulances and a fly car to do drug checks on between two people. I don’t think he worked a first again till he quit a year later.

 

[StCEMT]

One would assume from the scenario given that there will be an imminent respiratory arrest. RR of 3? One would also assume that the PT is already getting BVM, so intubation would be the next step. We have intubated pts in the ED with bradypnea and given Narcan which sometimes worked, sometimes didn't. And yes, when it did work, they were extubated.

Unless I find myself working in a place where people require absolutely massive doses of Narcan for any effect, I'll never need to intubate a run of the mill OD. I've given an obscene amount of Narcan in my years of urban EMS and not one needed a tube and rarely did I ever have to give a top off dose to keep them from dipping down again.

 

[Carlos Danger]

Admittedly, it has been a few minutes since I worked an opioid OD in the field. But I did a a bit of them back in the day and more importantly, given what I do for a living now I am still very aware of the pertinent presentation and related interventions and pharmacology.

That said, I can think of almost no reason to ever intubate a patient for the purposes of opioid OD, no matter how low their Sp02 is.

In many if not most cases you probably don't even need positive pressure ventilation; a jaw thrust and high flow oxygen and an OPA or NPA should improve the Sp02 of anything other than an apneic (or very near-apneic) patient. If you DO need to ventilate, then of course do it. This buys you time to draw up drugs and start an IV or administer IM naloxone. This is worth considering since adequate BVM ventilations are not always easy and are never without risk.

Obviously there are times that the etiology isn't clear, or other factors muddy the waters and in those cases I think it's hard to place any blame on a clinician for for using a BVM or even an ETT on a patient who is in respiratory failure.

But any time the etiology of opioid OD seems apparent, just remember that it takes the same amount of time to give naloxone as it does sux, and the former probably presents fewer risks to the patient and requires less work on your part.

 

[StCEMT]

Admittedly, it has been a few minutes since I worked an opioid OD in the field. But I did a a bit of them back in the day and more importantly, given what I do for a living now I am still very aware of the pertinent presentation and related interventions and pharmacology.

That said, I can think of almost no reason to ever intubate a patient for the purposes of opioid OD, no matter how low their Sp02 is.

In many if not most cases you probably don't even need positive pressure ventilation; a jaw thrust and high flow oxygen and an OPA or NPA should improve the Sp02 of anything other than an apneic (or very near-apneic) patient. If you DO need to ventilate, then of course do it. This buys you time to draw up drugs and start an IV or administer IM naloxone. This is worth considering since adequate BVM ventilations are not always easy and are never without risk.

Obviously there are times that the etiology isn't clear, or other factors muddy the waters and in those cases I think it's hard to place any blame on a clinician for for using a BVM or even an ETT on a patient who is in respiratory failure.

But any time the etiology of opioid OD seems apparent, just remember that it takes the same amount of time to give naloxone as it does sux, and the former probably presents fewer risks to the patient and requires less work on your part.

On a related note, when I've had OD's of a rather thick build in a bathtub with only room for me to do anything, I have absolutely put an NPA and NRB on and that's all they get until I get an IV and Narcan in. The near apneic oxygenation isn't my preference, but it has been my only good option on more than one occasion.

 

[E tank]

On a related note, when I've had OD's of a rather thick build in a bathtub with only room for me to do anything, I have absolutely put an NPA and NRB on and that's all they get until I get an IV and Narcan in. The near apneic oxygenation isn't my preference, but it has been my only good option on more than one occasion.

Apneic oxygenation is a thing...next time, instead of a NRB, cut the tubing and shove it into the NPA itself and then turn the flow all the way up. Quasi jet ventilation/apneic oxygenation. You might put in an OPA as well to allow excess gas to vent out of the mouth tho.....

 

[StCEMT]

Apneic oxygenation is a thing...next time, instead of a NRB, cut the tubing and shove it into the NPA itself and then turn the flow all the way up. Quasi jet ventilation/apneic oxygenation. You might put in an OPA as well to allow excess gas to vent out of the mouth tho.....

Oh I'm aware it's a thing. Bathtubs with an obese patient and very little work space just isn't my ideal time to mess with it.

I've done some unorthodox **** over the years....doing that would probably top them all though lol

 

[Carlos Danger]

Apneic oxygenation is a thing...next time, instead of a NRB, cut the tubing and shove it into the NPA itself and then turn the flow all the way up.

I frequently cut the prongs off a NC and slide the tubing into the NPA. It’s just easier than trying to keep the nasal prongs properly positioned over the trumpet. Works great.

 

[CCCSD]

Apneic oxygenation is a thing...next time, instead of a NRB, cut the tubing and shove it into the NPA itself and then turn the flow all the way up. Quasi jet ventilation/apneic oxygenation. You might put in an OPA as well to allow excess gas to vent out of the mouth tho.....

Thank you for giving me another tool in the box.

 

[EpiEMS]

Thank you for giving me another tool in the box.

Another *BLS* tool

 

[CCCSD]

Had an anatomical shoulder replacement done last week. I do not care for narcs. Working on dumping them as soon as I can.

My jaw is a little tight from being intubated. Interesting to be on the other side.

 

[E tank]

Had an anatomical shoulder replacement done last week. I do not care for narcs. Working on dumping them as soon as I can.

Three words...Colace...Colace....Colace....take the prescribed dose and multiply it by 3.....then increase it.

 

[ffemt8978]

Three words...Colace...Colace....Colace....take the prescribed dose and multiply it by 3.....then increase it.

You sure you didn't confuse that with the Tequila prescription?