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Cpap Protocols


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#41 ST RN/PM

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Posted 28 December 2009 - 09:31 PM

Hey all. To all that have read this thread, I apologize for "biting" and responding to negative posters. I also apologize (on behalf of Flightweb)to those that are trying to better themselves and get kicked down. Travis, good luck with your quest for advancement of your career and your organization. There is a lot to learn from many people on this forum, and I hope that the negativity that occasionally takes place does not deter those that are hungry to learn. I have learned a lot from intelligent posters on Flightweb. The learning (for me) is not lost in the presentation. I take what is valuable and apply it. I am not the best out there by any stretch, nor am I the worst, but I treat my patients as though they were my family, and get a fair amount of feedback that I do a decent job. I am through responding to those that use this forum for anything but 2-way, intelligent conversation. To everyone, Happy New Year, fly and drive safely, and here's to a safer, better 2010! Steve
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Steve T. RN, PM

#42 BackcountryMedic

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Posted 28 December 2009 - 10:19 PM

Travis-

I don't have anything to add about CPAP. The RT folks on this site have been giving you good info. I have been through a protocol change process a number of times. I think the best route is go to your med director and tell him you are interested in working on this. You want to take the initiative and research it. You will bring him a couple drafts, but make it clear that the final decision is his. This processes will be even stronger if you have a few other paramedics that are interested as well. Then go do the research. Look at position papers, guidelines and consensus statements from national organizations first. Then find a good medical librarian to help you find peer reviewed articles (preferably multi-center validation studies; Double blinds would be great, but rarely exist in emergency medicine). Write a clear document, with references, and bring it to your med director. He might tweak a few things, but if you've done your homework he will approve it.

Implementing a new protocol is a whole other challenge. Good luck.
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#43 scottyb

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Posted 28 December 2009 - 11:01 PM

This is becoming increasingly pointless. FloridaMedic, I have no doubt that you know your stuff very well - better than I do on much of the material in question here. That is not the issue. I am in firm agreement front-line EMS education is often still pretty dismal, and that transport providers, be they paramedics, RN, RT or some combination, need to be genuinely well educated. To become a critical care paramedic in my system takes about five years IF all the stars lined up for you; it's usually longer. I do not teach any of the shortcuts you mention above to flight paramedic students. However, you have to tailor teaching to the student; if you want students to become more advanced, you can't expect them to step to your level in one go; you have to start where they are and where they can go right now, then help them work there way up. Talking over peoples heads, browbeating them, or engaging in personal slag-fests, well, it just wastes the time and the opportunity for learning is lost. I enjoying reading your tips and I'd sure enjoy the chance to pick your brain for a while if I ever got the chance to work with you, but the snarliness just turns people off. When you or Pink or Speed start going at each other personally, I just stop reading, so the knowledge you could legitimately pass on just goes in the great cyber-trash can. Can I suggest that everyone take a breath and let the next opportunity to slag someone pass by, so that maybe OP and the rest of us could go back to actually learning.

By the way, I have no illusions that I am fixing EMS or transport medicine in any way. I've just been lucky enough to learn from great people, and I'd like to help pass that on to other people who would like to learn. I am here to learn from you all as much as OP is.

I (aka Mr. Pink) have not contributed in any way (positive or negative) to this thread, nor do I intend to. Other folks are taking this thread way off the deep end, as usual. Please don't couple me with them.

Travis...thanks for the original post and never stop learning.
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Scott Bild RN, FP-C

#44 tmuhler

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Posted 04 January 2010 - 09:27 AM

I am sorry about not fully participating in this disscussion, however, I do plan on reading these posts today and replying. To all that have already responded, thanks for letting me pick your brain.
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"Any intelligent fool can make things bigger, more complex, and more violent. It takes a touch of genius -- and a lot of courage -- to move in the opposite direction." - Albert Einstein

Travis S. Muhler
Firefighter/ NREMT-Intermediate
Paramedic by August

#45 tmuhler

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Posted 04 January 2010 - 09:37 AM

Oh, also what are some thoughts of Nasaltracheal Intubation versus CPAP in the patient with acute heart failure?
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"Any intelligent fool can make things bigger, more complex, and more violent. It takes a touch of genius -- and a lot of courage -- to move in the opposite direction." - Albert Einstein

Travis S. Muhler
Firefighter/ NREMT-Intermediate
Paramedic by August

#46 GravyMedic

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Posted 04 January 2010 - 09:53 AM

Oh, also what are some thoughts of Nasaltracheal Intubation versus CPAP in the patient with acute heart failure?


Why nasotracheal intubation? Start with non-invasive, which is the CPAP. But either way, you're still only treating part of the equation. As Florida was saying, try figuring out what else the pt needs, ie dopamine/dobutamine, lasix, ntg, all or none. Dobutamine is great as you get better contractility and lower svr. Typically we see individuals on ntg, but only 20-30 mcgs/min, sometimes these people need upwards of 100 mcgs/min or more to lower their svr's and relieve sypmtoms. Also, if you're that high on your ntg, consider nipride for lower volumes. Each case is drastically different.

My personal thoguhts about nasotracheal intubations are that they are a thing of the past or almost last resort. They carry a higher risk for infection and typically cause more trauma. Also, anecdotally I've seen lower success rates with both first time pass rate and overall success of nasal intubations. And what if you're unsuccessful with the nasal intubation? now you've got a bad situation, with a highly anxious, oxygen hungry, pt in pain and more than likely blood in the airway. Not ideal.

Do you have access to RSI meds?
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#47 JLP

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Posted 04 January 2010 - 04:08 PM

Oh, also what are some thoughts of Nasaltracheal Intubation versus CPAP in the patient with acute heart failure?


I have nasally tubed several severe CHF patients before we had CPAP or facilitated ETT. Frankly, it's a crapshoot, and the odds are not great - you may get an improvement from being able to assist ventilation, but more often the attempt fails, it takes too long (during which you are not assisting with the BVM) and on a couple of occasions I had already unstable CHF patients vagal into bradycardia (and really go downhill) from the prolonged stimulation of the nasal ETT attempt. Not an alternative to CPAP IMHO - the downsides outweigh the potential for improvement. Having done many nasal ETT's, I agree with Gravy - they should be a near-last resort.

Good to see we're back to the discusion at hand. Hope you all are having a good New Year
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#48 ST RN/PM

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Posted 04 January 2010 - 05:48 PM

Hey!
Happy New Year! Agree with Gravy, JLP and Florida. Nasal Intubation used to be the way to take control of the airway in a severely hypoxic, awake patient.... a clinical scenario that was usually seen in Acute/Flash Pulmonary Edema associated with CHF. When CPAP became available to the prehospital arena, the services that I worked for all experienced a drastic decline in the amount of intubations that were performed. This non-invasive treatment was an excellent way to save patients from intubation. When caught quickly enough, institution of CPAP, nitrates, Dobutrex would often turn a patient around before they even made it to the unit.... and take a patient that , at the beginning of a shift was Critical... and by the end of the shift, was stable on a nasal cannula. IMHO, nasal intubation serves a purpose, but is to be used only when RSI, CPAP/BiPAP and difficult oral intubations are not available or working. Keep on learning....... and good luck! Steve
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Steve T. RN, PM

#49 tmuhler

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Posted 04 January 2010 - 09:58 PM

I see that a little background is in order. I am an NREMT-Intermediate, which is capable of doing all skills that an NREMT-Paramedic can do with the exception of a surgical cric. I have been released with the responsibilities as a medic for 3 years with some critical care experience. Yes, I understand this is a very short time, but I am only 23. Spotsylvania County Department of Fire, Rescue, and Emergency Management are a career department in both suburban and rural areas. Transport times can be minutes to up to an hour in the rural areas from which I am currently stationed. We are both Fire based EMS and ground Medic units while we are on duty. During the nights and weekends the volunteers take over staffing. Our county has a universal protocol system which the regional EMS council dictates the protocols and training. There is a regional Operating Medical Director, and each county has an Operating Medical Director. The agencies Operating Medical Director can allow protocol changes at their discretion, but it is to my understanding that the regional OMD will not support their changes.

Recently, we just received a protocol to do etomidate alone intubation, which I have already wrote a position paper against. We also have ETCo2 and 12 lead capabilities. Although in my 12 leads my interpretation ends at looking for ST-Elevation and reciprocal changes. This is the reason why I am in Paramedic school.

For IOs, we have the fast sternal IO. It is rather barbaric of a device, but it has had studies that it will allow drugs to enter the heart quicker than in intravenous access.
EZ-IOs were looked at but the start up cost was too expensive, because of the drills.
Of course the patient will need to be Awake Oriented to Person, Place, and Time for the risks of aspiration, and with the morbidity of aspiration pneumonia.

Addressing BIPAP, we are taking baby steps as Steve said. We started with the Autovent 3000, which only has limited amount of tidal volume adjustability; Fi02 is always 1 because it is O2 driven. Maybe one day when this equipment becomes cheaper we will start to get some more advanced equipment, but in an economic recession I am happy to have a job.

I understand that CPAP is not a tool to be used without intravenous access. What I was saying is in this case, I did not have an IV and was not able to use CPAP or Lasix and morphine because my patients SpO2 was not below 95% on a NRB. My reccomendations so far are to use increased work of breathing/ dyspnea, fatgue, rales, systolic blood pressure above 100 mmHg, Alert and Oriented to Person, Place, and, Time. I am planning on taking bits and pieces from this forum, emergency medical journals, and my text books that I currently own to write a position paper.
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"Any intelligent fool can make things bigger, more complex, and more violent. It takes a touch of genius -- and a lot of courage -- to move in the opposite direction." - Albert Einstein

Travis S. Muhler
Firefighter/ NREMT-Intermediate
Paramedic by August

#50 tmuhler

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Posted 04 January 2010 - 10:06 PM

The closest thing we have to RSI is etomidate alone intubation. Dr. William Bozeman wrote a journal entry about etomidate as a sole agent for intubation. The success rates for etomidate alone were significantly lower than versed alone and obviously with etomidate and sux.

Here is the citation:

Etomidate as a sole agent for endotracheal intubation in the prehospital air medical setting
Air Medical Journal, Volume 21, Issue 4, Pages 32-37
W.Bozeman, S.Young
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"Any intelligent fool can make things bigger, more complex, and more violent. It takes a touch of genius -- and a lot of courage -- to move in the opposite direction." - Albert Einstein

Travis S. Muhler
Firefighter/ NREMT-Intermediate
Paramedic by August

#51 tmuhler

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Posted 04 January 2010 - 10:18 PM

The thought of nasotracheal intubation is for last resort when CPAP is contraindicated. ALOC, Hypotension, Obvious decompensate shock. Obviously were going to treat A-Airway B-Breathing first, but C-Circulation (Heart) is the problem with heart failure. Once airway is situated we can go to vasopressors like dopamine to stimulate alpha and beta response in a 15-20 mcg/kg/min dose, but starting at 5-10 mcg/kg/min. Personally, titrating a IV med is tough with variables. Like the truck bouncing will allow more of the drug into the body. When I worked for a ground transport agency with IV pumps definitely made life a lot easier titrating the dosage to precision. Though, it would not be practical or feasible for ground EMS to have IV pumps yet.
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"Any intelligent fool can make things bigger, more complex, and more violent. It takes a touch of genius -- and a lot of courage -- to move in the opposite direction." - Albert Einstein

Travis S. Muhler
Firefighter/ NREMT-Intermediate
Paramedic by August

#52 croaker260

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Posted 05 January 2010 - 11:14 PM

OK, I appologize if others have posted their protocols as the OP asked, I simply cruised over the thread (all 3 pages) rather rapidly as much of it degenerated to bashing.

That said, we are a ground 99% 911 EMS service. here are our two pertinant protocols.

http://www.adaweb.ne...CqLs=&tabid=798

http://www.adaweb.ne...t0ik=&tabid=798


- Steve
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"Boldness is like a condom. If you depend on it all the time, no matter how good it is, and no matter how good you are, eventually it will break. " -- Walter SLovotsky

"In crisis we do not rise to the occasion, but sink to the level of our training" -- Lt. Col (ret) Grossman

"Personally, I believe that if we write our CE, text books, and curricula at the physician level instead of the kindergarten level, our medics and EMTs will rise to the occasion and meet the higher standard, maybe with some bitching but they will do it. There are plenty of precedents in every day life and other professions for this. The patients will only benefit, as will our own professions and the level of respect I believe we need and want, but maybe don't yet deserve." Steve Cole

#53 GravyMedic

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Posted 10 January 2010 - 10:46 AM

The thought of nasotracheal intubation is for last resort when CPAP is contraindicated. ALOC, Hypotension, Obvious decompensate shock. Obviously were going to treat A-Airway B-Breathing first, but C-Circulation (Heart) is the problem with heart failure. Once airway is situated we can go to vasopressors like dopamine to stimulate alpha and beta response in a 15-20 mcg/kg/min dose, but starting at 5-10 mcg/kg/min. Personally, titrating a IV med is tough with variables. Like the truck bouncing will allow more of the drug into the body. When I worked for a ground transport agency with IV pumps definitely made life a lot easier titrating the dosage to precision. Though, it would not be practical or feasible for ground EMS to have IV pumps yet.


Dopamine at 15-20mcgs is a horrible choice for heart failure, unless they're circling the drain and you're maxed out on other meds. It's easy to make the situation a whole lot worse without properly understanding the pathophys, pharmacology and end-points with therapy.

And am I understanding correctly that you dont use IV pumps when transporting HF pt's on dopamine of 15-20mcgs? And I will assume you're not transducing A-lines for accurate pressures. HF pt's are typically so vasoconstricted, it can be almost impossible to get an accurate NIBP. So, exactly what critieria are you using to titrate your drips? I understand it can be done. Working for a GEMS that only had dial-a-drips, I've done it many times. Now I realize how irresponsible it was and would absolutely refuse to transport a patient requiring drips, without IV pumps and accurate hemodynamics.

It sounds like you guys are in WAY over your heads. I think you need to write a position paper against transporting critical care patients until you get different protocols, basic equipment and more education.
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