Medical. : Intro/Qualifications/Goals

policemedic said:
Interesting, since they all require the medic to know his/her pharma and A&P. How many people quickly see the cAMP issue in #3 and reach for the Glucagon?
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Surprisingly, the newer medics see it before some of the more experienced but I say half in half. I am also happy to see that some medics understand that the dose of Glucagon is way higher than we carry in the box but they start off after calling MEDDCOMM, giving it all. Some medics that think outside the box request Epi drips, which will most likely not work but they ask, so I am told by docs. Sometimes it works. Edit: Sometimes I get..."we are too close to the E.R. Lets just transport". Doc Jaslow likes to tell them then.." We practice the first hour of emergency medicine in 25 mins. It makes a difference and if we stay on scene to try to correct a life threat, do it"...

The reason I put these scenarios into play is that I have had them. I have thought outside the box. I like to add crush including rhabdo after being on the floor for hours after an O.D. or fall. Hypotension, extreme tachycardia or rapid AFib, all the s/sx. with that and I like to see who cardioverts instead of using large doses of NSS IV, calcium, bicarb, albuterol....The typical ACLS is a canned course and I hate that shit...

F.M.
 
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policemedic said:
Interesting, since they all require the medic to know his/her pharma and A&P. How many people quickly see the cAMP issue in #3 and reach for the Glucagon?
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Nice. And higher than usual amounts.

Also, I wonder what the QRS duration was for #2?

IV Lipid Emulsion should take care of #2 and #3.
 
8654Maine said:
Nice. And higher than usual amounts.

Also, I wonder what the QRS duration was for #2?

IV Lipid Emulsion should take care of #2 and #3.
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The pt. for #2 doc was Sinus tach, then a wide complex tech under 150 then v-tach. I told dad to grab all scripts and when I saw Doexpin, she coded. I shocked at biphasic 200J, IO, standard ACLS but added Bicarb off the bat (called MEDCOMM off the bat also which is not the norm but this case was weird and I knew I would need expert consult / we practice under a broad standing order). Orders were for another Bicarb and with another 2 mins of CPR, a sinus rythmn (wide / narrowing during transport) was secure with pulses and ok b/p. NSS wide open, pressors not needed but ordered per doc if needed, intubated w/o difficulty. She did this again but was resus'd again and transfetred to ICU. She is alive today.

@8654Maine . Doc. Can you explain the lipid emulsion therapy?

F.M.
 
Good call with grabbing all meds and seeing the Doxepin. Prolonged QRS (>100ms) is usually the danger sign for Sz with TCA toxicity.
Good call on the Bicarb.

ILE (IV Lipid Emulsion Therapy) is the new kid on the block for treatment of certain overdoses.

It has been used for drugs with high Volume of Distribution (lipophilic drugs, i.e. more tissue bound).

The proposed mechanism is that it takes it out of circulation/tissue and surrounds it into a lipid cage to be metabolized and excreted safely.

It has been used in toxicity from Beta blockers, Calcium channel blockers, Local anesthetic toxicity, antidepressants.

I've used it several times and had success.
 
8654Maine said:
Good call with grabbing all meds and seeing the Doxepin. Prolonged QRS (>100ms) is usually the danger sign for Sz with TCA toxicity.
Good call on the Bicarb.

ILE (IV Lipid Emulsion Therapy) is the new kid on the block for treatment of certain overdoses.

It has been used for drugs with high Volume of Distribution (lipophilic drugs, i.e. more tissue bound).

The proposed mechanism is that it takes it out of circulation/tissue and surrounds it into a lipid cage to be metabolized and excreted safely.

It has been used in toxicity from Beta blockers, Calcium channel blockers, Local anesthetic toxicity, antidepressants.

I've used it several times and had success.
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Roger that doc. Thanks for the info. Good to know. Have not heard about this yet.:thumbsup: Another question. Would this current therapy be used for overdoses with severe s/sx. such as anticolinergic toxicity or sympathomemtic toxicity?

F.M.
 
Firemedic said:
Sometimes it works. Edit: Sometimes I get..."we are too close to the E.R. Lets just transport". Doc Jaslow likes to tell them then.." We practice the first hour of emergency medicine in 25 mins. It makes a difference and if we stay on scene to try to correct a life threat, do it"...



F.M.
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Jaslow has his shit wired tight.
I hate lazy medics; lazy is often accompanied by stupidity. "I don't know what to do, so I'll order a diesel infusion."
 
Firemedic said:
Roger that doc. Thanks for the info. Good to know. Have not heard about this yet.:thumbsup: Another question. Would this current therapy be used for overdoses with severe s/sx. such as anticolinergic toxicity or sympathomemtic toxicity?

F.M.
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Yes. That's why it's used for neurotoxic meds, including pesticides, herbicides and anti-depressants, local anesthetics.

Here's an easy way to think of it. Think of drugs as hydrophilic or lipophilic. The hydrophilic drugs are relatively easy to get rid of.

The lipophilic ones are more difficult. They enter tissue and cross the blood/brain barrier easily and are hidden from the usual antidotes that are circulating in the blood stream.

The favored mechanism of action is that the the emulsion acts as a lipid "sink" which attracts the offending drug from the tissues (i.e. brain or heart) and bring it into the circulation and out of the toxic location.

This is a very simplified way but it helps me understand. Hope this helps.
 
8654Maine said:
Yes. That's why it's used for neurotoxic meds, including pesticides, herbicides and anti-depressants, local anesthetics.

Here's an easy way to think of it. Think of drugs as hydrophilic or lipophilic. The hydrophilic drugs are relatively easy to get rid of.

The lipophilic ones are more difficult. They enter tissue and cross the blood/brain barrier easily and are hidden from the usual antidotes that are circulating in the blood stream.

The lipid emulsion is able to cross the barrier and "chase" the offending drug and bring it into the circulation and out of the toxic location.

This is a very simplified way but it helps me understand. Hope this helps.
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I understand doc. Thanks! I recently had a pt. who ingested a large amount of Benadryl, Tramadol and an unknown third med. Found unconscious, responded to pain and then remained responsive to verbal. Also displayed myoclonus, HTN, tachycardia and tachypnea with hot but moist skin. Expect for the moist skin, the typical anticolinergic toxidrome...I gave Versed after consulting with MEDCOMM but the myoclonus remained. I asked about Physostigmine but got no answer from attending (not the most docs that like to teach). Guess I ask too many question because I like to learn...:wall:

F.M.
 
8654Maine said:
Yes. That's why it's used for neurotoxic meds, including pesticides, herbicides and anti-depressants, local anesthetics.

Here's an easy way to think of it. Think of drugs as hydrophilic or lipophilic. The hydrophilic drugs are relatively easy to get rid of.

The lipophilic ones are more difficult. They enter tissue and cross the blood/brain barrier easily and are hidden from the usual antidotes that are circulating in the blood stream.

The favored mechanism of action is that the the emulsion acts as a lipid "sink" which attracts the offending drug from the tissues (i.e. brain or heart) and bring it into the circulation and out of the toxic location.

This is a very simplified way but it helps me understand. Hope this helps.
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Oh! How does the drug used with the treatment clear body? Urine? Forgives if this sounds stupid doc...

F.M.
 
That's a good question. The answer is multifold.

2 theories for clearance:
(1) Eliminated similar to chylomicrons, i.e. fat metabolism.
(2) Eliminated by the Marcrophages (white blood cells).

Brother, you've really got me stretching my neurons here. That's good.
 
8654Maine said:
That's a good question. The answer is multifold.

2 theories for clearance:
(1) Eliminated similar to chylomicrons, i.e. fat metabolism.
(2) Eliminated by the Marcrophages (white blood cells).

Brother, you've really got me stretching my neurons here. That's good.
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Thanks doc. I like stretching my neurons also. LOL. Thanks again doc!

F.M.
 
8654Maine said:
Yes. That's why it's used for neurotoxic meds, including pesticides, herbicides and anti-depressants, local anesthetics.

Here's an easy way to think of it. Think of drugs as hydrophilic or lipophilic. The hydrophilic drugs are relatively easy to get rid of.

The lipophilic ones are more difficult. They enter tissue and cross the blood/brain barrier easily and are hidden from the usual antidotes that are circulating in the blood stream.

The favored mechanism of action is that the the emulsion acts as a lipid "sink" which attracts the offending drug from the tissues (i.e. brain or heart) and bring it into the circulation and out of the toxic location.

This is a very simplified way but it helps me understand. Hope this helps.
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as an aside.... Bacon, IV, STAT!!! back to the seriousness of the thread. Sorry for the hijack.
 
Firemedic said:
Paging @Red Flag 1...What's you're imput doc?

F.M.
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:zzz::zzz::zzz:.........Hello.........What??!! you want to give IV Bacon??!!..................A,a, er,.....Bacon, you said.....well....Did ya call the Resident yet?..........He did, did he!......well sure, just read this, http://www.thepoisonreview.com/2012/07/30/lipid-emulsion-therapy-for-poisonings-a-review/, & ,http://emergencypedia.com/2013/06/20/intravenous-lipid-emulsion-therapy/ , before ya do OK?

For some history, anesthesia providers administer large volumes of local analgesia/anesthetics in the course of some regional techniques. It is possible for some of the injectate to go intravascular. If the volume is great enough, there can be cardiotoxic events. Some of the agents we use can have very long lasting effects, with cardiac standstill/asystole as a result. The worry is greatest with the use of Bupivicane , because of it's long acting ability. As the article points out, the mechanism of action of is not fully understood, the result is a "Lipid sink" sort of pulling off the toxic agents. The best analogy I can think of is a "Heat Sink" when doing any soldering in radio/computer equipment. Between the soldering point, and other components, the tech puts a metal clamp to provide an alternate route for the heat to go, and protect other components from the heat generated by soldering. I have to be honest, though and say that being retired for a few years now, I have no experience in using ILE. We were the first to use lipid emulsions as induction agents, Diprivan to be specific. It was really hard to push the plunger on the Diprivan syringe for the first time; 20ml of what looked like milk directly into a vein:-/:-/:-/.

I expect ILE will show up in ACLS, if it has not already. It seems to be effective for Sodium and Calcium Channels, and tricyclic antidepressants like Elavil. Now, let me get back to.........:zzz:.......just mail me the $5.00, and remember to call the resident first....:zzz::zzz::zzz:.
 
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