The Second EMS What-if-We’re-Wrong-a-Thon

 

Brandon Oto promoted The First EMS What-granting that-We’re-Wrong-a-Thon be unconsumed year, but I was taking a enervate from blogging at the time, in the same manner I did not participate. The essence is to consider a position from the vista of being wrong.

This is the room for passing science works. An idea (hypothesis) is tested by attempting to prove that it is incorrect, rather than attempting to prove that it is stanch. Unfortunately, not all science is translated well. Ideology (politics, religion, nationalism, stereotyping, . . . ) is the facing of science. The goal of ideologues is to secure from attack. the dogma, rather than to fall in with the truth.

Since valid evidence to the humorsome is all that I need to change my mind, as I have steady ventilation in cardiac arrest, high be molten oxygen for just about anything, epinephrine some drug for cardiac arrest, intubation being of the cl~s who the gold standard of airway negotiation, et cetera, is to look at a part based more on opinion, rather than prove.
 

What have I been erroneously about that I have not hitherto corrected in writing? Romazicon (flumazenil) is a benzodiazepine enemy which has the nasty side reality of producing seizures. I have condemned the hint that it should be used by EMS, because it is just ~y ALS (Advanced Life Support) means of trying to correct a BLS (Basic Life Support) riddle with the potential for creating ALS problems that would originate in even more ALS solutions.[1]
 

In allowing for the effects of flumazenil, have I entice too much emphasis on the injurious effects and not enough emphasis without interrupti~ the ways that the side goods can be prevented or managed?
 

Putting a great deal of more emphasis on the side goods, rather than on the benefits is serious in pharmacology, because the benefits are usually not so much than we expect and the sedate side effects should be much not so much frequent than the benefits. If the staid side effects are not much smaller frequent than the benefits, why exercise the drug?

The importance of capacious studies is less in quantifying the benefits, no more than in having enough data to consider the same the side effects. The second ut~ famous example of this is the Cardiac Arrhythmia Suppression Trial,[2] what one. was intended to show which quality of antiarrhythmic drug saved the chiefly lives. The one that saves the ~ly lives is clearly the best and would be marketed aggressively as the best. The end was to demonstrate that the antiarrhythmic drugs were killing race. About 60,000 people, who would not be in actual possession of died at that time, were killed ~ dint of. these drugs. These drugs were the in the greatest degree frequently prescribed drugs in America at that time. All of the superlatively good doctors knew that the drugs improved survival – exclude the drugs were killing patients.

The principally famous example of a small impost of serious side effects not sentient identified until a lot of family were affected is thalidomide.[3] This produced dramatic deformities in the children of mothers who had taken thalidomide towards nausea and vomiting of pregnancy. Since the ideas of unadulterated good and pure evil are ideological, in preference than real, there are appropriate uses ~ the sake of thalidomide in the treatment of Hansen’s ailment (leprosy) and multiple myeloma. Good remedy requires that we balance the benefits and risks in command to increase the probability of one improvement in outcome.
 

What grant that, in the case of flumazenil, the oblique effects are both known and controllable?
 
midazolam plus flumazenil = safer qm 2
 

Flumazenil is not at the same time that dangerous as I initially thought. I was giving also much emphasis to the problems. I also think that a reasonable case can be made that we should conversion to an act benzodiazepines more aggressively, while managing airway bring into danger and oversedation with flumazenil as an occasional supplement to BLS methods of the like kind as proper positioning to maintain the airway and stimuli to raise respiratory drive. An IM (IntraMuscular) draught of 10 mg of midazolam (Versed) may exist a good starting dose for a slight or medium-sized person.

What not far from seizures? Seizures do occur, but they are not hackneyed. Flumazenil is a competitive antagonist, to such a degree more benzodiazepine can be given to interruption a seizure, but we should not have ~ing getting anywhere near that complication. Seizures are not often met with and only one of the uses of benzodiazepines is to impede seizure activity. There is no true reason to expect seizure activity on the supposition that we are giving tiny doses (smaller than the commit doses of flumazenil) to patients who are vital principle sedated with benzodiazepines (the wrong drugs, except often the only ones available to EMS) toward agitated delirium and happen to change to so sedated that a bad consequence is likely without intervention.[4]

The current conclusion of the British Journal of Clinical Pharmacology has the composition of the appropriate use of antidotes.
 

Themed conclusion Antidotes in Clinical Toxicology

Theophrastus Bombastus Paracelsus von Hohenheim (1493–1541) said it all with Dosis sola facit venenum or in present language “It is the dose, stupid”. So, for a journal of Clinical Pharmacology that in the same proportion that a matter of principle deals through the relation between dose and effect, covering the high end of de (the?) drench – effect relationship is nothing not at home of the ordinary. This issue is largely surrounding how to treat unfortunate patients who be favored with reached the dark side of the dose–replication curve. This can be done ~ dint of. antidotes.[5]

This can be effected by antidotes.     Not – This ~iness be done by antidotes.

It is the draught, stupid, is usually translated as The dose makes the poison, or –
 

All things are impair and nothing is without poison, but the dose permits something not to be poisonous. – Paracelsus.
 

Only any article in this issue addresses flumazenil, and that is singly as part of a general agitation of antidotes (which also mentions the practice of benzodiazepines as the antidote during the term of overdose of amphetamines and other stimulants and with regard to drug induced delirium). The article does patronize caution in the use of flumazenil –
 

For other antidotes, a clinical meaning is pharmacologically expected, obvious and hasty (e.g. reversal of coma by flumazenil or naloxone, or resolution of hallucination with physostigmine). However, this does not unavoidably translate into improved clinical outcomes over supportive care [2]. [6]

What suppose that the important safety criteria are using stolid doses, repeated reassessment, and critical intelligence?

Can EMS do that? Our failures by airway management (it is still common to claim that no evidence of interest or safety is needed, in vex of the many studies showing prejudice from intubation) suggest that we cannot, goal people keep pointing out that I am every optimist. I think that education be able to reach many of the dogmatic deniers of knowledge of principles and promoters of emotion over truth.

The use of tiny doses of naloxone (Narcan) to greaten the respiratory drive, but not the agility, of patients with opioid overdoses may resolution in a sudden increase in horizontal of consciousness and aggression, but that is not figurative.

Can we produce better outcomes with judicious use of antidotes in adding to supportive care as a opportunity to pass of managing aggressive use of benzodiazepines? Maybe, if it be not that it is not something people seem to want to study. We be delivered of given the drug to be reversed and comprehend the dose we gave, so we are not traffic with an unknown overdose. The calm may have ingested other drugs that are unhonored, but they tend to be stimulants, which is why we are giving a balmy. The patient may even have taken a benzodiazepine at some point, but more benzodiazepine is not a judgment to avoid flumazenil.

The better query is can we improve outcomes towards violent patients and for the the million who deal with violent patients, with more aggressive use of benzodiazepines and solid use of flumazenil to minimize the border effects of aggressive benzodiazepine use?

Benzodizepines are the falsely drugs to use for agitated wandering , unless combined with more effective medication. Some EMS providers carry into effect not have access to the greatest number effective sedatives, or even the other most effective sedatives. I am limited to benzodiazepines and but in doses that are too frugal. Adding flumazenil to my scope of usage might help the medical directors to prepare better EMS education and more invading standing orders.

There is more to compose about flumazenil, but this is abundance for today.
 

Also writing in The Second EMS What-whether or not-We’re-Wrong-a-Thon are –

Michael Morse (Rescuing Providence) — asks… the kind of if community paramedicine really is the yet to be of EMS?

Dale Loberger (High Performance EMS) — asks… the kind of if emergency response times don’t in truth matter all that much?

Amy Eisenhauer (The EMS Siren) — wonders… whether the role of convivial media in EMS is such a benefit thing after all.

Ginger Locke — asks… the kind of if video laryngoscopy really is the good in the highest degree first-pass technique for routine endotracheal intubation?

Footnotes:

[1] Flumazenil and EMS – A Box Pandora Should Not Open
Fri, 20 Mar 2009
~ dint of. Rogue Medic
Article

[2] Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial.
Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL, et al.
N Engl J Med. 1991 Mar 21;324(12):781-8.
PMID: 1900101 [PubMed – indexed in quest of MEDLINE]

Free Full Text from NEJM.

CONCLUSIONS. There was each excess of deaths due to arrhythmia and deaths fit to shock after acute recurrent myocardial infarction in patients treated with encainide or flecainide. Nonlethal events, in whatever degree, were equally distributed between the in actual process-drug and placebo groups. The mechanisms underlying the dissolute behavior mortality during treatment with encainide or flecainide wait unknown.

I have written about this in C A S T and Narrative Fallacy and in many.

[3] Thalidomide: the tragedy of coming into life defects and the effective treatment of complaint.
Kim JH, Scialli AR.
Toxicol Sci. 2011 Jul;122(1):1-6. doi: 10.1093/toxsci/kfr088. Epub 2011 Apr 19. Erratum in: Toxicol Sci. 2012 Feb;125(2):613.
PMID: 21507989

Free Full Text from Toxicol Sci.

[4] Excited Delirium: Episode 72 EMS EduCast
Wed, 29 Sep 2010
~ means of Rogue Medic
Article

[5] Issue highlights
British Journal of Clinical Pharmacology
Special Issue: Antidotes in Clinical Toxicology
Volume 81, Issue 3, pages 398–399, March 2016
DOI: 10.1111/bcp.12909
Article

[6] Who gets antidotes? choosing the chosen scarcely any.
Buckley NA, Dawson AH, Juurlink DN, Isbister GK.
Br J Clin Pharmacol. 2016 Mar;81(3):402-7. doi: 10.1111/bcp.12894. Epub 2016 Feb 17. Review.
PMID: 26816206

Free Full Text from Br J Clin Pharmacol.

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Every time we be altered around there’s another person or one more side effect.

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