April 26, 2024

Welcome to UH EMS-I’s Pharmacy Phriday.  In this installment of the weekly CE offering, we continue the focus from last week looking at the “Respiratory Distress/ Asthma/ COPD” and “Anaphylactic Reaction” algorithms in the UH EMS Protocols.  Last week’s focus was on the Albuterol/Ipratropium aerosol.  The medication we review this week is Methylprednisolone.

Methylprednisolone is a synthetic steroid with potent anti-inflammatory properties that plays a major role in the treatment of respiratory distress following acute treatments like aerosols, Epinephrine injections, or CPAP. Asthma and many cases of COPD have inflammation as an underlying cause.  The Beta agonists included in our protocol, such as albuterol and epinephrine, as well as the anticholinergic Ipratropium can reverse bronchospasm but do little for inflammation.  Methylprednisolone will aid in lessening inflammation and suppressing the body’s immune response.

The medication is often forgotten in the treatment of emergencies mentioned above.  It may be due to its lower place in the algorithms or, quite possibly, because the prehospital provider may not see the full effects of such an administration. The onset of effects with the medication can be up to 1-2 hours or longer.  However, the medication is still very beneficial.  “Steroids can be considered an important part of treatment, so these need to be given as early as possible if able.  Multiple studies have shown a decreased hospital stay, improved lung function and symptoms, reduced treatment failure risk by 50%, and even reduced relapse risk at 1 month.” [1]

A goal often cited regarding the time frame for the administration of steroids in such cases is within an hour of such episodes.  Due to many factors, administration can often be accomplished much faster in the prehospital setting as compared to the ED setting. 

Methylprednisolone is limited to use by the paramedic provider.  The standard adult dose of Methylprednisolone is 125 mg, with the pediatric dose 2 mg/kg, both administered as a slow IV push.   IM administration is an option in cases when IV access cannot be obtained. 

You will notice that Methylprednisolone has an additional use under the Pediatric Sepsis protocol. Methylprednisolone is also recommended for use in the rare case of Adrenal or Addisonian Crisis when the patient does not have an emergency supply of steroids that can be administered by the provider. (More can be found about this condition HERE).

Methylprednisolone is usually supplied to the provider in an Act-O-Vial containing a concentration of 125 mg / 2ml.  The medication must be reconstituted prior to administration.  The following LINK provides a video on the use of the Act-O-Vial. Following reconstitution, the provider may notice that the mixture has a slightly cloudy appearance. However, it should quickly change to a clear solution.

Numerous contraindications and precautions are documented with long-term corticosteroid use but are less of a concern with short-term emergency use, such as in the prehospital setting.  UH Protocols site Methylprednisolone’s use with caution in diabetic patients and hyperglycemia (it can have a hyperglycemic effect on the body) and in the case of a recent MI.  Side effects can include hyperglycemia, increased risk of infection, and GI bleeds, with the most common adverse reaction being hyperglycemia.

For more on the use of steroids in the prehospital setting, be sure to check out the archived episode of the Prehospital Paradigm Podcast from July of 2023 HERE.

Until the next installment, stay safe!

[1] Stat Pearls CE - https://www.statpearls.com/ArticleLibrary/viewarticle/43326

Sincerely,



The UH EMS-I Team

University Hospitals

February 3, 2023

Dear Colleagues,

Welcome to UH EMS-I’s Pharmacy Phriday.  In this installment of the weekly CE offering, we will review another change made in the 2023 UH Protocols.  The medication we look at today is Solumedrol.

The protocol change relating to Solumedrol is a very minor change.  In the previous protocols, the IM route of administration was mentioned only as a side note but not included within the treatment algorithms as an acceptable route.   In the 2023 version of the protocols, the IM route is now indicated within the algorithm as an option when IV attempts have failed.  However, the IV route should be considered the standard practice and remains the preferred route.

Solumedrol is a synthetic steroid with potent anti-inflammatory properties that plays a major role in the treatment of respiratory distress. (In 2022, the medication was in the top ten administered in the UH EMS systems). Asthma and many cases of COPD have inflammation as an underlying cause.  The Beta agonists included in our protocol, such as albuterol and epinephrine, as well as the anticholinergics, such as Atrovent, can reverse bronchospasm but do little for inflammation.  Solumedrol also suppresses the body’s immune response and is very important in the treatment of moderate to severe anaphylaxis.

Unlike some of the other emergency medications that are administered in these cases, Solumedrol is a medication the prehospital provider may not see the full effects of.  The onset of effects with the medication can be up to 1-2 hours or longer but can still be very beneficial. “Steroids can be considered an important part of treatment, so these need to be given as early as possible if able.  Multiple studies have shown a decreased hospital stay, improved lung function and symptoms, reduced treatment failure risk by 50%, and even reduced relapse risk at 1 month.” [1]

Solumedrol is limited to use by the paramedic provider.  The standard adult dose of Solumedrol is 125 mg, with the pediatric dose 2 mg/kg, both administered as a slow IV push. You will notice that Solumedrol does have an additional use under the Pediatric Sepsis protocol. Solumedrol is also recommended for use in the rare case of Adrenal or Addisonian Crisis when the patient does not have an emergency supply of steroids that can be administered by the provider.  (More can be found about this condition HERE.)

Solumedrol is usually supplied to the provider in an Act-O-Vial containing a concentration of 125 mg / 2ml.  The medication must be reconstituted prior to administration. Here is a video on the use of the Act-O-Vial.  Following reconstitution, the provider may note the mixture having a slightly cloudy appearance. However, it should quickly change to a clear solution.

Numerous contraindications and precautions are documented with long-term corticosteroid use but are less of a concern with short-term emergency use, such as in the prehospital setting.  UH Protocols site Solumedrol’s use with caution in diabetic patients and hyperglycemia (it can have a hyperglycemic effect on the body) and in the case of a recent MI.  Side effects can include hyperglycemia, increased risk of infection, and GI bleeds, with the most common adverse reaction being hyperglycemia. 

Be sure to download your copy of the new protocols by visiting https://uhems.org/ and clicking on the “Protocols” tab to view all of UH’s protocols.  The 2023 EMS Protocol can also be accessed as an application for your device at https://www.responsoft.com/.  The customer ID to enter for the UH protocol is 1160105.  Be aware that the ‘Home” or cover page in the app currently indicates the version as 2022 R1.1, but it is the new 2023 version.  One way to confirm this would be to look up the “Respiratory Distress/Asthma/COPD “page and check to see that the change reviewed above is indeed included.

Until the next installment, stay safe!

Sincerely,



The UH EMS-I Team

University Hospitals

July 11, 2022

Dear Colleagues,

This past weekend many of us witnessed at least one firework show. It strikes me that there seems to be a lot of waiting related to such an event. Waiting for the show to start, waiting for the aerial displays after they fire out of their mortar tubes, and of course, the waiting in traffic trying to get home. But all in all, the waiting seems to be worth it. Not everything is instantaneous!  

The waiting from the firework show this past weekend caused me to think of our weekly drug review. This week we are reviewing Solumedrol, a corticosteroid often administered in cases of respiratory distress such as asthma and COPD as well as allergic reactions and anaphylaxis. Unlike some other emergency medications we administer such as DuoNeb, epinephrine, or Benadryl, the prehospital provider may not see the full effects of the medication Solumedrol. There is a longer wait for the medication’s effects to occur, with an onset of effects up to 1-2 hours or longer but can still be very beneficial.

Solumedrol is a slow-acting corticosteroid whose effects are evident within one hour. It is similar to a natural chemical in the body called cortisol that has vast and complex pharmacological actions. Solumedrol’s ability to suppress inflammation, reverse capillary permeability, potentiate smooth muscle relaxation, and thus improve oxygenation in the patient experiencing an airway emergency is the most common reason it is administered in the prehospital setting. 

In various studies, using steroids such as Solumedrol by EMS for respiratory emergencies had benefits such as reduced incidence of hospital admissions, quicker resolution of symptoms, and reduced length of stay for those patients who were admitted to the hospital. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7390576/

Solumedrol is limited to use by the paramedic provider. According to the manufacturer, Solumedrol can be administered via the IV and IM route.  However, the preferred route in an emergency is the IV route and should be provided as a slow push. Higher doses and too rapid an IV push have been documented to cause cardiac arrhythmias, hypotension, and other serious side effects. 

The standard adult dose of Solumedrol is 125 mg, while the pediatric dose is 2 mg/kg. You will notice that Solumedrol does have an additional use under the Pediatric Sepsis protocol. Literature suggests the medications used in this case to counteract the uncontrolled inflammation that may characterize sepsis. Solumedrol is also recommended for use in the rare case of Adrenal or Addisonian Crisis and the patient does not have an emergency supply of steroids that can be administered by the provider. (More can be found about this condition at the following link: https://www.ncbi.nlm.nih.gov/books/NBK441933/ )

Solumedrol is usually supplied to the provider in an Act-O-Vial containing a concentration of 125 mg / 2ml. To reconstitute the medication prior to administration, the medic should:

1. Press down on the plastic activator to force diluent into the lower compartment.

2. Gently agitate to effect solution.

3. Remove the plastic tab covering the center of the stopper.

4. Sterilize the top of the stopper with a suitable germicide.

5. Insert needle squarely through the center of the stopper until the tip is just visible. Invert vial and withdraw dose.

Following reconstitution, the provider may note the mixture having a slightly cloudy appearance. However, it should quickly change to a clear solution.

Numerous contraindications and precautions are documented with long-term corticosteroid use but are less of a concern with short-term emergency use such as in the prehospital setting. UH Protocols site Solumedrol’s use with caution in diabetic patients (it can have a hyperglycemic effect on the body); GI bleeds ( it can cause abdominal distention, bowel and bladder dysfunction, and may increase the risk of a perforation); and febrile patients with sepsis or infection (more susceptible to infections and can exacerbate systemic fungal infections). Solumedrol is a class C medication under the pregnancy class and should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. The most common adverse reaction from the use of a corticosteroid is often hyperglycemia

As mentioned previously, the prehospital provider is not likely to see the benefits of Solumedrol’s administration in the prehospital setting. However, in the interest of quality medical care and a positive medical care experience for the patient, it is a medication and treatment the prehospital provider should consider.

Once again, thank you for all you do to make the patient’s experience a positive one! Till next time, stay safe!

Sincerely,

The UH EMS-I Team

University Hospitals