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Old 11-29-2011, 01:26 AM   #11
Farmer2DO
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Opinions on transfers without a vent?
I think an agency that lets patients be bagged for 45-120 minutes is doing their patients a huge disservice. It can be difficult, often downright impossible, to manage the finer points of mechanical ventilation with a BVM: fine tuning FiO2, RR, TV, PEEP, PS, mode, I time, etc. You need a ventilator to manage breaths in synch with a patient. Often times, in my experience, these patients need to be paralyzed, and that's sometimes not in their best interests. At my current job, we use a ventilator for a 1.4 mile IFT.



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Opinions? For IFT, do you prefer paralytic onboard or favor increasing dosage of the sedatives?
If a paralytic is going to be used, sedation and analgesia should be optimized first. I understand that sometimes it's a patient safety issue and may need to be done with sub-optimal sedation and analgesia. I try to avoid routine paralysis. I've been shown the IVC on US of a trauma patient who is intubated and paralyzed, and you can see the IVC collapse with every breath.


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Old 11-29-2011, 01:30 AM   #12
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Unless discharging home or to the MJ ranch, why not use more of the same drug instead of a mix?
Less side effects when you use lower doses. And you get the benefits of both agents, like sedation, pain management, reduction of MAP (if you want it).
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Old 11-29-2011, 01:31 AM   #13
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you know, as someone who has never intubated someone, the thought of giving analgesea has never crossed my mind. Sedative + paralytic = RSI, and I don't think I ever heard pain medication given. and most unconc people who get tubes don't get analgesea either (although they tend to be pretty messed up for us to tube them anyway). ditto someone is is RSIed, odds are if you are being tubed, you have bigger problems than if the tube is causing the patient pain, and are trying to keep the person alive until they get to the hospital.

granted, our transport time for 911 jobs can be between 4 min and 30 minutes depending on where in our coverage area we are, but I don't think I've ever heard any paramedic push pain meds.

I think I'm gonna ask some of the ALS providers I know, as well as some of the ER docs what they think of it.

thanks
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Old 11-29-2011, 07:37 AM   #14
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Originally Posted by usafmedic45 View Post
You can always tell medical professionals who have been tubed and vented because they are very liberal with sedation and pain control.
I was tubed in ED and spent a short while in the unit..once upon a time. I can't remember any details obviously but I have this odd and vague memory of having been in pure agony for a few days.

For some completely unrelated reason, I am very passionate about post tube analgesia.

Go figure.
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Old 11-29-2011, 08:35 AM   #15
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Less side effects when you use lower doses. And you get the benefits of both agents, like sedation, pain management, reduction of MAP (if you want it).
So you get the side effects of multiple drugs?

Plus propofol depresses CMRO2, fent does not.

It decreases cerebral blood flow, ICP, and intraoccular pressure.

Has no clinically significant side effects on renal, hepatic or endocrine organs.

Let's compare it to fent?

Side effects common: nausea, vomiting, itching.

Muscle rigidity more common in induction doses.

as an analgesic and not an anestetic agent patient can be immobilized and aware.

Over saturation of hepatic and renal metabolism with prolonged or high doses.

I think I will stick with higher dose propofol given the choice.
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Old 11-29-2011, 10:30 AM   #16
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They used propafol and ativan on me for cardioversion

Other than the first degree burns around the patches, no issues, other than I felt about 5 points lower on the IQ scale for the next week.
Just saying. I am remembering the old days of scopolamine for childbirth, it still hurt like hell and they hallucinated, but they forgot it all afterwards.

Hey, wait a minute!
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Old 11-29-2011, 11:09 AM   #17
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Propofol is generally not available to EMS except in the IFT arena, for those patients a benzo/opiate combination is what you have to work with.

In my experience, analgesia is woefully under used during induction or the short term post intubation period, both in and out of the hospital. I'm not sure why that is, but I see it daily.

A case from 2 weeks ago, R/O head bleed that we RSI'd in the field, Fentanyl, Etomidate, Sux for induction, Versed/Fentanyl for post intubation sedation. Pt had about 40 minutes between induction and ED arrival, old school ED doc who studied and worked in New Orleans for most of her career (graduated in 1973) was horrified that we gave Versed/Fenanyl. Her first comment was that since the pt recieved Etomidate there was no reason for Versed. When I stated that the induction dose of Etomidate lasts about 5 minutes her comment was "Versed doesn't last any longer". Her next problem was Fentanyl. She doesn't use it, and the 200 mcg the pt recieved was apparently way above any dose of Fentanyl she had ever heard of, and promptly ordered a Narcan drip. This is a true story, not from some deserted island but a large medical facility in a city full of academic medical centers.

Pt was inducted w/150 mcg Fentanyl, 20 mg Etomidate and 120 mg Sux, post intubation recieved 5 mg Versed x 2 and 50 mcg Fenanyl.
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Old 11-29-2011, 12:25 PM   #18
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Originally Posted by Veneficus View Post
My point was you can use propofol in large enough quantities to induce an anesthetic state.

Unless discharging home or to the MJ ranch, why not use more of the same drug instead of a mix?
That was my thought too. I was just too loaded on USAFMedic45 brand Nighty Night Juice (Benadryl) to formulate a good argument for it.
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Old 11-29-2011, 12:31 PM   #19
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you know, as someone who has never intubated someone, the thought of giving analgesea has never crossed my mind. Sedative + paralytic = RSI, and I don't think I ever heard pain medication given. and most unconc people who get tubes don't get analgesea either (although they tend to be pretty messed up for us to tube them anyway). ditto someone is is RSIed, odds are if you are being tubed, you have bigger problems than if the tube is causing the patient pain, and are trying to keep the person alive until they get to the hospital.

granted, our transport time for 911 jobs can be between 4 min and 30 minutes depending on where in our coverage area we are, but I don't think I've ever heard any paramedic push pain meds.

I think I'm gonna ask some of the ALS providers I know, as well as some of the ER docs what they think of it.

thanks
Which is one reason why I've always argued that ketamine is a damn near ideal medication for RSI in the field. A lot of times you can intubate with it alone and do not need to give a paralytic which negates that tiny issue of stopping whatever respiratory effort the patient may have going on which makes a failed airway situation a little less Under-roo ruining in nature. You get pain control, don't have to worry about drops in BP, it has a bronchodilatory effect and there are some apparent neuroprotective effects from its use. Other than the patient drooling some with it and emergence reactions, there really isn't a better drug out there for this purpose.
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Old 11-29-2011, 01:34 PM   #20
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I think it should be remembered that the emphasis on pain management in awake patients is still relatively new and often poorly done, still. It can take decades to overturn old/bad practices. It doesn't surprise me that many RNs and physicians think analgesia isn't needed in these situations where patients are usually heavily sedated. It really wasn't too long ago that it was common knowledge that morphine was detrimental to the physical exam of the patient complaining of abdominal pain (and there are plenty of people who are still misinformed about this). At one point, it was standard practice to NOT give analgesics (or only very low doses) to BURN patients (look up Dax Cowart if you're curious). Anyhow, there is a reason JHACO had to set pain management standards in 2000. Opiates still carry a stigma, especially fentanyl, which many older physicians are only familiar with as a drug used by anesthetists. Additionally, there are a lot of physicians practicing EM and critical care that were not formally trained in such practices, thus there is a bigger disconnect between what is taught and what is practiced in some places.

From what I've read, there have been a couple cases of physicians being sued for inadequate pain management. There is at least one study where patients who underwent ED RSI were interviewed about their experience and about 1/2 had some sort of recall and most reported experiencing pain. These two things might help in persuading the skeptics or gaining the attention of those who don't want to take the time to listen.
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