75yo Male - post LOC wrist #

[8jimi8]

its not about reversal agents, its about the possibility of somebody dying under your nose.

Umm... excuse me... did you that 39 was DEAD?

 

[Shishkabob]

its not about reversal agents, its about the possibility of somebody dying under your nose.

Umm... excuse me... did you that 39 was DEAD?

Pay closer attention

 

[Veneficus]

Carry flumazenil for Benzos and Narcan for narcs and you should be fine.

Sedation when it's called for beats no sedation because of fear.



Now... just to get EMS agencies to carry flumazenil like they do Narcan...

I don't think a reversal agent is the answer to all the problems. First, if you are over sedating, then you need to get that under control.

A reversal agent is not always the best idea either even n the emergent setting. In EMS much is discssed on the topic of not "waking up" heroin addicts with narcan. But consider also not eliminating your sedation and pain control routes either. For example:

You have a burn patient with >40% BSI of partial thickness burn. He complains pain is 100/10 (as you would expect) so you dose him with some opioid of your favorite flavor. So it tanks his BP, respiratry drive, and mental status. If you reverse this with narcan you are going to eliminate opioid pain medication for the duration of the narcan. Not good at all.

There are many more examples of the above. Especially reversal agents post surg.

Flumazenil is also not as benign narcan. Narcan binds to opioid receptors which have highest specificity to pain stimuli. Flumazenil is going to decrease the post synaptic uptake of GABA, which is the major inhbitory neurotransmitter of the CNS. (stops you from firing on all cylinders at once) when you take that away you can have everything from hallucinations to seizures.

If you do induce a seizure with it, you may be forced to put the pt in a barbiturate coma to stop it, which incidentally attaches to a different part of the same receptor as a benzo and flumazenil, so you can really create some problems with benzo antagonists.

So lets take an example of an infant in febrile seizure. (PALS would be proud) The parents give the kid some rectal valium, you find the kid still seizing and add your benzo to it, decide it is too much and then reverse it back to seizure which you now cannot control. So rather than just controling ventilation till the benzo wears off, you now create a big problem for the child, and turn an ER visit into an PICU stay.

Depending on the strength of the opioid or benzo you may have to set up a maintenence dose of the reveral agent which may fall beneath theraputic range long before the medication you are reversing.

In the hospital a nurse cannot just walk around with reversal agents in the pocket incase of accidental OD over a period of hours.

I assure you that I am not shy about using pharm therapy, but there is a difference between aggresive and irresponsible.

 

[Shishkabob]

Oh agreed, it's better to avoid the over sedation to begin with, but there are patients who have more than expected reactions to medications for no apparent reason. But I'm in a firm belief that if you carry an agonist on the rig, you should be carrying the antagonist as well... don't do something that you can't fix.

I'm also not for waking up the patients that don't need it. If you can control the respiratory drive complications with .4mg, why push the whole 2? Risk has to be weighed with benefit, just like everything else we do.


I've been told horror stories of medics pushing narcan on patients that seem to be in narcotic induced coma, but end up having a cancer patient who was in said induced state because of the severe pain... than you're screwed.




But alas, I'm a new medic and I know I'll have quite a while before I know when to use what. *sigh*

 

[Smash]

Naloxone is carried to reverse opiod overdose in the field. If it is being used to reverse Paramedic induced overdose, something has gone horribly, horribly wrong on a whole lot of levels.

Even if a patient does have a high degree of sensitivity to a benzo, care is always just supportive; airway, breathing, circulation, drive to hospital. Flumazenil is not a nice drug at all (as veneficus pointed out), and generally not even the ICUs here like messing with BZD receptors. Look after them until they wake up and all is well.

You have a burn patient with >40% BSI of partial thickness burn. He complains pain is 100/10 (as you would expect) so you dose him with some opioid of your favorite flavor. So it tanks his BP, respiratry drive, and mental status.

Morphine, 2mg every 10 minutes to a maximum of 10mg? Should be fine with the BP and respiratory drive!

Pain relief is one of the most useful, most important and most humane things we can do for our patients, and combination therapy is usally the best way of achieving this. Some people might go well with 5-10mg of morphine for their broken limb, others will need, and should get, significantly more.
We know that acute pain has detrimental effects on the entire person, both physiologically and psychologically, and that the effects can be long lasting and profound (like chronic pain syndromes), yet we continue to essentially tell our patients to harden the **** up and put up with the pain, because we can't be bothered getting decent education, so Drs don't trust us with drugs (and who can blame them really?)

 

[Melclin]

If it is being used to reverse Paramedic induced overdose, something has gone horribly, horribly wrong on a whole lot of levels.

A thousand time yes. Even then, I still feel that in a lot of cases where naloxone has been used, a bit of supportive care and close monitoring would have been far more appropriate.

We know that acute pain has detrimental effects on the entire person, both physiologically and psychologically, and that the effects can be long lasting and profound (like chronic pain syndromes), yet we continue to essentially tell our patients to harden the **** up and put up with the pain, because we can't be bothered getting decent education, so Drs don't trust us with drugs (and who can blame them really?)

But, Smash, I had a broken clavicle for ten hours before I could drive myself to the hospital, and this blokes just got a guts ache, bloody sheila. Little bit of pain never hurt anyone, its character building. <_<

I don't think a reversal agent is the answer to all the problems. First, if you are over sedating, then you need to get that under control.

A reversal agent is not always the best idea either even n the emergent setting. In EMS much is discssed on the topic of not "waking up" heroin addicts with narcan. But consider also not eliminating your sedation and pain control routes either. For example:

You have a burn patient with >40% BSI of partial thickness burn. He complains pain is 100/10 (as you would expect) so you dose him with some opioid of your favorite flavor. So it tanks his BP, respiratry drive, and mental status. If you reverse this with narcan you are going to eliminate opioid pain medication for the duration of the narcan. Not good at all.

You are welcome to an equal portion of the thousand yeses I dealt Smash regarding reversal agents.

Despite the options for pain relief that our service has now, you still seem to see and hear of cases everyday where ambos will just bung in 3 mls of methoxyflurane and turn their brain off. Our pain guru at uni tries ever so hard to convince us to use adequate analgesia with well reasoned and evidence based arguments, and still people are super conservative, even in scenarios - like the patients pain will disappear once the you have satisfied the instructors need for you to "identify pain and initiate pain management". I'm seeing a nasty trend in some students who are presumably struggling with the volume of material to reduce ideas down to simple recipes: "If constricted pupils, Narcan 2mg", "If pain, penthrane 3 mls". "Drop in consciousness after paramedic opiate admin, narcan 2 mg". Sometimes I can't blame docs for lacking confidence in EMS.

 

[MrBrown]

I would ask anybody who thinks some methoxyflurane or like 2mg of morphine is adequate analgesia if they have ever been in pain. Like not ow I stubbed my toe or got a fat lip when the Mrs sucker punched me for hitting on her sister but severe, irretractable pain that is all consuming and makes you wish you could hurry up and die.

One night Brown ended up with torted testes and let me tell you it was not a fun experience limping into ED doubled over screaming in agony pulling my basketball sized gonad behind me. Bloody surgical registrar gave me two panadol because the anaesthesiologist was in theatre. First of all why is a surgical registrar covering the emergency department and I don't care if the anaesthesiologist at the dinner show, gimme something stronger I said!

Hence why I personally believe in not-so much dishing out morphine to everybody who goes "it hurts" but really taking an agressive approach to analgesia. You take away pain and the patient is going to be more comfortable, its less physiologically taxing on the patient, thier family calms down, and the whole thing just works ten million percent better.

Oh and stay the hell away from flumazanil that stuff is nasty.

 

[Veneficus]

Morphine, 2mg every 10 minutes to a maximum of 10mg? Should be fine with the BP and respiratory drive! ?

But not for your BP and respiratory drive when the patient starts stabbing you with the needle to get the rest of it from you.

With a large surface burn patient, if you need to call somebody after 10mg, you are going to be on the phone a lot. My record in the field was 50mg/IV (because that is all I had on the truck) during a 25 minute transport, and it might as well have been water I was pushing into him. It was a bit uncomfortable when he asked me to give him something that would kill him because I couldn't help with the pain.

When I got the the ED the doc asked me why I didn't just pour versed into him till he was out and tube him? (we didn't have RSI)

Now why didn't I think of that?

(because I was new and listened to horror stories of over medicating people and how I would lose my job, get sued, all that crap, and I didn't know sometimes such a teatment was actually indicated and humane.)

 

[MrBrown]

When I got the the ED the doc asked me why I didn't just pour versed into him till he was out and tube him? (we didn't have RSI)

How much midazolam is generally accepted as being required to knock somebody out you know, your average 80kg male?

For RSI we can give either 0.1mg/mg up to max 5mg midaz (which seems pretty piss poor if you ask me) or 1.5mg/kg ketamime, which seems slightly more appealing.

 

[Veneficus]

How much midazolam is generally accepted as being required to knock somebody out you know, your average 80kg male?

For RSI we can give either 0.1mg/mg up to max 5mg midaz (which seems pretty piss poor if you ask me) or 1.5mg/kg ketamime, which seems slightly more appealing.

0.1mg/kg is the textbook starting dose. The max listed is 0.5mg/kg. In my experience to sedate a patient to pass a tube without any other agent in the mix is varies between 10-30mg (most around 14-16) depending on their size and how agitated they are to start with.

In peds a max dose of 20mg prior is usually considered "safe."

But I have not seen anything with absolute dosing guidlines outside of agency specific protocol.

 

[Smash]

How much midazolam is generally accepted as being required to knock somebody out you know, your average 80kg male?

For RSI we can give either 0.1mg/mg up to max 5mg midaz (which seems pretty piss poor if you ask me) or 1.5mg/kg ketamime, which seems slightly more appealing.

5mg does seem a little light for some cases. 0.1mg/kg to a max of 10mg here, less depending on other parameters like bp. Given in concert with 100mcg of fentanyl. Ketamine is interesting for induction, certainly not without controversy, but I like that you have options. I'm curious about the restriction from using versed and ketamine together as versed is very commonly used to attenuate the potential for emergence phenomona with ketamine (more so with procedural sedation)

Vene, I don't think I've ever given that much morphine, but only because I have other options. As for how much we carry: Morphine 100mg, fentanyl 1500mcgs, versed 120mg. Haven't got ketamine on all the rigs yet (the wheels turn slowly) but maybe one day... Still, got enough to knock out any random charging bull elephant we may come across.

 

[MrBrown]

0.1mg/kg is the textbook starting dose. The max listed is 0.5mg/kg. In my experience to sedate a patient to pass a tube without any other agent in the mix is varies between 10-30mg (most around 14-16) depending on their size and how agitated they are to start with.

I should clarify that we use suxamethonium too and that midazolam is for people who have a neurogenic cause for coma with GCS equal to or less than ten.

Everybody else gets 1.5mg/kg of ketamine.

Because we use sux as well I'm going to place a bet on the midaz or ketamine being primary used for amnesia rather than neuromuscular blunting.

Perhaps that information was important? :unsure:

Now I have never personally had midaz so you give me 5mg and I will tell you if I can remember anything! (at 70kgs I can't have 0.1mg/kg under our RSI guideline because it's 5mg max)

I find anaesthesia rather fascinating and am aware that dosing of other common inducation agents like propofol and etomidate are much higher so 5mg of midaz looks a bit wimpy in comparison and I sort of have this self induced fear that it's not enough to knock the patient sufficently out so they don't remember anything.

 

[Aidey]

When I got the the ED the doc asked me why I didn't just pour versed into him till he was out and tube him? (we didn't have RSI)

Now why didn't I think of that?

(because I was new and listened to horror stories of over medicating people and how I would lose my job, get sued, all that crap, and I didn't know sometimes such a teatment was actually indicated and humane.)

^^^ In the area where I first started as a paramedic we didn't have RSI, and I worked an industrial job with a very high chance of bad burns and that was exactly what our doc told us to do.

The way he said it was "you're not RSIing, you're overmedicating and then treating the side effects".

I personally am a big fan of mixing opiods and benzos. In my experience it provides better pain management at lower doses of each.

 

[MrBrown]

Oops had a mental fart and forgot we're using fentanyl too.

Maybe I should just post up our recipe?

BTW can you conjure up an asthmatic who needs intubating having a GCS of 10 coz I sure can't?

6.3 RAPID SEQUENCE INTUBATION (RSI)
• Indicated for patients with a GCS <10 with airway or ventilatory compromise.

• Absolute contraindications:
a. Known history or family history of malignant hyperthermia or
b. Paraplegics/quadriplegics or
c. Any muscle disorder with long term weakness or
d. Hyperkalemia strongly suspected or
e. Electronic capnography unavailable or
f. No dedicated suitable assistant (2nd AP preferred).

• Relative contraindications:
a. Age < 5 or > 75 yrs or
b. Age > 75 years with stroke or COAD as underlying cause or
c. Predicted difficult airway or
d. Less than 15 minutes to hospital or
e. Underlying cause is likely to rapidly improve e.g. GHB poisoning or post seizure.

• Preparation:
a. Assess the patient for signs of difficult intubation.
b. Prepare all equipment and brief assistant.
c. Draw up and label drugs, ensure running IV line.
d. Ensure monitoring in place: SpO2, ETCO2, ECG and NIBP.
e. Pre-oxygenate for 3 minutes with 100% oxygen via manual ventilation bag.
If unable to pre-oxygenate administer 6 large breaths immediately after apnoea occurs.

• Medicines:
a. Give IV fentanyl over 1 minute, 2-3 minutes before induction.
b. Regimen 1. For all patients with neurological cause for coma
(e.g. TBI, stroke, post cardiac arrest) that do not have significant
shock - give IV midazolam and IV suxamethonium.
c. Regimen 2. For all other patients and particularly for those with
shock – give IV ketamine and IV suxamethonium.

• Intubate and confirm ETT position with capnography.
• If unable to intubate implement failed intubation drill.
• Give IV vecuronium once ETT confirmed in trachea.
• Ventilate to ETCO2 30-35 mmHg (exception – life threatening
asthma, ventilate at 6 breaths/min and ignore ETCO2).
• Give additional sedation (midazolam 1-3 mg and morphine 1-3
mg) and vecuronium as required.

RSI Drug Dose
• Fentanyl: 1mcg/kg (max 100mcg)
• Midazolam: 0.1mg/kg (max 5mg)
• Ketamine: 1.5mg/kg (max 150mg)
• Suxamethonium: 1.5mg/kg (max 150mg)
• Vecuronium: 0.1mg/kg (max 10mg)

• *Halve fentanyl and midazolam dose if: age > 60 yrs, or HR > 100/min or systolic BP < 100mmHg.
• Round the patients weight to the nearest 10 kg.
• Midazolam must be given using 1 mg/ml in a 5ml syringe.
• Ketamine must be diluted to 10 mg/ml in a 20ml syringe.
• Vecuronium must be diluted to 1 mg/ml in a 10ml syringe.
• Fentanyl in children must be diluted to 10 mcg/ml in a 10ml syringe.
• Suxamethonium in children must be diluted to 10 mg/ml in a 10ml syringe.

 

[Veneficus]

Vene, I don't think I've ever given that much morphine, but only because I have other options. As for how much we carry: Morphine 100mg, fentanyl 1500mcgs, versed 120mg. Haven't got ketamine on all the rigs yet (the wheels turn slowly) but maybe one day... Still, got enough to knock out any random charging bull elephant we may come across.

We had 50mg morphine, 60mg versed, and I forget how much toradol.(because I hardly ever gave it)

At the time fent was unheard of on an ambulance in the US. If my memory serves me correctly the Aussies were just starting their studies on it prehospital.

In all fairness we had 2 grams of mag sulfate that would put somebody down and I even got permission to to it once in the US. (one of my impossible feats. ie: it will never be done again in that location) In a jam you can use the CNS depressive properties of mag but outside of far Eastern Euope, Africa, and Asia, make sure you have permission from somebody higher up the food chain than yourself and there will probably be a policy never to do that again afterword.

Most certainly don't give it to a trauma patient.

 

[Veneficus]

Oops had a mental fart and forgot we're using fentanyl too.

Maybe I should just post up our recipe?

BTW can you conjure up an asthmatic who needs intubating having a GCS of 10 coz I sure can't?

Sure, history of right sided heart failure and COPD with reactive asthma and they wait a few hours to call while they try to control it themselves.

The systems over in the UK, NZ, and AU seem just super compared to the US. Would have been nice to work there for a while.

 

[Aidey]

How much midazolam is generally accepted as being required to knock somebody out you know, your average 80kg male?

I recently had surgery and I was given versed before they intubated me. I weigh 60 kg or so and they gave me 2mg. The last thing I remember was them pushing the med, and then me asking the RN how much they were giving me.

I also had 1mg Ativan on board about an hour previous, so that may have contributed, but I guess I am a light weight when it comes to sedation.

 

[MrBrown]

We're using fent, sux and vec too so I spoze the midaz or ketamine is not to knock them out enough to blunt the airway reflex but rather so they wont remember.

 

[Smash]

We're using fent, sux and vec too so I spoze the midaz or ketamine is not to knock them out enough to blunt the airway reflex but rather so they wont remember.

Fentanyl is to blunt sympathetic response to laryngoscopy and will help a little with sedation. Versed is to sedate, and sux is to provide muscle relaxation to allow passing of the ETT, and also eliminates airway reflexes that sill cause a spike in ICP. Vec will maintain paralysis and may or may not be indicated for particular cases.

Trying to obtund airway reflexes with benzos alone is crazy and dangerous. In order to do that you would require epic amounts of benzo, and then you are going to have destroyed the blood pressure. Not flash if you have say a head injured patient who is really quite attachd to their cerebral perfusion pressure.

 

[MrBrown]

Trying to obtund airway reflexes with benzos alone is crazy and dangerous. In order to do that you would require epic amounts of benzo, and then you are going to have destroyed the blood pressure. Not flash if you have say a head injured patient who is really quite attachd to their cerebral perfusion pressure.

We used to allow this in the past (giving people elephant approved dosages of midazolam) but it was a bit of a bugger for the reasons you mention and the mortality rate was found to increase (suprised?).

So now we have proper RSI with fent/midaz/ketamine/sux/vec.