FiremanMike
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I should rephrase my question to say "why is paralysis+sedation ALWAYS better?" Obviously I see that there are cases when paralysis is appropriate..
Mechanical Ventilation
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Merck
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Our program takes an approach of education over protocols. We don't have any written guidelines save for what is found in medical literature. Vent strategies are chosen based on patient presentation, diagnosis, and physiology. Paralysis is certainly not warranted for every patient and we spend a lot of time with our intensivists and anesthetists training in anesthesia and vent management. Overall I'd say the majority of our patients are on A/C Volume or PSV, but it's variable based on the patient.
We're using the LTV and I've always found it to be quite capable. We've taken a look at the Hamilton but have gotten mixed reviews from our group and the various RT groups around. We would like to go Revel but don't think it's available in Canada. We're also shortly going to start utilizing esophageal bulb monitoring prn.
We're using the LTV and I've always found it to be quite capable. We've taken a look at the Hamilton but have gotten mixed reviews from our group and the various RT groups around. We would like to go Revel but don't think it's available in Canada. We're also shortly going to start utilizing esophageal bulb monitoring prn.
OP
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This is definitely a consideration. I probably wouldn't give a long-acting at all if I were only 10 or 15 minutes from the hospital; if I did it would be a small dose.
Figure a 0.1 mg/kg dose of vec normally lasts roughly 45 minutes or so and you have, say, a 30 minute transport. You give the vec right after intubation and start transport 5 minutes later. In 30 minutes you are at the ED, and the vec only has 10 minutes left. By the time you get the patient unloaded, into the ED, moved over to the bed, and give report, it's been 45 minutes since it was given. Even if it's only a 20 minute transport, that's only a 10 minute difference. It doesn't need to be completely worn off in order for a patient to follow simple commands, and if you really need to, you can always just reverse it. And I'm not sure almost-worn-off vec would really give a worse neuro exam than if there were a bunch of versed and fentanyl on board.
No one else has a reason other than "I just use lots of sedation"? Is lots of sedation better than a little less sedation and NM relaxation?
MSDeltaFlt
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And what patient assessment techniques do you use in order to be able to tell that your paralyzed patient is still adequately sesated and hasn't regained consciousness?
Merck
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Paralytics are never off the table - they're just part of critical care. But suggesting that everyone should be paralyzed is like saying that everyone with chest pain should get morphine and nitro. In the context of a trauma sure, paralyze for the short term if appropriate. If a patient is profoundly hypotensive perhaps they can not tolerate normal doses of RSI agents. An asthmatic will likely have to be paralyzed depending on the vent. On the other side, someone intubated for hypercapneic respiratory failure may tolerate an awake intubation and PSV. Intubating and paralyzing a DKA patient could have nasty consequences. Regardless of the case, as is pretty much anything in medicine, a one-size-fits-all approach isn't necessarily the best way to go.
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DKA patients were the first thing I thought of. If we're going to intubate one I'd prefer to do it without paralytics and on SIMV so they could maintain their minute volume.
I'm going to agree with patient dependent rather than a blanket statement however is lean towards paralyzing vs not in most if we had that option.
I'm going to agree with patient dependent rather than a blanket statement however is lean towards paralyzing vs not in most if we had that option.
FiremanMike
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I believe I made my point a few times and it's not that.
Outside of RSI or extenuating circumstances I would lean away from pre-hospital NMB use.
I'll give you that considerations for NMB use in the ICU are probably slightly different than use in EMS, but they still have serious potential side effects and complications. I just think the risk:benefit ratio here needs to be weighed carefully.
If absolutely indicated and you are trained on their use and recognizing complications then go for it. If it's just for "adequate sedation" then I don't think the risk is worth it.
I'll give you that considerations for NMB use in the ICU are probably slightly different than use in EMS, but they still have serious potential side effects and complications. I just think the risk:benefit ratio here needs to be weighed carefully.
If absolutely indicated and you are trained on their use and recognizing complications then go for it. If it's just for "adequate sedation" then I don't think the risk is worth it.
OP
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Over my 12+ year HEMS career, I've always had liberal protocols that allowed much leeway and room for judgement in terms of choosing between NMB's, sedatives, and analgesics. I would never work someplace that wasn't like that.
My personal experience has been that paralyzed patients are simply easier to manage, and present fewer potential safety issues. You only need to wrestle a patient's hand away from the ET tube or the helicopter door handle a couple of times before you learn that in the stimulus-rich transport environment, with a patient you don't know well, your ability to judge how well sedated they are / how long that last dose is going to last is actually much more limited than you would like. Those problems don't happen every day of course, but in healthcare there are lots of uncommon events that we put a lot of effort into taking precautions against because when they do happen, they can be catastrophic.
The reason I asked the question to begin with was not because I think every intubated patient needs to be paralyzed for every transport. I asked because over my career, I've heard many paramedics, transport RN's, and MD's say things to the effect of "I only use paralytics if I really need them", and "if your patient is properly sedated, you don't need paralytics", without ever hearing anyone give a good explanation as to why it's better to avoid paralysis in transport.
Clearly there are lots of good reasons to avoid NMB in the ICU, and also no need for it with most patients. But transport is very different from the ICU. In transport, assessment of sedation level is difficult, and duration and effects of drugs are less predictable. I have had many patients who seemed well-sedated wake up and start moving unexpectedly, sometimes breaking through even large doses of sedation. They reach for their ET tube or their Cordis, breath against the vent, or flex limbs that pinch off A-lines or infusions of vasoactive meds. Most of us aren't as skilled at managing vents as the RRT's in the ICU are, so we may have a harder time syncing the patient and the vent with any less than deep sedation, which really sick patients often don't tolerate hemodynamically. Also, in transport there is no concern for the negative effects of long-term paralysis, because transports are generally brief; it's really no different at all than being relaxed for an hour or so long surgical procedure.
Here's the really important part that seems lost on many transport clinicians: it takes a lot less sedation to keep a paralyzed patient unaware and amnestic than it does to keep a non-paralyzed patient still. That is exactly why I think a "balanced approach" using sedatives, analgesics, and paralytics - rather than just larger doses of sedative and/or analgesics - is the best approach. You get a patient who is still and compliant with lower total doses of drug.
I know using NMB is not the only way to safely transport an intubated patient; it just seems like there are an awful lot of people who dismiss or avoid that option without even being able to articulate a good reason why.
My personal experience has been that paralyzed patients are simply easier to manage, and present fewer potential safety issues. You only need to wrestle a patient's hand away from the ET tube or the helicopter door handle a couple of times before you learn that in the stimulus-rich transport environment, with a patient you don't know well, your ability to judge how well sedated they are / how long that last dose is going to last is actually much more limited than you would like. Those problems don't happen every day of course, but in healthcare there are lots of uncommon events that we put a lot of effort into taking precautions against because when they do happen, they can be catastrophic.
The reason I asked the question to begin with was not because I think every intubated patient needs to be paralyzed for every transport. I asked because over my career, I've heard many paramedics, transport RN's, and MD's say things to the effect of "I only use paralytics if I really need them", and "if your patient is properly sedated, you don't need paralytics", without ever hearing anyone give a good explanation as to why it's better to avoid paralysis in transport.
Clearly there are lots of good reasons to avoid NMB in the ICU, and also no need for it with most patients. But transport is very different from the ICU. In transport, assessment of sedation level is difficult, and duration and effects of drugs are less predictable. I have had many patients who seemed well-sedated wake up and start moving unexpectedly, sometimes breaking through even large doses of sedation. They reach for their ET tube or their Cordis, breath against the vent, or flex limbs that pinch off A-lines or infusions of vasoactive meds. Most of us aren't as skilled at managing vents as the RRT's in the ICU are, so we may have a harder time syncing the patient and the vent with any less than deep sedation, which really sick patients often don't tolerate hemodynamically. Also, in transport there is no concern for the negative effects of long-term paralysis, because transports are generally brief; it's really no different at all than being relaxed for an hour or so long surgical procedure.
Here's the really important part that seems lost on many transport clinicians: it takes a lot less sedation to keep a paralyzed patient unaware and amnestic than it does to keep a non-paralyzed patient still. That is exactly why I think a "balanced approach" using sedatives, analgesics, and paralytics - rather than just larger doses of sedative and/or analgesics - is the best approach. You get a patient who is still and compliant with lower total doses of drug.
I know using NMB is not the only way to safely transport an intubated patient; it just seems like there are an awful lot of people who dismiss or avoid that option without even being able to articulate a good reason why.
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MSDeltaFlt
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Transporting an intubated patient at altitude is a safety issue. Especially when the patient is on the same side as the tailrotor. If the kick and punch out the window it can easily fly into it and the whole crew can become what I became: a lawndart. Trust me. It ain't fun. For those pts paralyzing is a safety concern. But not so much when you're already on the ground.
CANMAN
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We went from a patient receiving sedation in which they may have some periods of light sedation to now a patient is awake enough to punch out an aircraft window or open a door? Did I miss something? I think a few of us stated points why we wouldn't want that to be our first line or daily practice and there wasn't any acknowledgment of those reasons, just simply asking again why we wouldn't?
Unless you have ability with an EPOC or istat to measure ABG's on transport then any patient, as stated before, that has some profound acidosis, DKA, or certain short transport trauma patients are ones that I, my medical director, and receiving MD's generally do not want paralyzed for stated and obvious reasons.
As I stated before we aggressively sedate, commercial tube holder, and wrist restrain all intubated patients. That solves 90% of your problems. For the other 10% we will paralyze as needed and it's always in our minds and we an pull the trigger quickly on it if need be but in my years of flying it doesn't happen to often where we can't effectively manage the patient without it.
I am on both 145s and 135s, patient same side as tail rotor. For the patient to open a door means they are completely displacing me
from the airway seat, and to punch a window out means they have broken the restraint, we are behind the 8 ball on sedation, and they are sitting up enough to have that range of motion. Pretty far fetched scenario, at least in my
program and particular airframe. Other airframes may present more of an issue I guess.
If that's your practice then I am ok with it, like I said we all have different training, protocols, and work in different programs. I just personally don't see a justifiable need to practice this more often then not.
Unless you have ability with an EPOC or istat to measure ABG's on transport then any patient, as stated before, that has some profound acidosis, DKA, or certain short transport trauma patients are ones that I, my medical director, and receiving MD's generally do not want paralyzed for stated and obvious reasons.
As I stated before we aggressively sedate, commercial tube holder, and wrist restrain all intubated patients. That solves 90% of your problems. For the other 10% we will paralyze as needed and it's always in our minds and we an pull the trigger quickly on it if need be but in my years of flying it doesn't happen to often where we can't effectively manage the patient without it.
I am on both 145s and 135s, patient same side as tail rotor. For the patient to open a door means they are completely displacing me
from the airway seat, and to punch a window out means they have broken the restraint, we are behind the 8 ball on sedation, and they are sitting up enough to have that range of motion. Pretty far fetched scenario, at least in my
program and particular airframe. Other airframes may present more of an issue I guess.
If that's your practice then I am ok with it, like I said we all have different training, protocols, and work in different programs. I just personally don't see a justifiable need to practice this more often then not.
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