Nitronox. Why isn't it used anymore?

[Tigger]

IN Fentanyl is available. Entonox is not needed anymore.

What about for the non-paramedics amongst us?

 

[EpiEMS]

What about for the non-paramedics amongst us?

Agreed. For AEMTs, say - why not give them something analgesic other than the ice, splinting, and padding that we EMTs have?

 

[Handsome Robb]

IN Fentanyl is available. Entonox is not needed anymore.

I personally don't like IN fent. It has never worked whenever I've used it.

Nitronox is awesome. We still have it for standbys with ILS staffing, not on the 911 units anymore though which is a shame.

Our ALS ski patrollers carry it and use it pretty frequently and I always ask to use it to get the patient out of their ski jackets and what not so I can get an IV going. Works like a charm.

 

[the_negro_puppy]

I personally don't like IN fent. It has never worked whenever I've used it.

Nitronox is awesome. We still have it for standbys with ILS staffing, not on the 911 units anymore though which is a shame.

Our ALS ski patrollers carry it and use it pretty frequently and I always ask to use it to get the patient out of their ski jackets and what not so I can get an IV going. Works like a charm.

Exactly. At the moment we can only give I.N fent to children. Our alternative (methoxyflurane) takes less than 5 seconds to prepare and works well if used properly, particularly with younger children who fear needles. Its great for stuff like fractured femur, get a quick hx give immediate inhaled analgesia while you obtain IV access and give Morphine. I can then be used in conjunction with morphine. I have had one patient with a fractured femur state he could not even feel his leg at all after 2 x 5mg IV morphine + methoxy while we were applying a traction splint to his leg.

 

[bigbaldguy]

Do gases like nitrous or methoxy have a synergetic effect on IV meds? If you give gas can you use less fent or morphine?

 

[the_negro_puppy]

Do gases like nitrous or methoxy have a synergetic effect on IV meds? If you give gas can you use less fent or morphine?

Yes it appears very much so. I am always cautious when using multiple types of analgesia. If you aggressively inhale penthrane in can virtually render you unconscious, bradycardic. People have to be watched when hey self administer it. At the start they dislike the taste but as soon as they get used to it they puff away more and more

 

[MikeCivitello]

Does anyone have past or current experience using nitronox (A mix of nitrous oxide 50% and oxygen 50%) in an EMS system? From what I've seen online it seems like the perfect treatment for pain in the prehospital system. Low risk of side effects, very little risk of drug seekers calling 911 for it, also helps alleviate anxiety. I've also noticed that it seems to be less used by dentists lately as well. Is it still used in any EMS system?

The main reason why you don't hear much about Nitronox is because the Nitronox device went out of production about 5 years ago - and there has been no one to service existing units. The Nitronox device was owned by Matrx Medical - which gradually sold off various devices and business units over the years - including Nitronox. Nitronox got bought and sold a few times over a few year period and eventually ended up with a company that was not interested in manufacturing or servicing the device.

As of last month this has changed. Porter Instrument (Hatfield, PA) has aqcuired the rights to the Nitronox device and will begin manufacturing them again in the near future. Disclaimer - I work for Porter. I want to make sure I adhear to the forum rules - so not sure what I can/can't say beyond that.

I read through all of the posts and wanted to respond to some of the comments. Hopefully this information is helpful.

Nitronox vs Entonox - Nitronox is a "device" (not a gas) that blends both 02 and N20 (from separate cylinders) at a 50% mixture "on-demand" through a demand valve. Entonox is a "pre-mixed" gas of 50/50 02 and N20. Enotonox is not FDA approved for use in the US.

Nitrous Oxide use is absolutely widely used in Dental Offices. Approximately 50% of all US dental offices use N20 to help with anxiety as well as offer Minimal Sedation. About 95% of all Pediatric Dentists and Oral Surgeons use N20. No dental offices in the US use Nitronox or similar system. They use different types of systems that are continuous flow (not demand flow) and not patient self administered - but administered through a nasal hood breathing circuit that is on the patients nose at all times. Basically the dentist controls both the flow rates and can adjust the percentage mixture from 0-70% N20. Nitronox devices are demand flow, patient self administered (with full face mask or mouth piece), and fixed at 50%.

Occupational Exposure Issues - this is definitely an important issue and should never be ignored. Here in the US NIOSH has suggested 25 ppm over an 8 hour time weighted average for safe exposure rates. In other countries this is as high as 100 ppm and some countries do not monitor or suggest exposure safety rates at all. When using any mixture of N20 in a closed space (dental office, OR, office setting, etc.) you absolutely have to be connected to a Vacuum or WAGD system/wall outlet for safe and effective scavenging of waste gas - and to vent the gas to the outside. First Responders using something like Nitronox should have minimal exposure issues if using outside or if in an ambulance - as long as the ambulance is vented properly (open windows, vent system, fan, etc). Also - keep in mind the length of time for exposure for a First Responder would be substantially lower than that compared to use in Dental or Hospital. Dental and Hospital facilities are using a different type of N20 sedation device (continuous flow - not demand flow - which means more gas is flowing) - as well as for longer procedures - typically 30-60 minutes in length. First Responders may be exposed for a 15 minute duration - with only periodic use as the patient is self administering with a demand valve system. Maybe some of the people still using could chime in with experience on this and how they handle use inside the ambulance?

Cost - "pre-mixed" gas will typically cost more than using a device to "blend/mix" the gas - so I wouldn't say this is a reason why use dropped off. It had to do more with not having a device and somewhere to get devices serviced. We have reps in Europe where Entonox and Kalinox are used widely - and that was at least what they informed us. Obviously there is an up front cost of purchasing a device - but if properly cared for - they should last a long time.

Again - hope the information is helpful.

Mike Civitello

 

[Tigger]

When I rode in NZ we didn't even open a window in the ambulance. It was a demand valve type system, I can't imagine that much gas actually "escaped" into the vial ambulance, especially given The short transport.

 

[mycrofft]

Very few use nitrous in offices around here (Central California/Sacramento area).

 

[medicasaurus]

We use Entonox regularly here in B.C. and it's even on the EMR list of medications (105hr course). We carry a pre-mixed D sized tank with a on-demand regulator and the ambulance has vents which must be active when administering the gas. Works well for most cases however there is a push at the Primary Care Paramedic level to have a injectable medication as another option.

 

[Craig Alan Evans]

The number one reason is there's not a commercially available EMS friendly blender made anymore....

We have been using it for the past 20 years and this is definitely the no 1 reason you don't see it much. We are still using our original devices. We can't find parts for them anymore. We can't find anything else on the market that is feasible. Accountability is easy as we weigh the bottles each day. No gas is ever leaked into the patient compartment as it is self-administered through a demand valve so gas is only flowing when the patient is inhaling. There is definitely a patient population this drug is very useful for, but since IN fentanyl I have used it much less. Also in my experience I have found it either works really well or not at all.

 

[jwk]

When I rode in NZ we didn't even open a window in the ambulance. It was a demand valve type system, I can't imagine that much gas actually "escaped" into the vial ambulance, especially given The short transport.

Breathe in, breathe out - where do you think the "out" gas goes?

 

[Tigger]

Breathe in, breathe out - where do you think the "out" gas goes?

I got the idea that such exhalations contained a minimal amount of gas when compared to the volume of the ambulance. New Zealand's worker protection laws are far stronger than our own, if this was a significant problem I have hard time believing it would be ignored.

 

[bigbaldguy]

As I understand it the newer EMS version of this device will have a scavenger circuit that will remove exhaled or leaked gas.

From the website

• Built In Scavenging Interface - The Nitronox unit comes complete with a gas collection ring, tubing and a patented scavenging interface for the safe, effective removal of exhaled nitrous oxide.

http://www.porterinstrument.com/product/dental/Nitronox Portable Kit

 

[MikeCivitello]

Breathe in, breathe out - where do you think the "out" gas goes?

JWK is correct. N20 is not metabolized by the patient - so pretty much whatever they inhale - comes back out when they exhale.

The key with the first responder device is room air exchange and venting when used inside the ambulance. If you were in a closed room this would be an issue. The actual use would only be for a short period of time - and with proper venting exposure should be minimal. Keep in mind it is an 8 hr time weighted average that NIOSH is looking at.

N20 used in dental offices and hospitals will always have a scavenging line connected to a wall vacuum outlet or suction system - as they are exposed to higher concentrations of N20 as well as for longer durations of time. They also don't have the ability to open a window or turn on a vent fan.

 

[jwk]

I got the idea that such exhalations contained a minimal amount of gas when compared to the volume of the ambulance. New Zealand's worker protection laws are far stronger than our own, if this was a significant problem I have hard time believing it would be ignored.

And they still use methoxyflurane in Australia and New Zealand despite the significant dangers associated with it.

 

[Tigger]

And they still use methoxyflurane in Australia and New Zealand despite the significant dangers associated with it.

I was told that St. John New Zealand no longer carries it methoxyflurane and instead uses exclusively etenox.

 

[MikeCivitello]

Just as a follow up to posts in this thread - the device is now available again in the U.S. - as of this week!

 

[ThadeusJ]

Mike did a great summary of the current status of devices. I have worked in hospitals where there is no scavenging and they use it in the ED when snapping shoulders back in place. My understanding is that it is still used to a fair extent in the UK by pre-hospital services.

 

[boerbull]

Here in the Netherlands almost every ambulance carries entonox, but not everybody uses it. We are only allowed to use it outside of the ambulance. Problem is that most medics here don’t believe it works because they have tried it and it doesn’t work. My experience is that it is great to use in combination with Fentanyl. It lowers the stress levels and allows the fentanyl to work better.
I’ll use it for kids. For adults I prefer to use a combination of midazolam and esketamine if I know that I’m going to hurt them. That will knock them out just long enough to prepare them for transport. After that I use fentanyl during transport.