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Do ALS ambulance (paramedic) can use this drugs? Propofol, Etomidate ... for intubation? Or every state is different? CRNA - nurse specialised into anesthesia?

Hi! People from different countries please write about ambulance service in your countries. 1. who works in ambulance? (paramedic teams?, phisician teams? Nurses? nurse=paramedic?) 2. What drugs do you have and which drugs you can use without a doctor (especially write about sedative/anestetics, muscle relaxants,....)? 3. Are there any drugs that you can administer only after "call" to a doctor? 4. Which procedures can you do without doctor (intubation, cardioversion,...)? 5. EM studies - paramedic studies (years?), team leader-ambulance nurses (EM?/anestesia? specialisation?), phisician (specialisation?) -- I write example about EM in my country - Estonia, European Union. 1. We have 3 kinds of teams: nurse-teams ~65% (nurse+nurse+technician), phisician teams (doctor+nurse+technician), intensive care team/reanimobile (EM doctor or anestesiologist+nurse+technician) 2. Mostly all teams have the same drugs. (injections, tablets...) Inj.: Adrenaline, Dopamine, Noradernaline, Phenylephrine, Diazepam, Midazolam, Propofol, Sodium Oxybutyrate (anesthetic), relaxants (optional), Fentanyl (optional, some teams have in the north, and intensives), Morphine, Pethidine, Tramadol; Diclofenac/Ketoprofen, drotaverine, Metoclopramide, Clemastin, Prednisolon, Dexa., Salbutamol (inhal, inj.), Aminophylline, Metoprolol, Digoxin, Verapamil, Adenosine, Amiodarone, Propafenon, Enalapril, clonidin, Nitroglycerine, phenytoin etc.... 3. Usually relaxants for intubation are not used by nurses, some nurses or phisicians use propofol. In some regions it is possible to call to intensive care team - they come and help to stabilise patient. 4. Mostly all teams can do most of procedures - cardioversion with sedation, in CRP - intubation or LT-tube, live patient airway control with LT or intubation (with sedation or anesthesia). And usually we treat at homes (also nurse teams) - Atrial fibrillations, high BP-s, simple abdominal pains, we assess ECG and put diagnoses - if needed hospitalise. 5. to be team leader nurse must to pass EM exam or to study 1,5 years in EM and intensive care specialisation cource and get intensive care nurse specialisation. Doctor - it can be doc. with different or without specialisations. Thanks!!

I agree Suxamethon creates good condition for intubation. If use paralytics Midazolam sedation is ok, better with opiate premedication. I work in two services in the "south" and in the "north". In the south we have suxamethon, pipicuronium, propofol, midazolam, Sodium Oxybate, morphine. But some leader phisicians say that we - nurses, shouldnt use propofol or paralytics for intubation. Here I have used anestetics. Comatose patient in septic shock, hyperventilating. I ensured vasopressive and inotrope support and inducted anesthesia with ~15 mg Midazolam (less hypotensive drug) and 40 Propofol (although pretty hypotnsive and cardiodepressive drug) ---> I got good condition for intub. I didnt used suxamethon becouse didnt want to have problems with "leader" phisicians:) For this patient I would better use 15 midazolam and suxamethon ofcourse. Next he got anesthetic Sodium Oxybate - very good in shock. In the north we have Propofol, Fentanyl, Na Oxybate, Midaz. but no paralytics and I can use all. Propofol usually creates good conditions for intubation also without paralytics, but is very hypotensive. I like to combine Midazolam with propofol = less of hypotensive side efect.

Hi! Have you used Midazolam to induce anesthesia for intubation pre-hosp. without using muscle relaxants? It means you have breathing patient who must be intubated and mechanically ventilated. Midazolam in doses 0,2-0,35 mg/kg. And no use of relaxant (Succinylcoline). If you did Midaz. anestesia, please describe situation, how midazolam had effect on reflexes, blood pressure, spontaneous breathing. Thanks

We have Diazepam, Midazolam and Haloperidol. I prefer Midazolam 1-5 mg i.v. I.M. way --> Diazepam is not the best option for i.m. - absorbtion from muscle takes too much time.

I dont agree about muscle relaxants. If you use only anaesthetics/sedatives in appropriate doses you can get good conditions for intubation without using NM-blockers. I agree using of relaxants for intubation needs great experience and paramedics or nurses mustn't use that. Anaesthetics can be enough. Sometime we have to secure airway prehospitally and intubation is the best for it. Patient with status epilepticus, SpO2 with O2-mask was ~82%, temperature 39,5; Diazepam 10 mg and Midazolam, little of Fenytoin didnt help. BP after Diazepam 80... what to do. We started infusion 1 L of cristaloids, added Noradrenaline infusion and on this background decided to intubate becouse of hypoxemia and convulsiones. So we administered Midazolam 10 mg and little Propofol ~40 mg --> intub. was nice and soft. For transport did boluses of propofol 20 mg --> convulsions finished, SpO2 100, temperature lowered, without Neuromusc. blockers. Midazolam is less dangerous for hypotension, it is why i combine it with Propofol in hypotensive patient (add Midazolam and you need less of Propofol). We dont have Etomidate nor Ketamine in nurse teams. And I dont want to use Suxinylcholine.

And brain injury with coma must be intubated with using opiates - decreases reflexes --> intubation without ICP increasement. For example Midazolam 10 mg + Morphine 10 mg/Fentanyl. When intubated patient breaths in to the tube - Midazolam only probably doesnt help. It is good to combine midazolam sedation with myorelaxants. Can help also deep sedation/anaesthesia with propofol or Midazolam+opiate infusion. Example from my job. We had patient in septic shock, noradrenaline didnt help,--> BP 80. I decided to intubate him. But we dont have Etomidate nor Ketamine. We administered Midazolam 10 mg and Propofol 40 mg (propofol decreases BP much more then midazolam) --> we got good conditions for intub. Next patient was anestetized by Natrium Oxybutyrate (long lastening sedative and no influence on BP).

Hi, Patients with gag reflex should be sedated or done RSI. If you dont use muscle relaxants you should to sedate patient. If patient has lively gag reflexes it is better to use anesthetics like propofol (causes apnea and hypotension). - Propofol slow boluses 40+40.... mg - Midazolam - may need large doses for deep sedation - 10-20 mg - If you have only Midazolam, you can combine it with opiates - Fentanyl or Morphine --> does deeper sedation/aneasthesia = better conditions.