Etomindate

[Blue Goose]

You are correct. Etomidate should not be a substitiute. I assumed that when ambo said that the higher dose etomidate was used during RSI, that they were still paralysing the person (otherwise it would not be RSI).

I worked in a system that had the same protocols as Ambo has (may even be the same system); we did not have RSI but rather Drug Assisted Intubation. The DAI protocol for Etomidate in head injured patients called for 0.6 mg/kg IV and Versed 2mg increments IV up to 10 mg total as necessary for post-intubation sedation. For non-head injured patients the dosage of Etomidate was 0.3mg/kg IV, repeated in one minute if adequate sedation had not been achieved (same Versed dose). We also had the option of using Versed 4 mg IV (and 2 mg increments thereafter up to 10 mg) without Etomidate. Having worked several places in Illinois, I do not know of any EMS systems that currently use paralytics, but I could easily be wrong.

http://loyolaems.com/sop/sop.pdf See pages 27 and 28 for the complete protocol.

[fiznat]

There are services surrounding mine that have either "sedated intubation" (etomidate) or full RSI with paralytics. It seems that the smaller (easier to QA/QI?) services are the ones with RSI while the larger services either have sedated intubation or nothing. My protocols allow me to give 5 of versed AFTER I intubate, but not before. I guess just to keep patients from "bucking the tube" such as in ROSC situations etc.

[CTXMEDIC]

There are services surrounding mine that have either "sedated intubation" (etomidate) or full RSI with paralytics. It seems that the smaller (easier to QA/QI?) services are the ones with RSI while the larger services either have sedated intubation or nothing. My protocols allow me to give 5 of versed AFTER I intubate, but not before. I guess just to keep patients from "bucking the tube" such as in ROSC situations etc.

if you give versed after intubation, what do you sedate with before giving the paralytic? :?

[fiznat]

We don't have RSI or any sort of premedication before intubation. ....Just the versed afterward if they start fighting the tube.

[CTXMEDIC]

We don't have RSI or any sort of premedication before intubation. ....Just the versed afterward if they start fighting the tube.

so you put a tube down a concious, awake persons pipe and then give them versed when they get mad at you? LMFAO!!

PLEASE tell me im misunderstanding. what would you do if you had a patient with airway burns and edema? or any other concious person that needed to be intubated?

[fiznat]

Ah, either not intubate them or wait till they become unresponsive enough to intubate. OPA, BVM, high flow O2, etc. Same that every other service does when they don't have RSI.

The post-intubation versed is mostly for people who are barely conscious but still "bucking" the tube a little bit. The only time I ever used it was on a code save when the guy started actually regaining consciousness and tried to yank the tube.

[p3medic]

I think he said they have no protocol for pre intubation sedation, they use versed for Post intubation sedation. I agree, that putting a tube in someone that is aware is inhumane, however we are all constrained by our protocols. My biggest pet peave are people who intubate a pt, with or without sedation and then give a long lasting NMBA without sedation.

[CTXMEDIC]

My biggest pet peave are people who intubate a pt, with or without sedation and then give a long lasting NMBA without sedation.

in my service this is an automatic termination. Just saw his last post. didnt know they couldnt even snow someone to tube em...why have paramedics?

[akroeze]

Ok on the topic of Drug Assisted Intubation without paralytics.... I have Valium and Versed, Morphine and Fentanyl. What kind of doses/combinations do people use? I have seen a wide range of dosing schemes.

I only wonder because although I don't have a standing order for DAI, I could probably get permission from a doc to do it if needed via patch and I would kinda like to know what kind of doses to be asking for.

[akroeze]

Just doing some reading and it seems that 5mg Versed would be a reasonable amount for an adult to sedate to intubate. Does 10mg Valium translate well as they are roughly equivalent?