Prehospital sedation

[mobey]

I wanted to discuss a topic that I am kind of struggling with.

Whether sedating a patient to intubate them, or maintaining sedation during a transfer/procedure, the standard round these parts is Fentanyl/Versed.

For simplicity I would like to keep the discussion within the limits of a average weight, normotensive, adult patient with no previous medical Hx, that needs sedated deep enough to maintain intubation for whatever reason.

So, like I said, most of my education/experience is about 5.0mg Midazolam, Start at (varies) 3mcg/kg Fentanyl then paralytics if needed, or more fentanyl in the absence of paralytics.

Continued sedation is usually 2.5mg doses of Versed, and 100mcg of Fentanyl.

My "struggle" is that being out here in the sticks I would rather have an infusion to maintain a steady state of sedation, than the highs and lows of redosing. Unfortunatly, the agents used in infusions are not-so common prehospitally in my area, and I am not sure why (although I did see a doc hang a Versed drip).

I am really interested in hearing some views on Propofol infusions and Ketamine, along with other agents.

[chbare]

Unfortunately, an initial dose of 5 mg of midazolam for a 70 kg patient is rather suboptimal. A typical recommended dose for midazolam induction is 0.3 mg/kg. How many people do you see giving 21 mg of midazolam IVP? Therefore, many patients are being under-medicated. In addition, 21 mg can effect hemodynamics in the most "stable" patient. Of course, if we are looking at RSI, how "stable" is our patient?

One area we often overlook is good ventilator management. We frequently run for the drugs when out patient even twitches. However, we need to ensure we are meeting our patients needs prior to going down the route of halcyon dreams and neuromuscular blockade. One thing I have seen and have attempted to correct is inadequate flow. We are taught an I:E of 1:2 is "optimal." Therefore, I have seen providers run adult vented patients at flows as low as 17 lpm to ensure they have that perfect 1:2. Therefore, meeting your patients demand and attempting to facilitate good patient to ventilator interaction is paramount.

Infusions are a consideration and guidelines are all over the place. I have run midazolam infusions at 10 mg/hour and given fentanyl boluses as needed with good success. Mixing 10 mg in 100 ml makes for easy math. Ketamine is a consideration; however, you will need continuous infusions for prolonged transport and secretions along with increased sympathetic tone are considerations. Fentanyl infusions of say 1 mcg/kg/hr with boluses as needed are considerations. Some services carry diazepam and lorazepam for this purpose as well. Diprivan is a very fickle medication and precipitous drops in blood pressure are common. Additionally, you typically have to give very large doses in the stimuli rich environment of the transport environment. As it is, I have take care of many ICU patients who required vasopressor infusions to maintain blood pressure because of the high doses of Diprivan. It is also thick, milky, and loves to make bubbles that drive our minimed IV pumps crazy.

I typically use diazepam and fentanyl. For a typical 30-45 minute flight with the "generic" otherwise healthy adult patient, it is not uncommon for me to give 300 mgc of fentanyl in divided doses (of 100 mcg) IVP and 20 mg of diazepam (in doses of 10 mg) IVP.

Take care,

chbare.

[fireflymedic]

As far as intubation, if you are going to administer paralytics, you must administer sedation along with it. That is without question. Having said that standard "induction" doses to sedate a patient is betwee 4-6 mg versed though I have seen some patients require a bit more and 100mcg fentanyl. Etomidate is also an option with typical dosing being around 20mg (however remember etomidate does not have analgesic qualities). This typically will do well, however you should titrate doses to patient's respone and vital signs. For maintenance infusion of versed which is preferable in the transport environment to propofol with common dosage for sedation being between 2-5 mg/hr. I have struggled on many transports as due to all the stimulation in the transport environment with propofol and found you have to continuously adjust it to maintain the level of sedation that's adequate for the patient. It's preferable to midazolam or other sedatives in that it is quick on / quick off so evaluation of neuro status at receiving facility is easier than the extended time it takes for versed or others to wear off which is a positive in their eyes. However, the longer maintained sedation is preferable in the transport environment so I am partial to versed. However, propofol is quite popular in hospital and seems to do well within that realm. I've not seen a versed drip used in hospital, but have used it several times in transport.

I'm sorry but I do not have any experience with Ketamine and cannot help you. Perhaps one of the people from down under can assist you better as it seems to be used more frequently there.

Edited October 11, 2009 by fireflymedic

[chbare]

As far as intubation, if you are going to administer paralytics, you must administer sedation along with it. That is without question. Having said that standard "induction" doses to sedate a patient is betwee 4-6 mg versed...

That is actually a very small dose for the purpose of RSI. You may skate by with a minimum of 0.1 mg/kg. However, this will still be ~7mg in the "average" adult. With that, the slow onset and hemodynamic implications of midazolam do not make it a very good candidate for RSI.

Take care,

chbare.

[Kiwiology]

IFT sedation is something the RN or MD would be in control of; our ALS are not used like that for transfers.

As far as sedation and analgesia we have ketamine and midazolam.

Midazolam was orginally used alone for RSI when we first got it in 2005 at a dose of up to 5mg but we now use ketamine and midazolam combination.

Our starting dose of ketamine for analgesia is 20mg (if no morphine has been given) so I would immagine the dose of ketamine for RSI is quite larger but it's not in our guidelines because it is a specialised procedure only taught to select Advanced Paramedics so I don't know the exact dose.

We maintain the sedation with 1-2mg of midaz prn but our transport times are not really that long to require it I'd immagine

[flight-lp]

We use Ketamine for the intitial sedation of pedi's and bronchspasm patients. 1-2mg/kg IVP. Otherwise its Etomidate 0.3mg/kg and Fentanyl 1-5mcg/kg. Induction is with Sux, Roc, or Vec, Roc being my personal preference. If the transport is greater than 30ish minutes, then I'll start an infusion of either the NMBA or the benzo depending on the patient. If we pick them up on Propofol, then we'll keep them on it blood pressure permitting. Flexibility and individuality is the key.

[fireflymedic]

That is actually a very small dose for the purpose of RSI. You may skate by with a minimum of 0.1 mg/kg. However, this will still be ~7mg in the "average" adult. With that, the slow onset and hemodynamic implications of midazolam do not make it a very good candidate for RSI.

Take care,

chbare.

As far as versed's utilization for RSI I've actually had pretty decent luck with it. It is really patient dependent as you said and obviously if they have any type of benzo tolerance they are going to require higher doses. I have found though in combo with fentanyl that you do well with the sedation. I don't even go with paralytics until I am certain the patient is adequately sedated. I certainly don't want them remembering anything. Everything has to be titrated as you said taking into account their hemodynamic status and adequate maintenance of it. Point well taken though CH - sadly we call it RSI, however there isn't much rapid about it if done right unless you do it as a crash airway.

[mobey]

I have very little experience with said drugs, but the one experience I do have is 12.0mg Midazolam pushed to RSS an otherwise healthy CO pt. He was approx 85-90kg and his pressure toileted from the big dose.

[fireflymedic]

I have very little experience with said drugs, but the one experience I do have is 12.0mg Midazolam pushed to RSS an otherwise healthy CO pt. He was approx 85-90kg and his pressure toileted from the big dose.

try doing divided doses. Yes it takes a bit longer, but giving like 4 at a time and seeing how he responds may have helped. I've seen some patients be able to adjust with smaller divided doses given than with a large bolus and you still get the effect of sedation. You certainly don't want to have a patient tank out because of a large bolus and then have to work to get it back up. Just something to consider Mobey.

[chbare]

Or we could look at agents that are much better for the task of RSI induction agents. Currently, no better agent than etomidate exists. It acts very quickly (one arm brain cycle essentially), has a predictable duration (100 seconds for every 0.1 mg/kg dose), and it has no effect on hemodynamics. The next best would be ketamine IMHO. We must remember that sedatives such as Diprivan and diazepam do not provide analgesia. Sedation and analgesia are different topics.

So, I typically use etomidate, then follow up with diazepam and fentanyl.

Take care,

chbare.