Prehospital sedation

[Kiwiology]

Our procedure for RSI is

Fentanyl 1mcg/kg

Ketamine and sux 1.5mg/kg

Vec 0.1mg/kg

Midaz 0.05mg/kg

Fent and midaz is used for patients with TBI or neurogenic cause of coma (GCS < 10) while ket and fent are used for everything else

For standard analgesia ketamine is 5-10mg IV prn q 3-5

[NRPinNEPA]

In Pennsylvania, paramedics are not blessed with paralytics. Typically any pre-hospital sedation uses the combination of fentanyl and versed or (in more progressive regions) etomidate. The unfortunate thing about etomidate for us is that you must have two ALS providers on board to administer it, which becomes problematic in the more rural areas of the state, so many rural services don't even carry etomidate.

[fireflymedic]

Hello,

Here is a copy of one of our sedation protocols (Part One).

Cheers,

David

Are you ground or air based and are you much the fan of propofol ? We rarely utilize due to issues with maintaining adequate sedation in transport environment, potential for hypotension, etc. Typically for transport, we'll switch to versed - though the quick action of propofol makes it great for procedural or in hospital sedation (especially those that require daily wake ups) as it's quick on, quick off.

[firemedic37]

I work on a interfacility transport and a 911 service which have their own protocols. In our interfacility transports we usually continue what they have them on unless they are hypotensive. On the 911 side we do not do RSI but do Medicated Assisted Intubation which we use Etomidate 20 - 30 mg IVP, and Versed 2 mg IVP every 10 minutes (I don't use it since it is not a high enough dose for most patients) or Valium 5 mg IVP every 15 minutes. And if I need anything else for continued sedation I just call Medical Control and they usually give me any order that I need to keep the patient intubated and sedated. We do not carry Fentanyl on our 911 service yet, but I have a feeling that it is comming soon.

[MSDeltaFlt]

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.

Late in the game here. I apologize. I like the way CH thinks. He brings up some good points. Regardless of which meds you have at your disposal, there is something that needs to be made intimately aware of. There is a difference between "giving sedatives" and "sedating your patient". There is also a difference between "giving pain meds" and "treating pain". I, myself, was once on a Fentanyl drip in the ICU with an unstable C2 Fx and extubated myself. Thought I was dreaming. Apparently not.

Know the difference. Just my thoughts.

Edited January 9, 2010 by MSDeltaFlt

[SHARK1]

tHE CHALLENGE IN ANY SEDATION PROCEDURE IS MAINTAINING A AIRWAY AND EXCELLENT PERFUSION. BACK WHEN I WAS A MEDIC FROM 1977-1996 (PROMOTION) WE ALWAYS SEDATED BAD PULMONARY EDEMA PATIENTS . DUE TO THE HYPOXIC INDEX, REMEMBER IT ONLY TAKES 5% DE SATURATED BLOOD TO CAUSE ISCHEMEA AND CYANOSIS. YOU CAN HANDLE A PATIENT WITH LESS AGITITAION BUT THE RAMIFICATIONS ARE THESE.NO1. MANY ELDERLY PATIENTS ARE NOT WEENED OFF THE RESPIRATORS SOON ENOUGH AND USALLY DIE FROM SOME PNUEMOCOCCI VIOLATION. NO 2, WHEN INTUBATING A PATIENT THAT IS HYPOXIC FROM HEROIN OVERDOSE I HAVE SEEN SOME OF THESE PATIENTS LIERALLY PULL OUT A VOCAL CORD FROM NOT RELIEVING THE 10CC IN THE CUFF. BESIDES WE HAD ONLY MORPHINE WHICH CREATES VENOUS POOLING WHICH HELPS WITH REDUCING PRELOAD AND REDUCES THE HIGH PULMONARY PRESSURES; THE CONVERSE SIDE IS THE RESPIRATORY COMPONENT WHICH CAUSES HYPOVENTILATION WHICH NEEDS TO MAINATINED WITH A PULSE OXIMODOR. MIDAZOLAM IS A BY PRODUCT OF DIAZAPAM A BENZODIAZEPINE WHICH ACTS ON THE BRAIN FOR ANIETY AND MANY PEOPLE SEEM TO HAVE A ALLERGENIC RESPONSE TO IT. OF COURSE THERE IS NO REASON WHATSOEVER TO SEDATE A TRAUMA PATIENT AND MASK THE % OF BLOOD LOSS. WHAT MAKES A GOOD PARAMEDIC IS THE ABILITY TO BE INTIMATLY FAMILIAR WITH THE MEDS AND THEIR EFFECTIVENESS AND A MASTER DIAGNOSTICIAN.

[mobey]

tHE CHALLENGE IN ANY SEDATION PROCEDURE IS MAINTAINING A AIRWAY AND EXCELLENT PERFUSION. BACK WHEN I WAS A MEDIC FROM 1977-1996 (PROMOTION) WE ALWAYS SEDATED BAD PULMONARY EDEMA PATIENTS . DUE TO THE HYPOXIC INDEX, REMEMBER IT ONLY TAKES 5% DE SATURATED BLOOD TO CAUSE ISCHEMEA AND CYANOSIS. YOU CAN HANDLE A PATIENT WITH LESS AGITITAION BUT THE RAMIFICATIONS ARE THESE.NO1. MANY ELDERLY PATIENTS ARE NOT WEENED OFF THE RESPIRATORS SOON ENOUGH AND USALLY DIE FROM SOME PNUEMOCOCCI VIOLATION. NO 2, WHEN INTUBATING A PATIENT THAT IS HYPOXIC FROM HEROIN OVERDOSE I HAVE SEEN SOME OF THESE PATIENTS LIERALLY PULL OUT A VOCAL CORD FROM NOT RELIEVING THE 10CC IN THE CUFF. BESIDES WE HAD ONLY MORPHINE WHICH CREATES VENOUS POOLING WHICH HELPS WITH REDUCING PRELOAD AND REDUCES THE HIGH PULMONARY PRESSURES; THE CONVERSE SIDE IS THE RESPIRATORY COMPONENT WHICH CAUSES HYPOVENTILATION WHICH NEEDS TO MAINATINED WITH A PULSE OXIMODOR. MIDAZOLAM IS A BY PRODUCT OF DIAZAPAM A BENZODIAZEPINE WHICH ACTS ON THE BRAIN FOR ANIETY AND MANY PEOPLE SEEM TO HAVE A ALLERGENIC RESPONSE TO IT. OF COURSE THERE IS NO REASON WHATSOEVER TO SEDATE A TRAUMA PATIENT AND MASK THE % OF BLOOD LOSS. WHAT MAKES A GOOD PARAMEDIC IS THE ABILITY TO BE INTIMATLY FAMILIAR WITH THE MEDS AND THEIR EFFECTIVENESS AND A MASTER DIAGNOSTICIAN.

WHY ARE WE YELLING????

[DartmouthDave]

Are you ground or air based and are you much the fan of propofol ? We rarely utilize due to issues with maintaining adequate sedation in transport environment, potential for hypotension, etc. Typically for transport, we'll switch to versed - though the quick action of propofol makes it great for procedural or in hospital sedation (especially those that require daily wake ups) as it's quick on, quick off.

Hello,

I use to work for a ground and air program. Now, I work in an ICU. Sigh, I miss my old job......

Ok.

We used Propofol for transport (air). We ran (normally) 0-300 mg/hr with 25-50mg IV PRN. However, we have gone higher on occassion. In the ICU we use mcg/kg/min. It works well if your able to give enough to acheive your sedation goal. A RAAS 0f -3 worked well for most of our trips.

Like you noted, hypotension can be an issue. So, in most cases an arterial line is essential. A second issue (our fligts were long...3 hours+) was technical. We used a 60cc syringe and a syringe set for the Minimed III pumps. At the high rates a syringe wouldn't last very long at all.

Also, we rarely ran Propofol solo. We typically hung a Fentanyl infusion as well.

Coffee time is over....

Pardon the typos.....trying to fire off this eamil on the fly.

Cheers,

David

[fireflymedic]

Hello,

I use to work for a ground and air program. Now, I work in an ICU. Sigh, I miss my old job......

Ok.

We used Propofol for transport (air). We ran (normally) 0-300 mg/hr with 25-50mg IV PRN. However, we have gone higher on occassion. In the ICU we use mcg/kg/min. It works well if your able to give enough to acheive your sedation goal. A RAAS 0f -3 worked well for most of our trips.

Like you noted, hypotension can be an issue. So, in most cases an arterial line is essential. A second issue (our fligts were long...3 hours+) was technical. We used a 60cc syringe and a syringe set for the Minimed III pumps. At the high rates a syringe wouldn't last very long at all.

Also, we rarely ran Propofol solo. We typically hung a Fentanyl infusion as well.

Coffee time is over....

Pardon the typos.....trying to fire off this eamil on the fly.

Cheers,

David

Thanks - was just curious to see what side of the fence you were coming from. Always good to get different inputs. Don't knock yourself for bein in the ICU - lots of good experience to be gained there. Take care and stay safe.

[NRPinNEPA]

WHY ARE WE YELLING????

LOUD NOISES!!!!