Prehospital sedation

[mobey]

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.

Do you see Etomindate or ketamine prehospitally in your area?

I agree btw. Why these agents are not in use round here, is beyond me.

[fireflymedic]

Do you see Etomindate or ketamine prehospitally in your area?

I agree btw. Why these agents are not in use round here, is beyond me.

Etomidate is commonly used in the ER's here, but is not currently on the trucks. It seems that they are not wanting to make additions to the current approved medication list (though if your medical director applies for a waiver for your service you can get additional medications added along with certain procedures). I am aware though several surrounding states have Etomidate within their protocols with Sux and it seems they prefer Versed/Fentanyl with Roc. Using Vec as a paralytic and Ketamine as a sedative are not common within this area. Analgesia again is a pertinent factor as having a tube down your throat is less than comfortable so anything to lessen that discomfort is good.

Ch - I was trying to stay within the confines of meds he would have available within his service. I think we can all agree there are better alternatives, but you still have to work within what you have. Also curious as to your choice of diazepam over midazolam for continued sedation - any reason or simply personal preference?

Thanks for getting a good topic started mobey !

[mobey]

So, for those who use Ketamine, Do you still use supplimental analgesia?

I am becoming a big fan of Ketamine.... the more I learn about it.

[chbare]

Actually, it is the other way around in my area of the world. We almost exclusively utilize etomidate for pre-hospital RSI. My choice of diazepam & fentanyl is personal and rather anecdotal. First, I have had sudden hemodynamic changes with conservative doses of midazolam. This is not something a person with a head injury, altered hemodynamic status, or altered cardiac status likes very much. Unfortunately, these three patient compose many of my RSI's. Not that I actually perform RSI that frequently. Therefore, I typically use diazepam and liberal doses of fentanyl.

Most of my ketamine experiences are with conscious sedation for procedures. Typically, we will follow the dose of ketamine with doses of analgesics and benzodiazepines. Clearly, benzodiazepines blunt the possibility of an emergence reaction. Ketamine actually has both analgesic and sedative like effects by its self. However, there are many pitfalls to consider:

-Ketamine is a cardiovascular stimulant: perhaps not a good consideration in patients in heart failure or MI.

-Theoretical potential to cause harmful increases in ICP; rather dodgy evidence and in fact evidence that supports potential cerebral-protective benefits. However, it is still considered head injury taboo in the United States.

-Emergence reaction and psychological harm if you allow the person to "wake up" without the benefit of benzos.

-Increased secretions.

Therefore, choosing ketamine requires additional agents and considerations. You will most likely need to combat secretions, monitor for adverse cardiovascular effects, and prevent emergence. While emergency may not be a big consideration for RSI, how are you going to know if you quickly push your NDNMB after the intubation and neglect to follow up with a benzo?

At this point, I still advocate for etomidate as the quickest acting agent with less pitfalls than other agents on the market.

Take care,

chbare.

[paramedicmike]

Good discussion!

My service also uses Etomidate (0.3 mg/kg) for initial sedation in RSI (followed by succs, intubation, vec, versed 0.06=5 - 0.1 mg/kg and fentanyl 0.5 - 1 mcg/kg or morphine 0.05 to 0.1 mg/kg). For RSI sedation purposes, the Etomidate and versed/analgesia follow up works well. After intubation we can re-administer sedation meds as we feel necessary and in line with patient condition.

I agree with CHBARE in his assessment of Etomidate. There is talk of studies showing adrenal insufficiency with as little as one dose of Etomidate. However, given the circumstances in which we give this drug, there is really little else that offers the protective qualities demonstrated by Etomidate.

For non airway management patients, we rely on a variety of medications. Versed (by itself or in combination with analgesia at the same doses listed above) or Ativan (0.5 - 2.0 mg) are our standard. Again, we can re-administer sedation meds as necessary. It's not common but we do occasionally transport sedation infusions (e.g. Versed) usually deferring to bolus administration to free up a pump. During IFTs we can maintain Diprivan but cannot initiate it.

I like Diprivan. However, it needs to be constantly infused with a pump, there is a real risk of hypotension even in small titration amounts (patient dependent, of course), it offers no analgesic effects, and if, for whatever reason, it stops running it doesn't take long for the patient to begin to wake up.

Hope this helps.

-be safe

[1EMT-P]

I have used the following medications for prehospital sedation: 1. Valium + Morphine (Patient Assisted Intubation), 2. Valium + Nubain, 3. Versed + Morphine, 4. Versed alone.

[kohlerrf]

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.

I have no experience with Fentanyl however we use its lesser cousin morphine but only for pain relief and maybe in CPAP. Versed is my choice but only because we have relativly short transports. We generally use benzos or a hypnotic like Etomidate for RSI and to maintain sedation. Etomidate is nice however if not given with a bezo may cause myoclonic seziures. I am pushing for my service to get Propofol. I prefer to keep my intubated patient "light" and breathing on there own for numerous reasons and I feel Propofol would make this job much easier. Currently we carry Valium Versed Ativan Etomidate and Sux. While we never use Sux for long term, we do select our benzos according to length of effect among other reasons but as you pointed out we can’t maintain the blood level and consistent sedation with a bolus. In trying to reason out why we don’t have a drip sedation agent I believe it is because it’s a general practice to lighten up sedated patients every so often to "check in" and keep the body juices flowing. Having the ability for continuous sedation may cause complacency.

[mobey]

In trying to reason out why we don’t have a drip sedation agent I believe it is because it’s a general practice to lighten up sedated patients every so often to "check in" and keep the body juices flowing. Having the ability for continuous sedation may cause complacency.

I see your point, especially in head injured patients. "He was a combative head injury when I intubated him, but now when I let off on the sedation he stays flat"

But there is part of me that wonders if that is really neccisary,Do we REALLY need to know this information, all the while risking increasing ICP, and diplacement of a tube?

I think it is also bad medicine to practice a blanket sedation policy. So, for a head injury we use bolus sedation causing "Highs and lows" so we can reassess, but what about the medical patients? There is no reason a COPD'er that tuckered out and needed to be intubated requires reassessment of mental status...... in my mind anyway.

[fireflymedic]

Good discussion!

My service also uses Etomidate (0.3 mg/kg) for initial sedation in RSI (followed by succs, intubation, vec, versed 0.06=5 - 0.1 mg/kg and fentanyl 0.5 - 1 mcg/kg or morphine 0.05 to 0.1 mg/kg). For RSI sedation purposes, the Etomidate and versed/analgesia follow up works well. After intubation we can re-administer sedation meds as we feel necessary and in line with patient condition.

I agree with CHBARE in his assessment of Etomidate. There is talk of studies showing adrenal insufficiency with as little as one dose of Etomidate. However, given the circumstances in which we give this drug, there is really little else that offers the protective qualities demonstrated by Etomidate.

For non airway management patients, we rely on a variety of medications. Versed (by itself or in combination with analgesia at the same doses listed above) or Ativan (0.5 - 2.0 mg) are our standard. Again, we can re-administer sedation meds as necessary. It's not common but we do occasionally transport sedation infusions (e.g. Versed) usually deferring to bolus administration to free up a pump. During IFTs we can maintain Diprivan but cannot initiate it.

I like Diprivan. However, it needs to be constantly infused with a pump, there is a real risk of hypotension even in small titration amounts (patient dependent, of course), it offers no analgesic effects, and if, for whatever reason, it stops running it doesn't take long for the patient to begin to wake up.

Hope this helps.

-be safe

As far as Etomidate it is a useful induction agent and as stated, much less hemodynamic issues than some of the other agents. However, from my ER experience where it was used frequently, I did see experiences of myoclonus (which is a well documented side effect of etomidate) that some of the residents mistakenly took to be seizures. It may actually induce seizures in patients with a history of such. According to a few studies I've read, there is suggestion to still administer a low dose of benzos to prevent the myoclonus.

http://www.anesthesia-analgesia.org/cgi/content/full/105/5/1298

http://www.medscape.com/medline/abstract/9915320

http://www.umm.edu/altmed/drugs/etomidate-052950.htm#

Also, rather interesting study comparing propofol with etomidate for induction. Puts both on equal terms, with a slight advantage to propofol for induction - does anyone use it for just induction but not continued sedation?

http://www.med.upenn.edu/emig/etomidate%20versus%20propofol.pdf

For continued sedation I'm really not a fan of diprivan for a few reasons. The first being one of its biggest advantages - quick on, quick off. Because of that, if you have them on a pump and have a pump malfunction, then you run into issues of them waking up and you will have to continue bolusing them to maintain sedation until you get the pump issues resolved whereas with versed, you will still have some continued sedation. Also, with propofol you still run into issues of sometimes not being able to give enough to adequately sedate and maintain hemodynamic status. Finally, transport is a stimulation rich environment - it's tough to keep them happy. I am aware of the issues that can present with versed, but overall, I like it better, especially for prolonged transports.

With a concern of head injury and potentially increased ICP, I would have a concern of using an agent such as etomidate that has the potential to cause myoclonus which will increase it, or diprivan in the instance, should a patient wake up and starting bucking the vent or trying to extubate themselves, that will increase ICP as well. Something to consider all around. Just my 2 cents worth.

[kohlerrf]

I see your point, especially in head injured patients. "He was a combative head injury when I intubated him, but now when I let off on the sedation he stays flat"

But there is part of me that wonders if that is really neccisary,Do we REALLY need to know this information, all the while risking increasing ICP, and diplacement of a tube?

I think it is also bad medicine to practice a blanket sedation policy. So, for a head injury we use bolus sedation causing "Highs and lows" so we can reassess, but what about the medical patients? There is no reason a COPD'er that tuckered out and needed to be intubated requires reassessment of mental status...... in my mind anyway.

I agree there is no reason to check the mental status on a copd. I may have not been clear enough. I never fully wake the patient, as you pointed out this could cause unsafe fluctuations in ICP as well as other problems you also point out. I try essentially just to lighten them up to a state where the rate and depth of respiration voluntarily increase to like a level 2 dream state. Here is where Propofol would be great. I currently use versed, of the three it has the most rapid onset (some argue Ativan is faster). We monitor End tidal CO2 , respiratory rate and pulsox , pulse and BP when I see the numbers begin to rise I "check in" and then re-bolus with versed the pt goes down for another 10 min and never regains consciousness. I find it important to do this, as it allows the thorax to return to a negative pressure inspiration assisting blood return to the heart and maintains well perfused muscles of respiration making it easier to eventually wean the patient off the tube.