National shortage of Valium

[nypamedic43]

Lately we have run into the problem of being unable to restock our ambulances with Valium from the hospital pharmacies, due to a national shortage. So in a letter from our Medical Director, we have been given permission to use Versed for seizures. The approved protocol in NYS has not yet been adopted by the STREMS region.

I have to say that using Versed for seizures seems a bit odd to me, when Atavan is available and in our formulary. I have read the protocol and did some research on Versed, because it is a drug that is unfamiliar to me. I really am nervous about using it because we will be using it for a purpose that it is not regularly used for.

I think the reason I am so nervous about giving it is because of its amnestic effects. I mean a person having seizures rarely remembers the event but Versed can eliminate all memory of things, such as events prior to the seizure and wiping out memory will open us up for possible abuse allegations, on the extreme end.

I'm just not sure it was the best choice for the Medical Director to make and I am extremely uncomfortable using it. Any thoughts or advice on how I can get comfortable using it?

[Kiwiology]

We've been using midazolam for seizures since at least the very early 1990s ... don't worry about it

[nypamedic43]

Being told not to worry about it, isn't exactly the help I was looking for kiwi.

We've never had this drug to use before yesterday. I have concerns about using it. I come here, to a forum that has yrs of experience in its members, to ask for advice on how to get comfortable with a new drug thats primary use is for RSI not seizures.

Yeah...I'm not really feeling all that warm and fuzzy about it.

[chbare]

Your rational for worrying is a bit strange. Midazolam can cause haemodynamic problems and potentially alters protective reflexes along with depressing the respiratory drive. In fact, it has a black box warning for respiratory depression. These are my concerns with midazolam. However, this is where proper monitoring and dosing comes into play. Also, you should look at receiving proper education on the use and pharmacology of this medication. Simply rolling something out without education is a potential disaster.

[systemet]

* Ativan (lorazepam), Valium (diazepam), and Versed (midazolam) are all benzodiazepines; they all act at the GABA receptor, and share similar properties. This includes retrograde amnesia, which occurs with all benzodiazepines, including Rohypnol (flunitrazepam.

* Midazolam IM is commonly used in many systems for seizure control when IV access can't be obtained.

* Midazolam is more water-soluble, and doesn't need to be diluted before it's given, although you can if you prefer.

* It's onset is more rapid, the drugs less potent, so you see lower dosing with Versed vs. Valium

I'm suprised it's being used in preference to Ativan, as one system I worked in removed the valium and replaced it with ativan, as it was believed to be better for seizure control. I'll try and look for some studies if I have time.

I wouldn't be concerned about potential legal exposure -- the same risks are there with any benzodiazepine, and seizure control is a valid indication.

All the best,

Being told not to worry about it, isn't exactly the help I was looking for kiwi.

We've never had this drug to use before yesterday. I have concerns about using it. I come here, to a forum that has yrs of experience in its members, to ask for advice on how to get comfortable with a new drug thats primary use is for RSI not seizures.

Yeah...I'm not really feeling all that warm and fuzzy about it.

Edited November 1, 2011 by systemet

[paramedicmike]

I, too, am not quite sure why you're so bothered by this. I'm also curious what resources you used to read up on the drug that left you with so many concerns.

I'll echo CHBARE that if your medical director rolls this out with no education for providers then there is more reason to be concerned than simply worrying about the switch of a drug in your box.

[tcripp]

As we don't have lorazepam on our box, we do use midazolam as a secondary medication for seizures. It is used IV if refractory to diazepam and IM if we can't get a line. As systemet writes, they all share the similar properties, so you shouldn't be worried.

However, if you do have lorazepam on board, have you asked if that can be used as another resource? If so, what reasons have they given you for not? Why do you carry it in the first place (what are the indications as per your protocols)?

We have a patient who apparently responds better to the lorazepam than the other benzos, but we don't carry it on our ambulance. So, we are in the discussions of having it added to our drug box as another option.

[kyle308]

Versed is the only benzo carried on our ambulances. We use it for both seizures and chemical restraint. Have seen it used dozens of times for both uses. It's very effective and fast acting whether administered IV IM or IN.

[nypamedic43]

The reading that I have done was on the Internet. We have not been inserviced, just handed the protocol, told to go to the pharmacy and put the Versed in the box ( kind of like "put the lotion in the basket" ) I CHOSE to read up on the drug because I want to know what it does, how it works etc., and I will get my PDR out tonight and read some more.

I don't mind change or new drugs. But I want to be educated about the drug before I have to use it and it looks like I'm the only one so far here at work that has been proactive enough to even look it up on the Internet.....which freakin scares me. Everyone else is like...oh ok, 5 mg for an adult, .1 mg/kg for kids. Sweet let's roll.

Thank you for your replies. I feel a little better knowing that other services use it. Just still really confused as to why Versed and not Atavan but I'll ask my Med Director when I see him.

[tcripp]

I CHOSE to read up on the drug because I want to know what it does, how it works etc., and I will get my PDR out tonight and read some more.

You should be commended on taking the steps to read up on the drug and not just accept the directive to use it. (Well, you don't have a choice but to use it...but at least now you will understand the why.)

This is the difference between EMT-paramedic and Paramedic.