Ketamine

[spenac]

I was told once that you should not use sucs if you use ketamine. I can not find that in any of my drug books. Any truth to it? Links to the proof please. Google has not been my friend on researching it.

[Kiwiology]

I was told once that you should not use sucs if you use ketamine. I can not find that in any of my drug books. Any truth to it? Links to the proof please. Google has not been my friend on researching it.

None whatsoever, we use ketamine and suxamethonium routinely

Probably an old wives tale like the golden hour, high flow oxygen, spine boards and so on

[systemet]

I was told once that you should not use sucs if you use ketamine. I can not find that in any of my drug books. Any truth to it? Links to the proof please. Google has not been my friend on researching it.

There's some situations where it's nice to avoid paralysis. Some people might choose to use ketamine without succinylcholine for intubating a sick asthmatic, for example. But this is a function of the paralytic, not the ketamine.

[Kiwiology]

There's some situations where it's nice to avoid paralysis. Some people might choose to use ketamine without succinylcholine for intubating a sick asthmatic, for example. But this is a function of the paralytic, not the ketamine.

If you're intubating people you really should be using suxamethonium or equivalent; using sedation alone is bad ju ju

[systemet]

If you're intubating people you really should be using suxamethonium or equivalent; using sedation alone is bad ju ju

I think you have to examine this on a situational basis. Succinylcholine brinks with it a number of risks, including apnea, hyperkalemia, prolonged paralysis in a few susceptible individuals, MH, changes in IOP, ICP, IGP, and an increased risk of aspiration.

For a bad asthmatic, if you can preserve their ability to breath, even if their ventilation might be suboptimal, you may be presented with a few more options if you can't pass the tube.

[Kiwiology]

I think you have to examine this on a situational basis. Succinylcholine brinks with it a number of risks, including apnea, hyperkalemia, prolonged paralysis in a few susceptible individuals, MH, changes in IOP, ICP, IGP, and an increased risk of aspiration.

Any paralytic will cause aponea lol

Suxamethonium can cause hyperkalaemia and malignant hyperthermia which is why we avoid using RSI in patients at high risk for these problems

IOP I am not terribly concerned about, Nana with glaucoma who has been hit by a bus and has severe traumatic brain injury; which is more immediately problematic?

For a bad asthmatic, if you can preserve their ability to breath, even if their ventilation might be suboptimal, you may be presented with a few more options if you can't pass the tube.

We are specifically cautioned against using RSI in asthmatic patients indeed even a Consultant I have spoken with said he avoids it unless absolutely necessary

If an asthmatic patient is still spontaneously breathing then they are not in need of ventilatory assistance or so we are taught

If you're worried about not being able to intubate the patient then maybe you shouldn't be intubating them

[systemet]

Any paralytic will cause aponea lol

Which is why we're discussing using ketamine versus using ketamine + succinylcholine, right?

Suxamethonium can cause hyperkalaemia and malignant hyperthermia which is why we avoid using RSI in patients at high risk for these problems

Agreed, with the caveat that we can't always predict which patients are at risk until after the complication occurs, and the corollary that succinylcholine is not a benign drug and that we should use it cautiously.

IOP I am not terribly concerned about, Nana with glaucoma who has been hit by a bus and has severe traumatic brain injury; which is more immediately problematic?

Fair enough, and if Nana has a bunch of trismus, and rocuronium isn't an option, then we hope Nana's eyesight is ok afterwards. I'd be more worried if Nana had a penetrating injury to the eye, but despite the controversy about paramedic intubation, closed head injury is one of those situations where you're going to use RSI more often. As with everything, you have to have a back up plan if things don't work out. Is Nana going to be easy to ventilate via BVM? Is her jaw in a thousand pieces, have her dentures evaporated, is she a predicted difficult cricothyroidotomy? These might influence the decision making process.

We are specifically cautioned against using RSI in asthmatic patients indeed even a Consultant I have spoken with said he avoids it unless absolutely necessary

While I'm sure they don't care about my opinion, and probably shouldn't, I'd say they're right. But it is preferable to intubate them before at some point before they code. And if your transport time in an hour in a fixed wing, followed by 20 minutes by ground ambulance, then you've got to consider whether it's a good idea to intubate now.

If you're worried about not being able to intubate the patient then maybe you shouldn't be intubating them

I think you should always be concerned, and you should always have a backup plan. But sometimes you are faced with difficult airways, or high risk patient encounters where it may be necessary. Fortunately having the nonvisualised airway adjuncts make these situations a little less frightening now.

[snoopy911]

This is off the subject, but kinda is along the same lines. Do any of you know anything about/have heard of using ketamine infusions for treatment of RSD (reflex sympathetic dystrophy). I have been diagnosed with RSD in the last few months and my doctor was talking about low dose Ketamine infusions for treatment. I have done some research but it scares me. But at this point, I am willing to try about anything to keep my body from feeling like it is on fire 24/7. Was wondering if you guys had ever heard of using Ketamine for this?

[Kiwiology]

Which is why we're discussing using ketamine versus using ketamine + succinylcholine, right?

Erm, not exactly, I still don't think using sedation alone to facilitate intubation is a very good idea

Agreed, with the caveat that we can't always predict which patients are at risk until after the complication occurs, and the corollary that succinylcholine is not a benign drug and that we should use it cautiously.

True, some bloke who fell off a roof and needs RSI for his severe traumatic brain injury probably doesn't have a card in his wallet that says "I have a family history of malignant hyperthermia"

As with everything, you have to have a back up plan if things don't work out. Is Nana going to be easy to ventilate via BVM? Is her jaw in a thousand pieces, have her dentures evaporated, is she a predicted difficult cricothyroidotomy? These might influence the decision making process.

I think this speaks more to your pre-intubation evaluation, back up plan and tools available; if you don't have the resources at your disposal to manage a failed intubation with paralysis then you really shouldn't be intubating regardless of whether you are using suxamethonium or not

While I'm sure they don't care about my opinion, and probably shouldn't, I'd say they're right. But it is preferable to intubate them before at some point before they code. And if your transport time in an hour in a fixed wing, followed by 20 minutes by ground ambulance, then you've got to consider whether it's a good idea to intubate now.

Intubating an asthmatic carries a hefty load of bad ju ju and they're probably more likely to die because you intubated them then hyperventilated the snot out of them inadvertently causing dynamic hyperinflation and cardiac arrest.

Many patients with asthma can have attacks that last hours and the ambulance is only called when the patient has already started going downhill and/or respiratory arrested. For somebody who has life threatening asthma and an extended transport time it may be appropriate to intubate them, I would want to discuss the problem with the Consultant at the hospital we are going to first.

If we have a transport ventilator it's probably much easier to tube and ventilate them than if we have some bloke sitting on the end of a bag mask for two hours

[systemet]

I think this speaks more to your pre-intubation evaluation, back up plan and tools available; if you don't have the resources at your disposal to manage a failed intubation with paralysis then you really shouldn't be intubating regardless of whether you are using suxamethonium or not

The problem is, you don't know that you can manage the failed airway until you've already successfully managed it. You can have all the tricks in the box, but you're either able to direct the Bougie into the glottis or not, you're either able to successfully BVM the patient, or not, you're either able to perform a surgical cricothyrotomy without injuring large vessels or vascular tissue or not. And you can either do these rapidly enough that the patient survives without injury, or not. And you won't know until afterwards, because there are those grade IV airways walking around. There are people who will give EM and Anesthesia nightmares. Being diligent may help us identify some of these patients first, but it's not a guarantee. It's a tricky game.

Intubating an asthmatic carries a hefty load of bad ju ju and they're probably more likely to die because you intubated them then hyperventilated the snot out of them inadvertently causing dynamic hyperinflation and cardiac arrest.

Absolutely, and early intubation is a classic paramedic mistake. But some asthmatics will need intubation. If they can't breath for themselves, someone else is going to have to do it, or that cardiac arrest is going to be just as inevitable.

Hypeventilation is an issue. But this is why we should be giving smaller volumes less frequently. With a nicer ventilator you can worry about airway pressures.

Many patients with asthma can have attacks that last hours and the ambulance is only called when the patient has already started going downhill and/or respiratory arrested. For somebody who has life threatening asthma and an extended transport time it may be appropriate to intubate them, I would want to discuss the problem with the Consultant at the hospital we are going to first.

I respect that attitude, and agree that it's never a bad idea to get some advice from someone more knowledgable. But I do want to add that sometimes these situations deteriorate rapidly, and depending on your system you might not be able to get timely advice.