RSI

[Ace844]

"Asys,"

I'm going to have to disagree with you on this one and refer you to the article I posted on the previous page. Versed is an amnestic...So just because you got it, and then later can't remember that you had the pain, doesn't mean you and your body weren't still at the time experiencing the cruel, and undesirable physiologic side effects which can be very underirable in a patient population which is already physiologically compromised enough to warrant RSI-ETI emergently..Food for thought, Stay safe in the jungle,

ACE844

[Spock]

I wasn't aware we were arguing here but some things need corrected. To reiterate what ACE wrote, versed is a benzodiazepine and has amnestic qualities but has absolutely no analgesic properties. Fentanyl is a synthetic opioid analgesic and is effective as an anesthetic only at high doses (around 1000mcg).

RSI is a process with many steps and efficient performance usually requires more than one person. That's just the way it is. If you can't multitask then you get help or you don't do it.

Now I think I'll go back up to my Ivory Tower just as soon as I take a shower and wash the mud off from the call I was just on where I had to tube the patient with only lidocaine, versed and fentanyl because PA doesn't allow etomidate or suxs.

Live long and prosper.

Spock

[paramedicmike]

Just as a side note, Montgomery County PA is considering allowing etomidate. I think it's before the County EMS council now.

Now back to your regularly scheduled discussion.

[Asysin2leads]

All right, so, I imagine what you are talking about is a sympathetic response to pain, such as increased heart rate, increased respirations, and the associated mechanisms such as increased intercranial pressure and increased myocardial oxygen demand. I can see how that might be a problem, but then again, I still stand by the fact that were not dealing with a patient who has an entire medical history in electronic format and was sure to fast the night before, were dealing with patients we may have little to any information on, including their medications and past history.

Maybe you can point me to an article on the negative physiologic effects of percieved pain in a sedated patient, that would be good to look at. I once had a guy who bradyed himself down into the thirties by taking one of his mom's Xanax's on top of his normal daily dose of methadone, so I'm a little wary of the whole opiate/benzo interaction.

I guess it is sort of a moral question too, if the patient is in tremendous pain but will not remember the experience, do the same rules of pain management apply? That's a toughy.

[AZCEP]

It becomes a matter of thinking through the problem. Will every patient need an opitate, maybe not. Would it perhaps make long term management easier, maybe so.

The use of the opiates is truly a "consideration", not an absolute. I'm not willing to advocate that every patient needs them, and should get them. I'm also not willing to say that no patients should be given the benefits of them. Tachycardia, HTN, decreased response to the sedative of choice, should all play into your decision making. Using a little Morphine/Fentanyl might make a lower total dose of Versed/Etomidate/Ativan/Diprivan possible.

Good points to think about in the mean time.

[mediccjh]

I wasn't aware we were arguing here but some things need corrected. To reiterate what ACE wrote, versed is a benzodiazepine and has amnestic qualities but has absolutely no analgesic properties. Fentanyl is a synthetic opioid analgesic and is effective as an anesthetic only at high doses (around 1000mcg).

RSI is a process with many steps and efficient performance usually requires more than one person. That's just the way it is. If you can't multitask then you get help or you don't do it.

Now I think I'll go back up to my Ivory Tower just as soon as I take a shower and wash the mud off from the call I was just on where I had to tube the patient with only lidocaine, versed and fentanyl because PA doesn't allow etomidate or suxs.

Live long and prosper.

Spock

PA does allow Etomidate (it's on the State list); it's just up to the regional councils to approve.

[Spock]

The Executive Director of our region told me etomidate will be added to the state list only after the training module has been written. The state medical director told me the training module is still under development as is the state medication assisted intubation protocol. If you folks are using etomidate out east then more power to you and you are more advanced than the west. No surprise there.

Live long and prosper.

Spock

[fellinger]

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