Sedation of Vent Patient

[coolparamedic]

The other night one of our ambulances brings in an OD pt. The patient is being bagged and is unconsious . The medic didn't tube her on scene because they were only 30 seconds away from the ER. The lady had taken tylenol, benzo's, oxycodone. Needless to say the lady ended up getting paralyzed and intubated by the medic after arriving. After being paralyzed with suxs, vecuronium was given along with versed. Labs were drawn, tylenol level of 109 (i'm not quite sure of the way they measure it but high is 30). Mucomist, .8mg narcan were given also. Our hospital does not stock romazicon. We go to transfer her to a facility 75 miles away.The medic first asks the doctor why we have to give more benzo's on top of what she has already taken. The doctor replies, "to make sure she is out." the medic then asks if he can switch from versed to Ativan because of the long transport time. The doctor says no because he wants to stick the same drug. He says to give 1 mg Vecuronium and 2 mg of versed as needed. The Vec only lasted on her about 20 mins at a time. The transfer to the other hospital was uneventful.

Now here are my questions:

1. why keep giving benzo's to a pt that already OD on them?

2. Is there any reason, other than doctor wanting to stay with the same med, that the medic couldn't switch from versed to ativan?

3. Do you guys think 1 mg of vecuronium is a small dose for a 70 kg pt? ( I have always seen it given in 5 mg doses after the loading dose and it lasts for 30-40 mins)

[AZCEP]

Several good questions, but you are asking the wrong people. See, we weren't there, so we have no idea what the patient was presenting with. Aside from your description, we might be lacking some information that would make a difference.

Benzodiazepines are extremely safe for use. In the ventilated patient, it is near impossible to have any toxic effects from them. Switching to Ativan seems reasonable, but once you have given 20 mg of a BZD, the flavor really becomes immaterial. The utility of the Versed is due to it's short duration, you can make decisions on using more on things other than the level of sedation. Is their blood pressure maintainable with the sedation? Do they have hypotensive episodes following the drug?

The paralyzing dose of vecuronium is 0.1 mg/kg so a 1 mg dose would not be enough for the initial use. Maintaining the paralysis may be possible with that dose, but a consideration should be made for slightly higher doses to protect the ETT.

[tniuqs]

Ok;

1- Takes one hell of a lot of benzos to actually kill you, and attempting to reverse a mixed OD with Fluazamils could be a fatal error (just in passing).

Need some more info here...V/S would be a good start.

Reversed the Opiates....Did LOC change?

Then tubed? Then Chemical Paralysis... to keep the tube in? with no narcs to cover...it my be premature, but it sounds like this MD is just a meany.

Vecs normal loading dosage is 0.08 to 0.1 mgs per kg ideal body wt.

Maint is 0.01 to 0.015 mgs per kg ideal..

Whats the pt's wieght er ideal body mass, a more poltically correct term!

cheers

ps any ETCO2 or ABGS when intubated, or was a Ventilator not used, any Bicarb hung?

[tniuqs]

AZCEP

Benzodiazepines are extremely safe for use. In the ventilated patient, it is near impossible to have any toxic effects from them. Switching to Ativan seems reasonable, but once you have given 20 mg of a BZD, the flavor really becomes immaterial.

LMAO @ flavour!

[ERDoc]

The other night one of our ambulances brings in an OD pt. The patient is being bagged and is unconsious . The medic didn't tube her on scene because they were only 30 seconds away from the ER. The lady had taken tylenol, benzo's, oxycodone. Needless to say the lady ended up getting paralyzed and intubated by the medic after arriving. After being paralyzed with suxs, vecuronium was given along with versed. Labs were drawn, tylenol level of 109 (i'm not quite sure of the way they measure it but high is 30). Mucomist, .8mg narcan were given also. Our hospital does not stock romazicon. We go to transfer her to a facility 75 miles away.The medic first asks the doctor why we have to give more benzo's on top of what she has already taken. The doctor replies, "to make sure she is out." the medic then asks if he can switch from versed to Ativan because of the long transport time. The doctor says no because he wants to stick the same drug. He says to give 1 mg Vecuronium and 2 mg of versed as needed. The Vec only lasted on her about 20 mins at a time. The transfer to the other hospital was uneventful.

Now here are my questions:

1. why keep giving benzo's to a pt that already OD on them?

2. Is there any reason, other than doctor wanting to stay with the same med, that the medic couldn't switch from versed to ativan?

3. Do you guys think 1 mg of vecuronium is a small dose for a 70 kg pt? ( I have always seen it given in 5 mg doses after the loading dose and it lasts for 30-40 mins)

Personally, I like to use Ativan for its longer action and I like Roc. As for this pt, why did the doc give narcan AFTER intubating? What is the use at that point? As someone else said, this is almost torture. I would have tried the narcan prior to intubation. If it worked I would have considered a narcan drip if more narcan was needed. Seems like he could have saved the pt a whole lot of problems and possibly a transfer.

[coolparamedic]

Pt had taken pills an unknown time before her son called 911. Medic arrived to find 35 y/o female, GCS 3 resp. 4/min shallow.

Pts vitals were BP 105/ 70, Pulse 90 Sinus rythm on monitor without ectopy. Resp. 12 on vent O2 Sat 100% 22ga Left dorsum of foot, 18ga Right dorsum of hand, central line

She did not get hypotensive after the versed. OG tube placed, activated charcoal given but no gastric lavage.

Narcan did nothing

The funny thing is that only our ambulances have the equipment to measure ETCO2 not the hospital. She hung around 32 mmHg on an autovent with Resp 12, Tidal volume of 600. There were no ABG's done, just basic tox screen. No PH was taken, even though pt tested positive for TCA's

She was paralyzed first and then sedated post intubation.

Quote:

Takes one hell of a lot of benzos to actually kill you, and attempting to reverse a mixed OD with Fluazamils could be a fatal error (just in passing).

Why does giving romazicon to a mixed OD pt dangerous?

I know its difficult to answer all of these questions without actually being there, but I appreciate the answers I have gotten so far

[Ridryder 911]

Personally, I like to use Ativan for its longer action and I like Roc. As for this pt, why did the doc give narcan AFTER intubating? What is the use at that point? As someone else said, this is almost torture. I would have tried the narcan prior to intubation. If it worked I would have considered a narcan drip if more narcan was needed. Seems like he could have saved the pt a whole lot of problems and possibly a transfer.

I agree ! I personally like Roc for longer transport times. I do wonder what he was thinking of Narcan and then attempting to keep one sedated for vent care. Problem I see is a potential disaster of paralytic without sedation and near impossible for sedative to as effective with atagonist aboard.

For as Romazicon... nothing but danger! Especially if this patient is a chronic benzo user!

R/r 911

[tniuqs]

Romazicon in yankee speak...lol.

Reverse the effects of the benzos....and then the patient starts to sieze.

Really the only way to determine if the patient is siezing while under chemical paralysis is EEG.

Your options get really limited, I really don't think adding Phenobarb to this patient will do a lot of good, dont know what you use in your service but Dilantin is a pain in the snowflake (s)!

But my question is why no ABGs...no machine or what... this is mandatory when the patient is put on a vent in my hood, good call with the ETCO2 though, at least someone was thinking.

cheers

[coolparamedic]

Our hospital is a level IV hospital which means that we ship a lot of people. We don't even have an ICU. They do have the capability of doing ABG's but for some reason they didn't do it even though the patient was in the ER intubated for 2 hours. There was talk of doing one but I guess that no one got around to it.

[tniuqs]

EEE gads!

2 hours on a Vent, intubated without narcs.

No ABGs, with the capability in-house?

On a identified tylenol OD, with a positive for TCA (s)

And no gastric lavage?

Your co-workers patient may have been successful...it will just take longer than she originally planed as acetaminophen "peaks" are up to 24 hours after ingestion.

FYI:

Oral activated charcoal is used to treat drug overdose and is effective at reducing drug absorption when administered within 1 h of drug ingestion. There are fewer data on efficacy when the delay is longer, as is the case in most drug overdoses. This study investigated the efficacy of activated charcoal at preventing paracetamol (acetaminophen) absorption after simulated overdose when administration was delayed between 1 and 4 h. METHODS: An open randomized-order four-way crossover study was performed in healthy volunteers comparing the effect of activated charcoal 50 g on the absorption of 3 g paracetamol tablets when administered after an interval of 1, 2 or 4 h or not at all. Plasma paracetamol concentrations were measured over 9 h after paracetamol ingestion using h.p.l.c. and areas under the curve between 4 and 9 h (AUC(4,9 h)) calculated as a measure of paracetamol absorption. RESULTS: Activated charcoal significantly reduced paracetamol AUC(4,9 h) when administered after 1 h (mean reduction 56%; 95% Confidence intervals 34, 78; P<0.002) or 2 h (22%; 6, 39; P<0.03) but not after 4 h (8%; -8, 24). When administered after 1 h activated charcoal reduced individual plasma paracetamol concentrations significantly at all times between 4 and 9 h after paracetamol administration. Administration at 2 or 4 h had no significant effect. CONCLUSIONS: These results in healthy volunteers cannot be extrapolated directly to poisoned patients. However, they provide no evidence of efficacy for activated charcoal when administered after an interval of more than 2 h.