# Verced In Anxiety-Induced Hyperventilation



## RocketMedic (Sep 4, 2012)

19 y/o F c/o recurrent hyperventilation x2 days with multiple ER visits (1 discharge after coaching, 1 discharge after sedation). Med Hx of pediatric febrile seizures (stopped at 2 y/o), no current or relevent medical history, not pregnant, medications Xanax (out x 1 week) and depo shot, allergic to PCN. Complaining of severe pain, hyperventilation, SOB, carpopedal spasms of hands and feet, spasms to arms and legs as well, onset while lying in bedroom (same onset multiple times, home heater is off, rest of family is asymptomatic, no index of suspicion for hypoxia or CO poisoning). Initially encountered supine in back seat of car, very anxious, CAOx4, RR30/normal volume/normal effort, SpO2 100%, EtCO2 26 mmHg, P100, BP 130/90. Carpopedal spasms were evident, x30 minutes, pain 10/10. Anyways, I assessed this as anxiety-induced hyperventilation. Seeing as how the whole "NRB at 4L/min" is dangerously close to malpractice and this is a problem caused by hyperoxygenation, I decided on a slightly different course of treatment- 2mg of Verced initially followed up with another 3mg slow push to a total of 5mg to relieve the spasms, along with coaching. Patient's carpopedal spasms rapidly resolved after verced administration, pain was entirely resolved, patient remained CAOx4 throughout the transport (and much calmer!), coached RR to 20/normal, pulse remained around 90, EtCO2 increased to 32 over approximately 20 minutes with complete resolution of symptoms and a transient headache that resolved, O2 sats remained at 98-100%. A few of my coworkers opined that I should have done the low-flow NRB or a paper bag and withheld the verced. I'm pretty sure that I've done right by my patient and stayed within protocol, and I was able to justify it, but I'd like your take on this. 

My thoughts: coaching has failed, and although sound, it's not going to relieve the spasms or pain in a realistic amount of time. This patient's follow-on care is going to be anxiety management, which is outside of my scope. For my role, the concern is her pain (caused by muscle spasms), which are being caused by hyperoxygenation and hypocarbia. Increasing the concentration of CO2 in rebreathed air would eventually "help" her by relieving presumed respiratory alkalosis/hypocarbia, but she's still going to hyperventilate and has proven to simply continue to do so with discontinuation of "paper-bag therapy". I learned in school that it's not appropriate to paper-bag our patients, especially those who are in pain, and that pain is likely going to render coaching a futile exercise. Verced (with protocols for sedating an anxious patient) nicely gift-wraps spasm relief and sedation for us, allowing the patient to relax and titrate her CO2 levels back towards normal, relieves pain, and makes her feel better. Thus, it's a better treatment modality than induced hypercarbia until the spasm breaks or "she'll live with it", which are the alternates proposed.

Your thoughts? (I'm still pretty new, and this is the first time I've run across this, trying to do right by my patients).


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## VFlutter (Sep 4, 2012)

Just to clarify...you mean ver*s*ed, as in Midazolam, correct?


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## RocketMedic (Sep 4, 2012)

Touche, I do indeed. Shows why I should double-check Swype.


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## Merck (Sep 4, 2012)

A couple things. First I probably wouldn't treat this patient but rather she would go with a BLS crew to the hospital. Midaz can be funny sometimes. 5mg in one can be quite different than 5 in another pt. This girl is likely going to be fine.

That said, the paper bag thing is a no-no. The problem is that you are trying to correct her gasses based on a presumption. While it likely is anxiety that isn't always the case. I would say anecdotally that a pt with a psych hx of some sort is more likely to have a possibility of suicide attempt so be sure to rule out other things (ASA OD comes to mind). Also, anxiety is in my opinion a diagnosis of exclusion. So just be careful. 

Use you Midaz as you see fit but just my personal idea is that I likely wouldn't. Also, just to be clear, the problem is not caused by hyperoxygenation.


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## VFlutter (Sep 4, 2012)

Merck said:


> That said, the paper bag thing is a no-no. The problem is that you are trying to correct her gasses based on a presumption. While it likely is anxiety that isn't always the case. I would say anecdotally that a pt with a psych hx of some sort is more likely to have a possibility of suicide attempt so be sure to rule out other things (ASA OD comes to mind). Also, anxiety is in my opinion a diagnosis of exclusion.



Hypocalcemia is another zebra to consider. Does not neccesarily fit with the hyperventilation but could cause the spasms. What if the spasms happened first causing her to get anxious and hyperventilate?


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## Doczilla (Sep 4, 2012)

Out of xanax for a week, huh? How long was she on it previously? Benzo withdrawal causes anxiety, and if it was the case a "rescue" dose is not unreasonable. 

A lot of times they give out "blanket" meds for anxiety, then tapering does not occur due to poor compliance or provider complacency.


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## RocketMedic (Sep 4, 2012)

Merck said:


> A couple things. First I probably wouldn't treat this patient but rather she would go with a BLS crew to the hospital. Midaz can be funny sometimes. 5mg in one can be quite different than 5 in another pt. This girl is likely going to be fine.
> 
> That said, the paper bag thing is a no-no. The problem is that you are trying to correct her gasses based on a presumption. While it likely is anxiety that isn't always the case. I would say anecdotally that a pt with a psych hx of some sort is more likely to have a possibility of suicide attempt so be sure to rule out other things (ASA OD comes to mind). Also, anxiety is in my opinion a diagnosis of exclusion. So just be careful.
> Use you Midaz as you see fit but just my personal idea is that I likely wouldn't. Also, just to be clear, the problem is not caused by hyperoxygenation.



I was thinking somewhat along those lines. ASA OD and chronic hypocalcemica,were both screened for by the last er, and the fathers story didn't point to it either, but it is something I did worry about. Versed for either recurrant anxiety or hypocalcemia,or ASA OD would still be appropriate though?


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## RocketMedic (Sep 4, 2012)

Doczilla said:


> Out of xanax for a week, huh? How long was she on it previously? Benzo withdrawal causes anxiety, and if it was the case a "rescue" dose is not unreasonable.
> 
> A lot of times they give out "blanket" meds for anxiety, then tapering does not occur due to poor compliance or provider complacency.



"Since high school" and "sometimes I skip doses when I don't need it, but I haven't needed it lately."


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## Doczilla (Sep 4, 2012)

Case closed in my book. Obviously there would be underlying issues that need figuring out for her, but xanax is handed out like Motrin is in the army. Now she's Benzo dependent (maybe not aware of it) and thus the magnitude of her anxiety attacks are increased. 

By the way, go do PT! Its almost six.


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## RocketMedic (Sep 4, 2012)

Im almost out, brother. 4 days left.


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## bigbaldguy (Sep 4, 2012)

Sounds like you did the right thing to me. Anxiety was causing physical symptoms. You removed the symptoms by treating the anxiety (kinda). I wish more providers would understand that anxiety is a very real issue that needs to be addressed. It's no different than pain and should be treated when it's safe to do so. Of course there are a fair number of providers who don't really believe in pain either so there is that.


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## clearblueskies (Sep 13, 2012)

I would have to agree with you here. Versed would by NO MEANS be my first choice here! I would be far more likely to give 1-2 mg of ativan for this if I DID give anything. The neat thing about anxiety induced hyperventilation is that eventually they will blow off all of their CO2, they will get slightly alkalotic and will magically pass out, wake up shortly there after and will no longer be hyperventilating. I normally will try and talk someone down and if that doesn't work I will lay them down and let them fix their problem physiologically! The body does what it needs to fix its self and this is yet another example of it! If they do it a few times I will smoke them with 2 mg of ativan and let them sleep it off at the ER.


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## RocketMedic (Sep 14, 2012)

I understand that they will _eventually_ pass out, but that's still quite a bit of painful, spasmodic suffering. With an SpO2 of 100%, there's no real reason to start oxygen or anything, but an IV line and 2mg of Versed (I don't have Ativan) worked wonders.


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## RocketMedic (Sep 14, 2012)

clearblueskies said:


> I would have to agree with you here. Versed would by NO MEANS be my first choice here! I would be far more likely to give 1-2 mg of ativan for this if I DID give anything. The neat thing about anxiety induced hyperventilation is that eventually they will blow off all of their CO2, they will get slightly alkalotic and will magically pass out, wake up shortly there after and will no longer be hyperventilating. I normally will try and talk someone down and if that doesn't work I will lay them down and let them fix their problem physiologically! The body does what it needs to fix its self and this is yet another example of it! If they do it a few times I will smoke them with 2 mg of ativan and let them sleep it off at the ER.



Why not Versed, if I may ask?


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## clearblueskies (Sep 14, 2012)

Rocketmedic40 said:


> Why not Versed, if I may ask?



There is a lot of literature that we have been tasked with reviewing at work (stupid accreditation review coming up) combined with personal experience, versed seems to further exacerbate a left shift on the oxyhemoglobin dissociation curve when it is given for the purposes of sedation. This is essentially what you are trying to accomplish when you are giving it for anxiety and the associated hyperventilation. While you are not trying to sedate them back to the stone age, in order for you to get the results you are looking for it often take a bit more then 2.5mg of versed in these cases where someone is really spun up. This is because they are already shifted to the left on the curve and this makes versed slower to react then ativan. The like I said for some reason it exacerbates the shift and causes more problems in the next few hours. Pretty interesting albeit confusing information at times, but I really limit versed use if I can get away with in when I am practicing. I know we may be spoiled, but we carry quite a few things that work better and are safer in my mind, especially in a patient that is already Ph compromised like the severe hyperventilation patient is. If I am going to give anything I try to stick to Ativan.


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## jwk (Sep 14, 2012)

clearblueskies said:


> There is a lot of literature that we have been tasked with reviewing at work (stupid accreditation review coming up) combined with personal experience, versed seems to further exacerbate a left shift on the oxyhemoglobin dissociation curve when it is given for the purposes of sedation. This is essentially what you are trying to accomplish when you are giving it for anxiety and the associated hyperventilation. While you are not trying to sedate them back to the stone age, in order for you to get the results you are looking for it often take a bit more then 2.5mg of versed in these cases where someone is really spun up. This is because they are already shifted to the left on the curve and this makes versed slower to react then ativan. The like I said for some reason it exacerbates the shift and causes more problems in the next few hours. Pretty interesting albeit confusing information at times, but I really limit versed use if I can get away with in when I am practicing. I know we may be spoiled, but we carry quite a few things that work better and are safer in my mind, especially in a patient that is already Ph compromised like the severe hyperventilation patient is. If I am going to give anything I try to stick to Ativan.



Huh?

You have a left shift because they're alkalotic from hyperventilation.  I'm not sure why you think giving something to sedate the patient and thus slowing down their respiratory rate somehow further shifts the curve to the left.  That makes no sense to me, and it makes no sense that since these pharmacologically similar drugs depress respiration, that one would somehow make things worse and the other doesn't.  Slowing the respiratory rate, regardless of if it's done with a brown bag or a drug, will bring the curve back to the right as the CO2 rises.

Also - Ativan has a much longer duration of action than Versed.  Why use a longer acting drug that's harder to titrate to effect when you have a shorter acting easily titratable drug, which in most cases should be fine for a short-term problem?


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## VFlutter (Sep 14, 2012)

clearblueskies said:


> eventually they will blow off all of their CO2, they will get slightly alkalotic and will magically pass out, wake up shortly there after and will no longer be hyperventilating.



Uh say what? Why would you let it get to that point?


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## RocketMedic (Sep 14, 2012)

ChaseZ33 said:


> Uh say what? Why would you let it get to that point?



That was my other functional concern- carpopedal spasms are painful and agitating the patient to the point where coaching was totally ineffective (as evidenced by the ER's failed earlier efforts). It didn't seem right to wait for her to potentially pass out- were I to do that, I'd literally be just a ride.

The other concern I had was that there's no good way to document "brown bag" or "NRB at 3LPM", nor do I have protocols for those. All I have is "general supportive care, oxygen if needed, coaching, consider sedation if patient condition permits."

New Mexico's EMS protocols are fairly disorganized.


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## clearblueskies (Sep 14, 2012)

it has absolutely nothing to do with slowing down of the patients respiratory rate causing the problem here. The problem is biochemical in nature and results from the confirmation change that the versed isomer goes through when introduced into an alcolotic environment. IE. the known alcolosis of a patient who is severly hyperventilating. It can (but does not always) precipitate a further deepening alcolosis by causing a further release of bicarb by the kidneys. This can cause a whole host of problems when trying to reverse it later on, not the least of which is the potassium suddenly becoming artificially low. This reaction doesnt occur with the other benzos. and no one is sure why. It has been detrimental enough that our facility and many i know have protocols against administration of versed to a known alcolotic patient unless there are no other options. It has also been taught to us in the classes im taking for my CRNA license. Ive had three different anastesiologists warn against this in school . One of them actually said it took a week to get his patient turned around in the ICU after giving it. I know i won't chance it after learning about it.


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## clearblueskies (Sep 14, 2012)

You are right the spasms are uncomfortable, but none the less hyperventilation and carpopedal spasms have never killed anyone that I have ever seen in the literature. They will and do go away on their own, just as hyperventilation does. For me giving medication for this is like saying that no woman can possibly safely give birth today without modern medical intervention. What would someone have done previous to versed administration of they started hyperventilating?? If it got bad enough they passed out and the problem stopped. Believe me I'm all about helping people, however the more that I learn in CRNA school about the very same medications that I use every day as a medic, I begin to realize that medics are far more apt to give a drug for something just because they have it. I might not always be the best thing to do by we want to do SOMETHING, even if we really don't understand 100% of the problems that can be associated with a drug. It is really no different then a medic who goes on a call for a benzo overdose that they can prove. The want to do something so they haul out their faithful flumazinil, because "By God I Can Fix This"!! They give the drug and then the patient begins to seize uncontrollably, and it can only be stopped in the ER with Phenobarb. Yeah we fixed the overdose but almost killed the patient with the Romazicon. I have seen this happen with patient who were NOT previous seizure patients, and just OD on their buddies valium or ativan. I'm not telling you that you shouldn't give versed for this, by all means if your protocols provide it then the call is yours. I'm simply telling you what I have learned and now understand about the medication and this situation overall. 


Rocketmedic40 said:


> That was my other functional concern- carpopedal spasms are painful and agitating the patient to the point where coaching was totally ineffective (as evidenced by the ER's failed earlier efforts). It didn't seem right to wait for her to potentially pass out- were I to do that, I'd literally be just a ride.
> 
> The other concern I had was that there's no good way to document "brown bag" or "NRB at 3LPM", nor do I have protocols for those. All I have is "general supportive care, oxygen if needed, coaching, consider sedation if patient condition permits."
> 
> New Mexico's EMS protocols are fairly disorganized.


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## VFlutter (Sep 15, 2012)

clearblueskies said:


> it has absolutely nothing to do with slowing down of the patients respiratory rate causing the problem here. The problem is biochemical in nature and results from the confirmation change that the versed isomer goes through when introduced into an alcolotic environment. IE. the known alcolosis of a patient who is severly hyperventilating. It can (but does not always) precipitate a further deepening alcolosis by causing a further release of bicarb by the kidneys. This can cause a whole host of problems when trying to reverse it later on, not the least of which is the potassium suddenly becoming artificially low. This reaction doesnt occur with the other benzos. and no one is sure why. It has been detrimental enough that our facility and many i know have protocols against administration of versed to a known alcolotic patient unless there are no other options. It has also been taught to us in the classes im taking for my CRNA license. Ive had three different anastesiologists warn against this in school . One of them actually said it took a week to get his patient turned around in the ICU after giving it. I know i won't chance it after learning about it.



But wasn't the biochemical problem caused by the increased respiratory rate? And by slowing down the respiratory rate would not not prevent a worsening of the alkolosis?

Also do you have a link to any information about benzos in alkolosis? I can't find anything in my pharm book or in google


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## clearblueskies (Sep 15, 2012)

ChaseZ33 said:


> But wasn't the biochemical problem caused by the increased respiratory rate? And by slowing down the respiratory rate would not not prevent a worsening of the alkolosis?
> 
> Also do you have a link to any information about benzos in alkolosis? I can't find anything in my pharm book or in google


This is the book it is in, I looked tried to access it from the internet but haven't figured out how as of yet.

You are right decreasing the respiratory should prevent a worsening alkolosis..... IF something else doesn't help it along. This is where I was going with the versed issue. It has been known to cause an already known alkolosis to get worse. 

http://books.google.com/books/about/Textbook_of_Anesthesia_for_Postgraduates.html?id=f2YOpCMNFD4C


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## Bieber (Sep 15, 2012)

Did the patient have a real medical condition?
Were the symptoms serious enough to warrant treatment?
Did you have the ability to provide that treatment?

If yes to all of the above (and I think they're all yes, based on what you've told), then I'd say you were absolutely justified in treating the patient's anxiety.

Clearblueskies is right to say that we should not provide treatment just because we can; but likewise, we should not withhold treatments when it's indicated just because we can either. Especially with something like pain.


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## clearblueskies (Sep 15, 2012)

That is what I said, I personally do not treat this exact particular condition in my practice I have decided after doing this for a long time and gaining some extra education that I don't feel as though it is necessary. That being said I would not fault someone if they wanted to do so. I was simply discussing that versed would by no means by my personal choice to treat it and have discussed why. I just posted the book where it came out of on here, and am frankly getting tired of defending the info. I would just tell anyone out there that continues to wonder about it, to continue your research and seek out further education on your drugs. I have had some real eye openers from my continued schooling. As medics we are taught just enough in many cases to be dangerous when it comes to medications. This even happens at the advanced levels of medic education such as CCEMT-P and FP-C, both of which I have. I am just suprised at how much I wasn't taught about some of the "simple" and supposedly benign drugs that we give on the street, in the aircraft etc.  


Bieber said:


> Did the patient have a real medical condition?
> Were the symptoms serious enough to warrant treatment?
> Did you have the ability to provide that treatment?
> 
> ...


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## TheLocalMedic (Sep 15, 2012)

Hyperventilating?  Nothing that a pillow and duct tape can't solve!  LOL

I have used benadryl with success several times to reduce anxiety reactions.  25-50 mg IV, dimming the lights and talking in my "soothing baritone" generally works.  And although I haven't ever done it myself, I have seen the low-flow NRB trick work like a charm.  I generally reserve versed for when I need to put someone down NOW, like psych patients, and although hyperventilation may cause painful spasms, it's not life threatening.  Plus breaking out the narcs always means more paperwork.  I know, I know, extra paperwork isn't a good excuse for not giving a med, but I know that I always sigh inwardly when I have to get out the lock box.


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## Meursault (Sep 15, 2012)

clearblueskies said:


> it has absolutely nothing to do with slowing down of the patients respiratory rate causing the problem here. The problem is biochemical in nature and results from the confirmation change that the versed isomer goes through when introduced into an alcolotic environment. IE. the known alcolosis of a patient who is severly hyperventilating.



[citation needed]
http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=search&term=Midazolam+alkalosis gives nothing relevant and Epocrates doesn't mention it.

I did find an unsourced comment:


> One other little example: midazolam is a benzodiazepine sedative drug. It is stored at an acidic pH to keep it water soluble. When it enters the bloodstream, the slightly basic pH induces a conformational change which makes it lipid soluble and easily capable of penetrating the brain-really pretty slick.


which is cool, but not actually relevant. I also remember reading a case report of a guy who got so much Ativan the propylene glycol diluent ended up killing him.


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## RocketMedic (Sep 15, 2012)

Could it be something about the pH of the metabolized byproduct or isomer of the Versed?

Biochem is pretty over my head, need to go back to school.


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## jwk (Sep 15, 2012)

clearblueskies said:


> it has absolutely nothing to do with slowing down of the patients respiratory rate causing the problem here. The problem is biochemical in nature and results from the confirmation change that the versed isomer goes through when introduced into an alcolotic environment. IE. the known alcolosis of a patient who is severly hyperventilating. It can (but does not always) precipitate a further deepening alcolosis by causing a further release of bicarb by the kidneys. This can cause a whole host of problems when trying to reverse it later on, not the least of which is the potassium suddenly becoming artificially low. This reaction doesnt occur with the other benzos. and no one is sure why. It has been detrimental enough that our facility and many i know have protocols against administration of versed to a known alcolotic patient unless there are no other options. It has also been taught to us in the classes im taking for my CRNA license. Ive had three different anastesiologists warn against this in school . One of them actually said it took a week to get his patient turned around in the ICU after giving it. I know i won't chance it after learning about it.



I think you're confusing longer-term alkalosis (metabolic or respiratory) with the short-term acute respiratory alkalosis from hyperventilation.  Surely at this stage of your anesthesia training you understand how quickly you can change the EtCO2/PaCO2.

I was using Versed even before it was released into the marketplace more than 25 years ago, in all sorts of critically ill patients.  Anecdotal evidence, as well as obscure foreign anesthesia texts, just don't do it for me.  We'll have to agree to disagree.  I'll take midaz over Ativan any day.


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## Veneficus (Sep 15, 2012)

*I had to take a special interest in this topic.*

I give out midazolam like candy. It is my favorite benzo and I am very comfortable using it.

When presented with this new information on alkalosis, I had to take time to research it.

I checked my sources.

I found nothing at all about this in The Pharmacological Basis of Theraputics.

I found nothing at all about this in Miller's Anesthesia

I found nothing at all about it in The textbook of Critical Care

Nothing in my anesthesia pocket guide either.

In a pubmed and medscape search of both versed and midazolam + alkalosis I got one hit.

A case study of milk alkali syndrome. 

I can find nothing outside of the cited textbook here that supports these assertations.

I am going to continue to use and support the case for midazolam.


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## NYMedic828 (Sep 15, 2012)

I don't exactly share the same level of experience and pharmacological knowledge as most of you, but I would be hard pressed to believe that 1cc of a medication, 5mg, would have the power to induce a metabolic acidosis.

We use 1mEq/kg of Bucarb to correct acidosis... If the effect of versed is that potent then why even use bicarb. (not serious)


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## RocketMedic (Sep 16, 2012)

The Benadryl treatment seems interesting too, at the risk of burying the problem and taking hours to go away. I'd have considered it downrange as a 68W with no benzos, but here, I think midazolam is a better option.


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## NYMedic828 (Sep 16, 2012)

Rocketmedic40 said:


> The Benadryl treatment seems interesting too, at the risk of burying the problem and taking hours to go away. I'd have considered it downrange as a 68W with no benzos, but here, I think midazolam is a better option.



Personally, I myself have never had IM or IV benadryl before so I can't vouch for the onset or sedative properties but if it is anything similar to the pills, it wouldn't touch me. 50mg PO does very little to knock me out and im only 180lbs. It also takes a good while to kick in. I really wouldn't be turning to it for sedative effects pre-hospital, when I have benzos at my disposal.


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## Veneficus (Sep 16, 2012)

I have found promethazine is a much more potent sedative than benadryl


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## TheLocalMedic (Sep 17, 2012)

Veneficus said:


> I have found promethazine is a much more potent sedative than benadryl



Unfortunately we don't carry promethazine where we are...

IV benadryl has a little more kick than taking it PO, and I generally see the sedation or anti-emetic effects kick in within 5 mins or so.  Not that I don't like versed, but benadryl is _my_ go to for mild sedation, I generally reserve versed for the quick 'boom, lights-out' situations.


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## Eli (Sep 25, 2012)

Merck said:


> A couple things. First I probably wouldn't treat this patient but rather she would go with a BLS crew to the hospital. Midaz can be funny sometimes. 5mg in one can be quite different than 5 in another pt. This girl is likely going to be fine.



WTF!! Are things that different up there? A patient with a respiratory problem that is acute and severe would get turfed down to a BLS crew? Is that something that passes muster with the physicians? This wouldn't happen in any system I've been around here in the States.


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## Aidey (Sep 25, 2012)

The PT isn't having a respiratory emergency. She is having a panic attack.


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## RocketMedic (Sep 25, 2012)

Breathing just fine, Eli.


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## Medic Tim (Sep 25, 2012)

Eli said:


> WTF!! Are things that different up there? A patient with a respiratory problem that is acute and severe would get turfed down to a BLS crew? Is that something that passes muster with the physicians? This wouldn't happen in any system I've been around here in the States.



Our bls is quite different from your bls. And as stated the pt was having an anxiety attack.


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