# Versed IN verses IM



## emtdansby (Apr 30, 2013)

Anyone here had issues giving versed IN. Very recently I've seen two patients given versed IN, one to treat seizure and the other to sedate for intubation. Both times the versed had no visible effects. Both were given 5mg, a dose that I expected to have some effects. Also, does anyone have protocols for IM versed, if so, how well does it work for seizure patients?


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## Medic Tim (Apr 30, 2013)

was an atomizer used?
IV is obviously the best but I have seen IM valium and IM versed work well on seizures. I have also seen IN Versed work quite well and fast though I am not sure of the dose (IN) used.


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## Carlos Danger (Apr 30, 2013)

IM midazolam should work fine for seizures once it is absorbed, but keep in mind that you are looking at 10-15 minutes for full effect via the IM route. If giving IM, I would increase the IV dose by 50% to compensate somewhat for the slower absorption. In a seizure, it is probably much better to place an IO and give an IV dose.

I have no experience with IN midazolam. In theory it works well, but I hear that patients often snort it out before it is absorbed.

Curious why IN versed was given for intubation, rather than IV? Also, 5mg is a very small dose for intubation. The normal intubating dose is 0.1 - 0.3 mg/kg, and even at that dose it doesn't work as well as other sedatives, which is why you don't see it used as much for intubation as other drugs. I would not expect to see anything approaching adequate RSI sedation in an adult with only 5mg, so it sounds like the lack of effect that you observed there could have been simply due to underdosing.


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## NomadicMedic (Apr 30, 2013)

I gotta think it would be pretty messy if you didn't use an atomizer. 

I've used intranasal versed with varying amounts of success. It's very patient dependent. Sometimes, it works like a champ. Other times… Not so much.

It's important to have a vial of versed that's 5 mg/1ml, with 0.5ml per nare, otherwise the atomized versed just becomes liquid and runs down the back of the naspharynx. And if your seizure patient is spitting and snarfing, they'll  just spit it out.


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## emtdansby (Apr 30, 2013)

We did use a MAD to admin IN. The intubation was with a pt who had become extremely combative due to hypoxia, 5mg is our allowed dose for intubation, I would prefer 7.5 to maybe a full 10.


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## Carlos Danger (Apr 30, 2013)

The proper dose range for an 80kg patient would be 8-24 mg, preferably towards the higher end.

Unfortunately, this is not the first time I've heard of protocols calling for a really low dose of midazolam as part of an RSI protocol. I don't understand why that is.

All I can say is, get used to seeing it not work.....:sad:


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## emtdansby (Apr 30, 2013)

We don't even have RSI protocols for our ground medics. We have a sedation protocol for intubation, but it's no good. However, once a person is intubated, a good versed drip, 4mg/hr infusion rate usually does the trick, works better than any other sedation drip I've seen, including propofol.


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## Outbac1 (Apr 30, 2013)

I've only used it once IN on a combative pt. 5mg IN with an atomizer. It took the better part of 5 min to work and the pt was out. But only for about 5-7 min. Then they woke up and became just as combative. It was taking 4 cops to hold him down. 
I don't know if IM would have been more effective. But IN certainly was safer than trying to poke a kicking squirming pt with a sharp needle.


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## Handsome Robb (Apr 30, 2013)

Halothane said:


> I have no experience with IN midazolam. In theory it works well, but I hear that patients often snort it out before it is absorbed.



This has been my problem with it. Our QA/I and MD are pushing for IN over IM although like you said IV would be preferred and is but if we don't have that option they prefer IN.

Narcan has worked fantastically IN for me, versed not so much. I've only given it a handful of times but it seemed like a waste since most patients were slobbering and "sneezing"(can't think of a better term at the moment) all over themselves during the seizure and blew it all right back out. One of those experiences though isn't really fair to use considering after the IN I maxed out my protocol IV and she was still seizing.


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## Carlos Danger (Apr 30, 2013)

Robb said:


> This has been my problem with it. Our *QA/I and MD are pushing for IN over IM* although like you said IV would be preferred and is but if we don't have that option they prefer IN.



That's interesting. Do you know why they prefer IN? Do you guys do IO's?


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## chaz90 (Apr 30, 2013)

Halothane said:


> That's interesting. Do you know why they prefer IN? Do you guys do IO's?



I don't know of any places that want to see IO access on seizure patients that you can't immediately get an IV on. Way too many IOs would be placed on relatively stable patients that could have easier venous access after you stopped the seizure with another route.


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## Carlos Danger (Apr 30, 2013)

Generalized seizures are a perfect indication for IO.

A patient doesn't need to be in extremis in order for an IO to be appropriate. An IO is indicated in any patient who needs meds more quickly than you can get an IV.


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## johnmedic (Apr 30, 2013)

I've used IN versed & it works very well & very quickly through the MAD. My first inclination is that you should start double checking your company's narcotic policy, backstock & start watching for other signs if ineffective narcotics.. Stay vigilant, it happens. :|


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## STXmedic (Apr 30, 2013)

I'll echo n7. I've had very varying results with IN midaz (and IN Fent for that matter). The last 4-5 times I've used IN midaz I have had little to no response. For a kid I'll absolutely use it first line. For an adult, I prefer to take a quick look for an IV first.


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## chaz90 (Apr 30, 2013)

Have you guys read the RAMPART Study regarding IV vs. IM benzodiazepine administration during seizures? They compare IM Versed to IV Ativan and their speed and effectiveness at stopping active seizures. I would have preferred to see them use Versed by both routes, but it still produced some interesting data. Basically, an IM dose of Versed was found to be more effective in stopping active seizure than IV Ativan when you took into account the additional time to start an IV. Our protocols give us the option of IM or IN Versed if we don't have an IV, so I choose to go with IM most of the time based on the problems mentioned with IN administration during seizures.


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## Handsome Robb (May 1, 2013)

Halothane said:


> That's interesting. Do you know why they prefer IN? Do you guys do IO's?



We do have IOs.

I could see it in a status epilepticus situation where you really couldn't get a line it in most seizure patients I don't see jumping to an IO being a good decision. 

I haven't heard a reason, just coworkers saying they've had the IN route suggested to them, I've had the same. If we justify why we chose a certain route it's not like they're throwing a horsy fit because we didn't give it IN.


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## Milla3P (May 1, 2013)

Robb said:


> Narcan has worked fantastically IN for me, versed not so much. I've only given it a handful of times but it seemed like a waste since most patients were slobbering and "sneezing"(can't think of a better term at the moment) all over themselves during the seizure and blew it all right back out. One of those experiences though isn't really fair to use considering after the IN I maxed out my protocol IV and she was still seizing.



This sums it up for me. I love atomizing things just because I love sticking things up peoples nose, but all my IN Versed has been really iffy. It works eventually but it takes longer to have its full effect than with IM. 

Narcan works like a dream nasally.


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## usalsfyre (May 1, 2013)

PoeticInjustice said:


> I'll echo n7. I've had very varying results with IN midaz (and IN Fent for that matter). The last 4-5 times I've used IN midaz I have had little to no response. For a kid I'll absolutely use it first line. For an adult, I prefer to take a quick look for an IV first.



Mirrors my experience exactly.


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## usalsfyre (May 1, 2013)

emtdansby said:


> We have a sedation protocol for intubation, but it's no good.



I'm surprised no one's reached up, snatched the layrengoscope out of a medics hand and beat them with it....


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## emtdansby (May 1, 2013)

usalsfyre said:


> I'm surprised no one's reached up, snatched the layrengoscope out of a medics hand and beat them with it....



Trust me, I try several other treatments before I even consider sedating someone to intubate them.


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## mike1390 (May 1, 2013)

IO for a seizure? brutal....


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## NomadicMedic (May 1, 2013)

mike1390 said:


> IO for a seizure? brutal....



Seriously? Status seizures get drilled. No question.


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## Carlos Danger (May 1, 2013)

DEmedic said:


> Seriously? Status seizures get drilled. No question.



I know. I'm pretty surprised at the squeamishness about IO's among the folks here. If you wouldn't place an IO for a seizure, when would you place one?

I've placed dozens of them for seizures, RSI's, traumas, everything. Seizures are actually a perfect, textbook indication for an IO. 

Put it in, push the meds, and when you eventually get an IV you can pull it out and put a bandaid over the small wound. No big deal.


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## joshrunkle35 (May 1, 2013)

I notice no one prefers the rectal route


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## chaz90 (May 1, 2013)

Halothane said:


> I know. I'm pretty surprised at the squeamishness about IO's among the folks here. If you wouldn't place an IO for a seizure, when would you place one?
> 
> I've placed dozens of them for seizures, RSI's, traumas, everything. Seizures are actually a perfect, textbook indication for an IO.
> 
> Put it in, push the meds, and when you eventually get an IV you can pull it out and put a bandaid over the small wound. No big deal.



I'm not squeamish about IO placement. They have their place, and are an absolutely essential tool as far as I am concerned. My question about placing them in seizure patients was only in reference to not preferring them over IM or IN Versed. If IM Versed stops active seizures ~80% of the time, why not stop the seizure then grab a quick IV? 

If I have a status seizure patient refractory to IM Versed, I would have no problem drilling them for additional dosing.


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## Carlos Danger (May 1, 2013)

chaz90 said:


> I'm not squeamish about IO placement. They have their place, and are an absolutely essential tool as far as I am concerned. My question about placing them in seizure patients was only in reference to not preferring them over IM or IN Versed. If IM Versed stops active seizures ~80% of the time, why not stop the seizure then grab a quick IV?
> 
> If I have a status seizure patient refractory to IM Versed, I would have no problem drilling them for additional dosing.



I don't doubt that IM works most of the time, but it's the slowest and most variable of all the routes of administration.

The potential problem with the strategy of giving IM and then switching to IO if needed, is that with 10-15 min to onset via the IM route, you are potentially looking at waiting 15 minutes before you know whether you have to re-dose. That's a long time if the patient has already been seizing a while.

IN might be a good option, but it seems like the jury is still undecided. IV is clearly the gold standard if you can get one quickly, and distribution and onset of IO is very similar to IV.

I think of all the options, IM really should be the last resort.


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## chaz90 (May 1, 2013)

The RAMPART study seems to indicate that IM Versed is far faster than 15 minutes and has a high efficacy. I'm not saying that's the end all study by any means, but it's certainly some good evidence.


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## Carlos Danger (May 1, 2013)

chaz90 said:


> The RAMPART study seems to indicate that IM Versed is far faster than 15 minutes and has a high efficacy. I'm not saying that's the end all study by any means, but it's certainly some good evidence.



Just looked at that quickly. I've heard of it before but never read it before now.

I'm not sure why anyone would even want to study IM midazolam vs. IV lorazapam? Kind of comparing apples & oranges, in that midazolam is well known to have a faster onset than lorazapam.

You are right about the onset in that study, it was extremely fast.....almost suspiciously fast....as in, IV midazolam isn't even that fast sometimes..... 

I'll look at it more closely tomorrow.


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## Handsome Robb (May 1, 2013)

Halothane said:


> I know. I'm pretty surprised at the squeamishness about IO's among the folks here. If you wouldn't place an IO for a seizure, when would you place one?
> 
> I've placed dozens of them for seizures, RSI's, traumas, everything. Seizures are actually a perfect, textbook indication for an IO.
> 
> Put it in, push the meds, and when you eventually get an IV you can pull it out and put a bandaid over the small wound. No big deal.



I wouldn't call it squeamish. I agree that in a status seizure patient and IO is absolutely indicated and probably safer, in all honestly, for the patient and provider than an IV. Firefighter holds the leg, find your landmark, clean it real quick then drill it and you're done, don't have to worry about holding tamponade then securing it.

I've drilled two successful live IOs and two unsuccessful ones, both because of lack of a bariatric needle which still puzzles me to this day why we don't carry them. One successful one was a trauma patient that arrested shortly thereafter however did regain ROSC and maintain it until surgery, the other was an acute liver failure patient with a massive lower GIB that coded later that day in the ICU. 

There's a time and a place for IOs, I just don't think the majority of seizures are that place. I may be misinformed but I was under the impression placement of an IO guarantees a long road of IV antibiotics afterwords, we are not permitted to disconnect them.

Per protocol we can go to an IO afte two peripheral attempts or can humor to it on the medic's discretion with a good reason as to why.


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## Carlos Danger (May 2, 2013)

Robb said:


> I may be misinformed but I was under the impression placement of an IO guarantees a long road of IV antibiotics afterwords,



Yeah, you were given some bad info there.....IO's require no post-treatment whatsoever. It is exactly the same as DC'ing an IV. 

The other big advantage to an IO vs. IM is that once it's placed....you have vascular access. If you have a seizing patient and you give midazolam, and it doesn't work and the seizure continues and the patient decompensates, you already have a route in place for resuscitation meds and fluids. You can push RSI meds, epi, anything that you can give IV.

I was the educator at a HEMS program that served as one of the market test sites for the EZ-IO. We did a lot of education on IO's in general and the Vidacare device specifically, and used the device A LOT during the several month trial period and after. We had great results with it, and my program's experience was the basis for much of the research that was used to help market the device. My medical director at the time had always felt like IO was an under-utilized route of medication administration, and that the main limiting factor was lack of a good device for placement (the FAST1 sucked). My experience with them there taught me how useful they are and convinced me, too, that they are underutilized in both EMS and the hospital. 

That was back in 2003, and since then there's been a pretty substantial body of research done on IO's, and it generally shows that IO's are faster to place and least as reliable as PIV's, and result in the same or fewer rates of complications. That's why when I hear about people fiddling around with IN and IM meds and CVC's during crisis situations, I kind of cringe and the first thing I ask is "did you consider using an IO"?

The primary deterrent to greater acceptance of IO placement seems to be the perception that it is exceedingly painful.....and that really isn't true, either. The one study that I know of (unfortunately was not published, I don't think) that looked at pain showed that patients thought that IO placement was less painful than a large-bore IV placement. And that's about in line with my experience. Infusion can be quite painful, but if you are just using for meds, it only takes a few seconds to push and flush. 2% lido helps some people a lot, and fentanyl does too.


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## Dwindlin (May 2, 2013)

I'm going IN everyday of the week before I attempt any kind of invasive access.


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## DPM (Dec 18, 2014)

In my county we can go IV/ IM/ IN Midazolam for Seizure. 

I had a 5 month old seizing the other day. Weight 5kg per Braslow tape so she was going to get 0.5mg IV/IO/IM or 1mg IN. As I normally do, I drew up the entire 5mg / 1cc of versed, popped on the atomizer and then 0.1cc up each nair. Shortly after the baby started "drooling" for a better word. Still seizing, suctioned the mouth. A few mins later the seizure broke. Baby's now awake and crying, Sat is still good, it looks good.

My questions are this:

Safely administering 0.1cc at a time was tough. This meant I had to do it slowly, which is the concern. Our protocols say to administer it briskly, which I couldn't really do, and I was concerned that some of the "drool" was the midazolam leaking into her mouth. Any one had this problem? One solution I've thought up is to only draw up the initial dose, so I don't have to worry about giving too much. Any one got any other ideas?

I'm liking IO, I didn't think about it at the time and I will in future. We didn't manage access prior to ER arrival, but we luckily we didn't need it. I'm hesitant to go IM. Thoughts?


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## Angel (Dec 19, 2014)

hmm, will an atomizer fit on a 1cc syringe (never tried it)...i highly doubt it couldve been versed leaking from her mouth but anythings possible i suppose. IO seems like over kill for this patient, especially because you can always give it IM.
it would be a lot easier (especially not to accidently give too much) to just pull out the amount you need and give it that way. then to waste just get a new syringe. 

did you try an IV or just straight to IN? Ive gotten 22G on 1 year olds so it is possible.


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## DPM (Dec 19, 2014)

Went straight to IN. And yeah, in future I'll only be drawing up what I need. The MAD fits on the little 1cc syringe, its the same size as everything else. 

The IV is definitely possible, I had a good look but didn't find anything in the time I had. In my experience going straight for IN works well, I just had that issue in this case.


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## RocketMedic (Dec 22, 2014)

I agree the IO is safe and effective, but sadly, most of us still live in the QI dark ages. Drilling a nonarrested patient is deeply frowned upon by paleolithic sorts.


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## Angel (Dec 22, 2014)

Drilling a patient you could easily get an IV or give the med IM/IN just doesn't make sense to me, QI aside, least invasive to most invasive just seems better for the patient.


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## RocketMedic (Dec 22, 2014)

Depends on the ease of access. I've honestly never really had a problem with starting an IV if I've got the hands and they've got the veins.


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## EMT11KDL (Dec 22, 2014)

Angel said:


> hmm, will an atomizer fit on a 1cc syringe (never tried it)...i highly doubt it couldve been versed leaking from her mouth but anythings possible i suppose. IO seems like over kill for this patient, especially because you can always give it IM.
> it would be a lot easier (especially not to accidently give too much) to just pull out the amount you need and give it that way. then to waste just get a new syringe.
> 
> did you try an IV or just straight to IN? Ive gotten 22G on 1 year olds so it is possible.


The atomizer will fit on any syringe, it twist in just like a normal needle does.


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## DesertMedic66 (Dec 22, 2014)

I'll take a look for IV access, if I can't find anything fairly quickly then I'll go to IN/IM. I'm not going to drill an average seizure patient.


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## EMT11KDL (Dec 22, 2014)

DesertEMT66 said:


> I'll take a look for IV access, if I can't find anything fairly quickly then I'll go to IN/IM. I'm not going to drill an average seizure patient.



Usually I can get something in the hand Or wrist, if not IN


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## RocketMedic (Dec 22, 2014)

I think a decent dose of midazolam im is a decent treatment.


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## DPM (Dec 23, 2014)

Pt was actively seizing on arrival, am I right in thinking some of you would get the IV and go that way, over an immediate dose IN/IM?


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## STXmedic (Dec 23, 2014)

I'll give an IM dose and then get the IV. Screw intranasal.


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## DPM (Dec 23, 2014)

Not busting balls, but why do you feel that way about IN?


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## STXmedic (Dec 23, 2014)

Variable, unreliable absorption. That, and it limits me to 2mg of versed. The only time I use the MAD is for fentanyl for pediatrics.


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## DPM (Dec 23, 2014)

Ok, so you like being able to use the smaller dose so you have more left to work with? That's certainly a good point


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## RocketMedic (Dec 23, 2014)

Not that, DPM. 2mg is generally an ineffective dose to resolve grand mal seizures. Coupled with unreliable adsorption, I have doubts as to the overall effectiveness of IN versed.


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## DPM (Dec 23, 2014)

Ah ok. I can give a full 5mg for adults, IN. Would that make a difference in you choices? My county likes IN, so did my preceptor etc, and that's probably why I like it too.  I've never really had trouble with it, but I am interested in what the brain trust has to say too.


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## STXmedic (Dec 23, 2014)

DPM said:


> Ah ok. I can give a full 5mg for adults, IN. Would that make a difference in you choices? My county likes IN, so did my preceptor etc, and that's probably why I like it too.  I've never really had trouble with it, but I am interested in what the brain trust has to say too.


What is your concentration of versed?


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## DPM (Dec 23, 2014)

5mg /ml


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## STXmedic (Dec 23, 2014)

Ah, gotcha. And no, would still go IM.


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## DPM (Dec 23, 2014)

My other issues is that IN is a double dose, so if that 5mg of my 6mg max doesn't work then I've only got 1mg left... Definitely going to give IM a go and see how I like that. (I've only used IM versed for sedation.)


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## NomadicMedic (Dec 23, 2014)

5mg/1ml of Versed IN has (anecdotally) worked well for me.

However, 5mg/5ml is a pain in the butt to squirt up a snout.


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## epipusher (Dec 23, 2014)

Love IN use for Versed admin. Used for seizures and chemical restraints.


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## gotbeerz001 (Dec 23, 2014)

I like IM if IV unavailable.


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## Angel (Jan 4, 2015)

I have no problem doing any route. Max for adults here is 8 and peds is 4 in 1-2mg increments or 8 im or in based on weight


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## Smitty213 (Jan 4, 2015)

Since the debut of IN Narcan here, our Medical Directors have been poking around the idea of broadening the med's that can be given via that route. IN Versed was one that got rolled out this year; 5mg max, IV preferred, however IN if starting a line was "unsafe" to patient/provider. Haven't seen/done/heard of anyone I know here doing it that way, but it was a "highlighted change"...


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## HotDrop89 (Jan 18, 2015)

STXmedic said:


> Variable, unreliable absorption. That, and it limits me to 2mg of versed. The only time I use the MAD is for fentanyl for pediatrics.


You don't like using nasal narcan?


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## STXmedic (Jan 18, 2015)

HotDrop89 said:


> You don't like using nasal narcan?


Not in the slightest. I'll take IM Narcan over IN any day.


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## HotDrop89 (Jan 18, 2015)

STXmedic said:


> Not in the slightest. I'll take IM Narcan over IN any day.


Interesting...there's opiate overdoses every day where I'm from, it's become an epidemic.  It's kind of sad because its a fairly small town, about 40,000 in the off season, over 100-120k in the summer.  Anyways, nasal seems like the go to method even if the patient isn't breathing spontaneously.  Or IV if you have one.  What's your reasoning on this?  Specifically with narcan?  Curious to learn other providers thought process because nasal seems the least invasive, and it works VERY well most of the time


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## NomadicMedic (Jan 18, 2015)

I use IN Narcan every time. It works, every time. 

Anecdotal? Sure. But, in my experience, why use a sharp when you can use a MAD?


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## triemal04 (Jan 18, 2015)

HotDrop89 said:


> Interesting...there's opiate overdoses every day where I'm from, it's become an epidemic.  It's kind of sad because its a fairly small town, about 40,000 in the off season, over 100-120k in the summer.  Anyways, nasal seems like the go to method even if the patient isn't breathing spontaneously.  Or IV if you have one.  What's your reasoning on this?  Specifically with narcan?  Curious to learn other providers thought process because nasal seems the least invasive, and it works VERY well most of the time


What's your reasoning for using IN instead of IM or if you already have one IV?

Provider preference aside, there aren't that many reasons to choose one over the other.  Anecdotatlly I've gotten quicker results using an IM injection with narcan and there are more times that I've seen than not that IN wouldn't work with versed, but other's have probably seen the opposite, and there likely isn't enough of a real difference in time to matter.

If it's a safety issue...meh...while IN might be technically safer than giving an IM injection, even if you don't have some form of safety needle (and if you don't they're very cheap and worth looking into) if you are that concerned about getting a needle stick from an IM shot...you need to work on your technique and process.


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## HotDrop89 (Jan 18, 2015)

HotDrop89 said:


> Interesting...there's opiate overdoses every day where I'm from, it's become an epidemic.  It's kind of sad because its a fairly small town, about 40,000 in the off season, over 100-120k in the summer.  Anyways, nasal seems like the go to method even if the patient isn't breathing spontaneously.  Or IV if you have one.  What's your reasoning on this?  Specifically with narcan?  Curious to learn other providers thought process because nasal seems the least invasive, and it works VERY well most of the ti





triemal04 said:


> What's your reasoning for using IN instead of IM or if you already have one IV?
> 
> Provider preference aside, there aren't that many reasons to choose one over the other.  Anecdotatlly I've gotten quicker results using an IM injection with narcan and there are more times that I've seen than not that IN wouldn't work with versed, but other's have probably seen the opposite, and there likely isn't enough of a real difference in time to matter.
> 
> If it's a safety issue...meh...while IN might be technically safer than giving an IM injection, even if you don't have some form of safety needle (and if you don't they're very cheap and worth looking into) if you are that concerned about getting a needle stick from an IM shot...you need to work on your technique and process.


I wasn't talking about safety necessarily. I'm saying it's less invasive.  If we're talking about safety, why bring out a sharp if you can quickly push 1mg in each nostril with an atomizer.  Avoiding use of a needle doesn't mean you have bad technique if you can give the drug a different route that works just as well.  Reminder I was asking about narcan not versed.  Even though the thread is about versed lol my apologies.  Thank you


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## triemal04 (Jan 18, 2015)

HotDrop89 said:


> I wasn't talking about safety necessarily. I'm saying it's less invasive.  If we're talking about safety, why bring out a sharp if you can quickly push 1mg in each nostril with an atomizer.  Avoiding use of a needle doesn't mean you have bad technique if you can give the drug a different route that *works just as well.*  Reminder I was asking about narcan not versed.  Even though the thread is about versed lol my apologies.  Thank you


My point is that, barring department mandates, it's really going to come down to provider preference.  Your preference is to use IN because it's less invasive.  You even mentioned that it works just as well as IM/IN...so...all about personal preference.


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## HotDrop89 (Jan 18, 2015)

triemal04 said:


> My point is that, barring department mandates, it's really going to come down to provider preference.  Your preference is to use IN because it's less invasive.  You even mentioned that it works just as well as IM/IN...so...all about personal preference.


Fair enough! How effective has IM narcan been for you?  Does it take significantly longer to get desired effect etc.


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## STXmedic (Jan 18, 2015)

HotDrop89 said:


> Interesting...there's opiate overdoses every day where I'm from, it's become an epidemic.  It's kind of sad because its a fairly small town, about 40,000 in the off season, over 100-120k in the summer.  Anyways, nasal seems like the go to method even if the patient isn't breathing spontaneously.  Or IV if you have one.  What's your reasoning on this?  Specifically with narcan?  Curious to learn other providers thought process because nasal seems the least invasive, and it works VERY well most of the time


I work in the inner city of a city with a population over 1mil. Heroin is seen daily (although synthetic marijuana laced with PCP has been the theme of the last month or two). Anecdotally, I've seen IN work in 30 seconds to not at all, and varying tremendously in between. When I give IM, I know that it'll start to kick in in about a minute nearly every time. If it takes longer, it's because we had to re-dose because it was a stronger batch or laced with fent. As to the safety of using needleless, just don't stab yourself...


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## Chewy20 (Jan 18, 2015)

STXmedic said:


> just don't stab yourself...


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## triemal04 (Jan 19, 2015)

HotDrop89 said:


> Fair enough! How effective has IM narcan been for you?  Does it take significantly longer to get desired effect etc.


Very, it's all I use for probably 90% on my narcotic OD's.  It does take longer than IV, and probably slightly longer than IN (though that hasn't been my experience), which really isn't a concern.


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## Posterior (Jan 25, 2015)

Our protocol for Sz's is .2 mg/kg Versed IM. We no longer carry Valium. We are supposed to repeat the Versed until the Seizure stops. There was a case study that I am unable to locate citing that Versed is water soluble allowing it take affect quicker than other medications. From experience and the findings in the study, it takes approx 15 seconds to control and seizure.


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## Carlos Danger (Jan 25, 2015)

Posterior said:


> Our protocol for Sz's is .2 mg/kg Versed IM. We no longer carry Valium. We are supposed to repeat the Versed until the Seizure stops. There was a case study that I am unable to locate citing that Versed is water soluble allowing it take affect quicker than other medications. From experience and the findings in the study, it takes approx 15 seconds to control and seizure.



What allows midazolam (and other fast-acting CNS drugs, like propofol and etomidate and fentanyl) to take effect quickly is its *lipid* solubility.....meaning it can cross the blood-brain barrier more easily than less lipid soluble meds.

Midazolam has a unique property that makes it interesting, though......it is water soluble in acidic solution, meaning it doesn't need to be mixed in a solution that makes it burn on injection, like propofol, etomidate, ativan, etc.....however, when exposed to physiologic pH, its imidazole ring opens and it becomes lipid soluble, hence it's rapid onset. Pretty cool.


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## triemal04 (Jan 25, 2015)

Posterior said:


> Our protocol for Sz's is .2 mg/kg Versed IM. We no longer carry Valium. We are supposed to repeat the Versed until the Seizure stops. There was a case study that I am unable to locate citing that Versed is water soluble allowing it take affect quicker than other medications. From experience and the findings in the study, it takes approx 15 seconds to control and seizure.


Did you really mean to say 0.2mg/kg?  As a single dose?  Because for someone my size you're talking about giving 18mg IM.


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## chaz90 (Jan 25, 2015)

triemal04 said:


> Did you really mean to say 0.2mg/kg?  As a single dose?  Because for someone my size you're talking about giving 18mg IM.


We use that weight based dosage for peds, which always strikes me as funny since you get to the adult dose quite quickly. It specifies not to exceed the adult dose so it's no big deal, but it's always been interesting to me. 

I could totally give you 18 mg IM in a single dose in a big muscle if I had a big vial of that 5 mg/mL concentration. Not saying it would be at all conducive to you maintaining any kind of spontaneous respiratory effort, but c'est la vie!


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## triemal04 (Jan 26, 2015)

It would certainly stop the seizure...


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## Posterior (Jan 27, 2015)

triemal04 said:


> Did you really mean to say 0.2mg/kg?  As a single dose?  Because for someone my size you're talking about giving 18mg IM.



Yes that's correct. That's whats the protocol reads.  That's also the same for a combative patient. However, I rarely administer the full dose because like you implied, that's a lot in a single dose and I prefer to see how the medicine will react or a patient will respond. I seem to get the "wanted" effects at .1 mg/kg IM. As always, think outside the box, and the book is the box.


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## cfd3091 (Feb 21, 2015)

We had an attempted suicide yesterday. Unknown quantity of weed killer. He was alert and combative, did not want us or LEO anywhere near him. We finally got him in the rig and I was able to get the monitor on him (still struggling) two LEO's helping. Sinus tach 110 and 88% 02. Medic calls and gets approval for Versed IN up to 5mg. He gives him 2mg,1 in each. About 2 minutes later the cops let go and 1 minute later he tells us he now loves us and sleeps the whole way in. Put a NC at 2 lpm and drove in . I have never seen Versed IN work so well.


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## samiam (Feb 21, 2015)

DEmedic said:


> However, 5mg/5ml is a pain in the butt to squirt up a snout.



I read a study that there is no point to doing more then 1ml per nostril, it will not atomize correctly and not get absorbed.  I will post the link if i come across it again.



cfd3091 said:


> We had an attempted suicide yesterday. Unknown quantity of weed killer.



He turn out ok? Round-Up does not appear to be that toxic interestingly.


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## cfd3091 (Feb 22, 2015)

samiam said:


> He turn out ok? Round-Up does not appear to be that toxic interestingly.


Medically he seemed fine by the time we cleared. They were fixin' to move him to Behavioral when we brought another patient in about an hour later. It wasn't Round-up brand but it probably was chemically the same. Poison control was "0" help on the phone. Told us to be sure to keep his head up and airway clear. Well no ****, Thanks.


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## NomadicMedic (Feb 22, 2015)

samiam said:


> I read a study that there is no point to doing more then 1ml per nostril, it will not atomize correctly and not get absorbed.  I will post the link if i come across it



Yes, that's why 5mg/5ml is a pain. You have to do it a ml at a time.


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## samiam (Feb 22, 2015)

DEmedic said:


> Yes, that's why 5mg/5ml is a pain. You have to do it a ml at a time.


Ah I gotcha, How long do you have to wait between doses?


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## NomadicMedic (Feb 22, 2015)

samiam said:


> Ah I gotcha, How long do you have to wait between doses?



I'd give a ml in each nare, wait a few and if needed, give a little more. I think the protocol says to wait 5 minutes.


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