# Pre-Hospital post intubation sedation



## Sublime (Mar 21, 2014)

I know this has been discussed here, previously,  but I wanted to bring it up in hopes that someone can help me convince my medical director to change his mind. Our current protocol for PAI (we don't rsi) is Ketamine 0.5-1.5 mg/kg for induction. 

Post intubation sedation is versed 2.5 mg every 10 minutes as required.  Max 10mg.

People as such as myself have considered intubation a painful procedure and thus felt necessary to add fentanyl to post intubation sedation. We recently received a updated pearl and message from our medical director about this. He states "intubation followed by immediate opiate analgesia can mask how the patient is responding to the intubation. So give the patient time to react to the Ketamine and see how they respond to it and see how they respond to the intubation procedure itself. If pain is suspected post intubation call med control for pain management guidance". 

In the same message an educator at my service writes "our medical director has clearly stated that a triple drug cocktail of Ketamine, versed, and fentanyl is unacceptable and can be dangerous to your patient". 

I am guessing the concerns here are hypotension. I'm not sure what he means by mask how the patient is responding to the intubation. 

Either way I've searched through literature today and can't find anything that states not to use these drugs together for sedation purposes. I've recently listened to the EMcrit on post-intubation sedation where fentanyl is discussed as the a go to agent and has better outcomes for intubated patients. I know this is talking about ICU and ER care but I don't see why it couldn't apply to us as well. 

Anyone have thoughts, recommendations, or supporting literature that I could use to persuade my medical director? Or if I'm way off base in my thinking I'll welcome your opinion on that as well.


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## Medic Tim (Mar 21, 2014)

My CQI would be reaming me a new one if I only gave versed post intubation.
Our maintenance of paralysis / sedation guideline  suggests we use 0.5 mg/kg ketamine q 10 prn or 2-5 mg midazolam and 50-100 mcg fentanyl q 10 prn


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## Carlos Danger (Mar 21, 2014)

Ketamine at those doses is a potent analgesic. No need to add an opioid immediately. 

I disagree that intubation is painful. It is uncomfortable. It is anxiety-inducing. It should not be _painful_, however; that's different. If it is, something is wrong.

Versed alone is a pretty poor agent to use, I would agree. Versed + fentanyl is a good combo, because they potentiate each other and "cover all the bases". Personally, I feel strongly that every intubated patient should be paralyzed for transport. But that is another topic.

I don't understand why your MD is concerned about "masking" the "response" to intubation. The response is ugly. Masking it is the whole point.

I am not unaware of any reason not to give versed and ketamine and fentanyl together. I almost never give ketamine WITHOUT the other two - plus other meds - and have never seen an issue. 

Why not a repeat dose of ketamine, if nothing else? 

Don't even get me started on "PAI" vs. "RSI" in the prehospital realm....that is also a whole different topic.


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## Sublime (Mar 21, 2014)

Halothane said:


> Ketamine at those doses is a potent analgesic. No need to add an opioid immediately.



I think Ketamine alone is sufficient for PAI induction purposes, don't have a problem with this portion of the protocol. 



Halothane said:


> I disagree that intubation is painful. It is uncomfortable. It is anxiety-inducing. It should not be _painful_, however; that's different. If it is, something is wrong.



I see what you're saying. I don't disagree either but when you're only allowed to use fentanyl for pain management purposes and want to ensure your patient is comfortable.... You have to use the "pain" protocol to justify the fentanyl in these scenarios. 



Halothane said:


> Why not a repeat dose of ketamine, if nothing else?



That could be argued for as well,  and I believe is probably a more likely to go over well with the Medical director than fentanyl. He seems to have his mind set about that. 



Halothane said:


> Don't even get me started on "PAI" vs. "RSI" in the prehospital realm....that is also a whole different topic.



Agreed. Don't want to start down that road...  Different can of worms.


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## Rialaigh (Mar 22, 2014)

Our protocol goes to hefty doses of Versed, and Vec for long term paralytic post intubation. 

We can call for orders for morphine, don't currently carry fent, and have the option to use ativan or valium in addition to versed. We are suposed to be getting ketamine shortly


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## Sublime (Mar 31, 2014)

What do you guys believe is the optimal post intubation sedation package for pre-hospital providers? Obviously the perfect package is going to vary depending on the condition of the patient. But do you believe we should be using Fentanyl drips such as many ICU's are doing? Is using just a benzo sufficient for pre-hospital providers?


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## Handsome Robb (Mar 31, 2014)

I don't think we necessarily need to be using drips but I think analgesia is a requirement for appropriate post intubation care. 

I don't see why we can't alternate fentanyl and versed q5-10.


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## FiremanMike (Mar 31, 2014)

Robb said:


> I don't think we necessarily need to be using drips but I think analgesia is a requirement for appropriate post intubation care.
> 
> I don't see why we can't alternate fentanyl and versed q5-10.



That's what we do in my critical care gig.. Works pretty great!


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## Carlos Danger (Mar 31, 2014)

Robb said:


> I don't think we necessarily need to be using drips but I think analgesia is a requirement for appropriate post intubation care.
> 
> I don't see why we can't alternate fentanyl and versed q5-10.



Why do you want to have to give drugs every 5 minutes though? Why not just give them together and give enough that you don't have to repeat it every time you turn around?




Sublime said:


> *What do you guys believe is the optimal post intubation sedation package for pre-hospital providers?* Obviously the perfect package is going to vary depending on the condition of the patient. But do you believe we should be using Fentanyl drips such as many ICU's are doing? Is using just a benzo sufficient for pre-hospital providers?



I am a strong believer in the KISS principle, especially in the prehospital realm. 

I would advocate for a protocol that calls for something along the lines of: 

1 mcg/kg of fentanyl (simply their estimated weight in kg, rounded to the nearest 10kg)
0.1 mg/kg of versed (the fentanyl dose / 10 and given in mg)
0.1 mg/kg of vecuronium (same as the versed dose)

- Give the first doses immediately post-intubation
- Repeat Q30 min, earlier only if there are objective signs of them needing more sedation
- Repeat the vec only earlier if they start to move
- If the pressure is low, give half the versed dose
- If you give fentanyl prior to intubation, omit it from the first round of post-intubation dosing
- As an alternative to fentanyl, a healthy dose of morphine immediately post-intubation should cover you analgesia-wise for the duration of the transport.

Ketamine is a great option to have but I think is probably superior to versed & fentanyl combo only in select circumstances. I think it is a bit overhyped these days.



Sublime said:


> What do you guys believe is the optimal post intubation sedation package for pre-hospital providers? Obviously the perfect package is going to vary depending on the condition of the patient. *But do you believe we should be using Fentanyl drips such as many ICU's are doing?* Is using just a benzo sufficient for pre-hospital providers?



The only advantage an infusion offers over boluses is a more precise ability to titrate over time, and more stable serum concentrations which potentially leads to lower total doses over time. And of course it frees the bedside nurse from having to administer a bolus every 30 minutes or so. But in the prehospital phase, we are not concerned with stable serum concentrations or 24-hour opioid totals, and it takes more time to set up an infusion than it does to give a couple boluses. Plus, even with an infusion you usually start off with an initial bolus anyway. Personally, I would not bother with an infusion prehospital, unless the transport was going to be very long.




Sublime said:


> What do you guys believe is the optimal post intubation sedation package for pre-hospital providers? Obviously the perfect package is going to vary depending on the condition of the patient. But do you believe we should be using Fentanyl drips such as many ICU's are doing? *Is using just a benzo sufficient for pre-hospital providers?*



In all actuality, yes, versed probably is perfectly adequate for most patients post-intubation, providing of course that they don't have a painful injury or condition to begin with, and assuming that you didn't mangle their airway during the intubation. That said, adding an opioid only makes sense, both to cover any pain and to potentiate your versed.


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## FiremanMike (Mar 31, 2014)

Halothane said:


> Why do you want to have to give drugs every 5 minutes though? Why not just give them together and give enough that you don't have to repeat it every time you turn around?



Because then we'd be sitting around and twiddling our thumbs for 10 minutes instead of 5... 

As for your vec opinion, I'm only a fan of vec if you're doing hypothermia protocol or don't have a vent.  IMHO, a vent patient should really be on SIMV as much as possible..


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## Handsome Robb (Mar 31, 2014)

That's a very valid point Halothane...I didn't even think of that. Most every protocol I've seen calls for alternating doses, I was wondering if there was an issue just giving both concurrently...they're intubated and ventilated I'm not worried about their respiratory drive.


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## Carlos Danger (Mar 31, 2014)

FiremanMike said:


> Because then we'd be sitting around and twiddling our thumbs for 10 minutes instead of 5...
> 
> As for your vec opinion, I'm only a fan of vec if you're doing hypothermia protocol or don't have a vent.  *IMHO, a vent patient should really be on SIMV as much as possible*..



I cannot think of a single reason not to paralyze for transport, but I can think of several why you should.

You can still put them on SIMV if you really want to.  in my last couple years of flying I always used SIMV, whether paralyzed or not.

There are good reasons why patients who are intubated for prolonged periods should be encouraged to breathe spontaneously as much as possible, but none of them are relevant to the emergent prehospital setting any more than they are to the OR, where we paralyze people all the time for elective surgeries. It just isn't an issue for an hour or two at a time.

If you have someone well sedated enough that they tolerate not only intubation/mechanical ventilation but also the high-stimulus transport environment, chances are very good that they won't be breathing well enough to reap the benefits of SIMV or any support mode - they are going to require pretty much full support anyway. 

In the short-term prehospital setting with an emergent patient, the advantages of paralysis easily outweigh the potential/theoretical risks of it, IMO.


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## 18G (Apr 27, 2014)

If you want a comfortable patient post-intubation and want them to do well on the vent.... TREAT THEIR FREAKING PAIN!!!! Not providing post-intubation analgesia is asinine to me. I hate walking into EDs and finding out the patient received no post-intubation analgesia and has only been receiving a push dose benzo. 

Yes, intubation is a very uncomfortable and painful experience. The patient is already feeling horribly bad as it is given the underlying condition that warrants intubation. So, now we ran a metal blade into their mouth and place a rigid piece of plastic through their vocal cords and leave it there. Next, we subject them to the unnatural and uncomfortable sensation of positive pressure ventilation via the ventilator. This is all on top of being poked and prodded with NG tubes, IV catheters, central lines, foley catheter, and being bounced around down the road with this piece of plastic vibrating through the vocal cords. And what about some meds that may be infusing that are irritating at the infusion site? I think analgesia is a priority!

When I give my vent patients fentanyl... it works amazing to provide a comfortable and well sedated patient. It also prevents having to up the dose on the propofol. I give fentanyl as needed and use the propofol or a benzo on top just as additive. 

Patient's who are critically ill can experience allodynia which is pain due to a stimulus that does not normally cause pain. 

I highly recommend this podcast from EMcrit.org (A Bad Sedation Package Leaves Your Patient Trapped in a Nightmare): 

http://emcrit.org/podcasts/post-intubation-sedation/


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## Carlos Danger (Apr 28, 2014)

18G said:


> If you want a comfortable patient post-intubation and want them to do well on the vent.... TREAT THEIR FREAKING PAIN!!!! Not providing post-intubation analgesia is asinine to me.



No one is advocating withholding analgesia where it is needed. People experiencing pain should have their pain treated. We all get that.

What needs to be understood, though, is that a well sedated patient isn't "experiencing" pain. An adequate dose of versed or propofol puts the higher centers of the brain to sleep and the patient consciously experiences nothing. You could saw their leg off with a hacksaw and they wouldn't "feel" it at all. You will still have signs of sympathetic stimulation (tachycardia, etc.), but that does not indicate that the patient is experiencing pain or discomfort; it is simply a reflexive response to nociceptor activation that is separate from awareness pathways. 



18G said:


> When I give my vent patients fentanyl... it works amazing to provide a comfortable and well sedated patient. It also prevents having to up the dose on the propofol. I give fentanyl as needed and use the propofol or a benzo on top just as additive.



Of course they do better with fentanyl + propofol than with propofol alone. When you give the fentanyl, you are essentially doubling their dose of propofol without having to deal with the hemodynamic consequences of actually doing so. You are also blunting their respiratory drive to a greater degree than the propofol alone, which makes it easier to synchronize them with the vent (assuming they are still even breathing on their own). 



18G said:


> Patient's who are critically ill can experience allodynia which is pain due to a stimulus that does not normally cause pain.



This is actually an argument AGAINST using an opioid-based sedation strategy. Google "opioid induced hyperalgesia".


I am not making these points to argue that intubated patients shouldn't be given analgesia; I am simply pointing out that a protocol based on benzos or propofol, while probably not ideal, does NOT equate to "abusing" or "torturing" your patients (assuming, of course, that adequate doses are used). No one is committing an ethically questionable act by following a protocol that calls for propofol or versed and omits fentanyl. 

I *do* think that an opioid-based vent sedation is a much better choice than a benzo or hypnotic based one - especially in the field - but that primarily has to do with hemodynamic stability rather than improved comfort; it is simply easier to keep a good BP and a low HR with opioids than it is with large doses of versed or fentanyl. Other advantages of opioids include duration of action, synergism with the benzos, and (in the ICU) lower rates of pneumonia and improved weaning from the vent.


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## VPIMedic (Apr 30, 2014)

Robb said:


> Most every protocol I've seen calls for alternating doses, I was wondering if there was an issue just giving both concurrently...they're intubated and ventilated I'm not worried about their respiratory drive.



This is actually a much more complex topic.  There are two reasons why this approach is a poor practice IMO.  First: it promotes, and reinforces, the appropriately admonished practice of "cookbook medicine."  No single agent, nor any broad combination of agents, applies to every patient.  Each patient needs to be approached individually because the effect of each drug is different.  Everybody knows this but the very nature of protocols promotes this thinking.  Concomitant administration of medications at specific intervals for this circumstances appears to eliminate critical thinking by the provider. Again, my opinion.  

Why?  This creates an excellent segue into the second problem with concomitant administration.  You are correct that depressed respiratory drive is not a concern for intubated patients.  But this is not the only effect.  It is known that the specific combination of midazolam and fentanyl, or benzos and opiates in general, cause a decrease in hemodynamics. A modest drop is not an issue, and this is sometimes desired.  But the underlying pathology of the disease (ex:trauma/hypovolemia) as well as the physiologic state of the individual (ex: geriatrics, renal failure etc) can exacerbate the effects and consequences of this practice.  One episode of hypotension has significantly deleterious effects on morbidity and mortality in TBI.  

The cornerstone of post-intubation *care* is understanding that it is multifaceted and illness dependent.  You must ask yourself three basic questions each time.  What is wrong with the patient?  Where do they need to be?  How am I going to get there?


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## VPIMedic (Apr 30, 2014)

Halothane said:


> What needs to be understood, though, is that a well sedated patient isn't "experiencing" pain.



*Wrong*  See these papers:
Pain from ET tube alone--at it's most: 8.  At it's least:5! Rotondi AJ, Chelluri L, Sirio C, et al. Patients' recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. Crit Care Med. 2002;30(4):746-52.
Lewis KS, Whipple JK, Michael KA, Quebbeman EJ. Effect of analgesic treatment on the physiological consequences of acute pain. Am J Hosp Pharm 1994; 51:1539.



Halothane said:


> You could saw their leg off with a hacksaw and they wouldn't "feel" it at all. You will still have signs of sympathetic stimulation (tachycardia, etc.), but that does not indicate that the patient is experiencing pain or discomfort; it is simply a reflexive response to nociceptor activation that is separate from awareness pathways.



*Wrong again.* Probably more egregious than the first inaccuracy.  Too much literature to list, but sedatives and hypnotics do not provide analgesia.  Clearly established fact.  

Hyperalgesia is real.  Yet it is from chronic use of opiates.  In the acute setting, such as this...nah.  More harm from not treating pain.

Treating with benzos or propofol alone is unethical because it is not the currently accepted medical standard of care.  See Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41:263.

Yes we are talking about prehospital care...but these patients are critically ill and destined for an ICU.  Not an elective gallbladder removal that is sent home two hours after the procedure.


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## rmabrey (Apr 30, 2014)

Good thread. We dont give pain meds with intubation and ive been meaning to ask why.


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## Rialaigh (Apr 30, 2014)

rmabrey said:


> Good thread. We dont give pain meds with intubation and ive been meaning to ask why.



For a lot of agencies it gets all the way back to the most basic debate of all, and that is what our "job" is. Fact is prehospital pain medication post intubation does not reduce mortality or morbidity in any condition period. If you go back to the mentality that some people have, that all treatments that we do need to be justified by reduced mortality, morbidity, or reduced hospital stay times, then pain medication is no where to be found...along with most other prehospital ems treatments.


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## Carlos Danger (Apr 30, 2014)

VPIMedic said:


> *Wrong*  See these papers:
> Pain from ET tube alone--at it's most: 8.  At it's least:5! Rotondi AJ, Chelluri L, Sirio C, et al. Patients' recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. Crit Care Med. 2002;30(4):746-52.
> 
> Lewis KS, Whipple JK, Michael KA, Quebbeman EJ. Effect of analgesic treatment on the physiological consequences of acute pain. Am J Hosp Pharm 1994; 51:1539.



Did you even read those papers? They have nothing at all to do with what I wrote. The first one simply shows that _under_-sedated patients who receive mechanical ventilation in the ICU are uncomfortable and sometimes have stressful recollections of the event, and the second one describes negative physiologic responses to untreated severe pain. Neither piece of info is breaking news, and neither one addresses awareness of pain in well-sedated patients, or establishes the necessity of an opioid-based sedation strategy in the prehospital environment. 



VPIMedic said:


> *Wrong again.* Probably more egregious than the first inaccuracy.  Too much literature to list, but sedatives and hypnotics do not provide analgesia.  Clearly established fact.



Did I say that sedatives provide analgesia? No, I didn't....I'm not sure why you are barking up that tree. 



VPIMedic said:


> Treating with benzos or propofol alone is _unethical because it is not the currently accepted medical standard of care_. See Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41:263.



So the current accepted standard of care is the only arbiter of what constitutes proper care? "If it's in the protocol it's right, if it isn't it's wrong?" Isn't that exactly the kind of thinking that kept rigid backboards in everyone's protocols for so long?

I wonder if you've read this document, too, because it doesn't really say what you seem to think it says. It addresses many issues but when it comes to pain, it basically says "assess for pain frequently, treat it aggressively, tailor it to the patient's needs, and use multi-modal therapy where appropriate". 


Look man, I know a thing or two about analgesics and sedatives and how to use them so that patients can tolerate painful procedures. I think you are misinterpreting what I wrote partly because it's not what you've been taught, and partly because you don't have much understanding of sensory pathways and mechanisms of awareness or the way they are affected by these drugs, so what I wrote didn't make sense to you. Sorry you weren't able to follow.

Just to keep you happy, I'll say it again for the 3rd or 4th time in this thread: People in pain should receive analgesia. I do not nor have I ever advocated withholding analgesia in any case.


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## rmabrey (Apr 30, 2014)

Rialaigh said:


> For a lot of agencies it gets all the way back to the most basic debate of all, and that is what our "job" is. Fact is prehospital pain medication post intubation does not reduce mortality or morbidity in any condition period. If you go back to the mentality that some people have, that all treatments that we do need to be justified by reduced mortality, morbidity, or reduced hospital stay times, then pain medication is no where to be found...along with most other prehospital ems treatments.



That is the answer I expect


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## 18G (May 3, 2014)

Halothane. Sorry but have to disagree on all of your points. Sedated patients STILL FEEL PAIN. You're perpetrating a myth. Sedatives offer no analgesia. This is exactly like how a lot of nurses think because they lack understanding. Pain negatively effects the body. 

I had a vent patient just the other day on a Versed drip who was NOT comfortable. I got an order for fentanyl q15 PRN and I had a comfortable patient. These patients appreciate having their pain treated! This isn't just an opinion it is evidenced based.


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## Carlos Danger (May 3, 2014)

18G said:


> Halothane. Sorry but have to disagree on all of your points. Sedated patients STILL FEEL PAIN. You're perpetrating a myth. Sedatives offer no analgesia. *This is exactly like how a lot of nurses think because they lack understanding.* Pain negatively effects the body.



Oh, really? So if I go to paramedic school, I'll get the kind of in-depth education on pain and awareness pathways that it takes to provide anesthesia? 

I guess I'll forget everything I learned in my tens of thousands of hours managing sedated, intubated patients in the ICU's, helicopters, and ambulances, and the hundreds of RSI's I did in the field, not to mention my hundreds of hours in the OR. I'll purge my brain of all the trash they shoved in there during my graduate level anatomy, physiology, pharmacology, and anesthesia courses. I'll throw away my medical physiology and anesthesia texts, my neuroanesthesia text, and my pharmacology texts. 

Instead, I'll dig up my old 500 page paramedic text written at the tenth grade level and read it slowly.....maybe then and only then will I have an understanding as thorough as your own?

Or more likely, I'll just keep in mind that you really don't know what you are talking about, and ignore your attempted insult.


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## VPIMedic (May 7, 2014)

You know, Halothane is right in all of his posts.  This is not sarcasm.  I'll say that the delivery on the last one is a bit rough though.  Not trying to suck up here, but some good information is getting lost in this mess.  I'm guilty of thumping the sedation/analgesia war drum, not fully explaining my rationale, nor differentiating between Halothane’s first response and all subsequent posts.  This post is intended to offer an answer to the OP's question.   The second will be to Halothane’s questions of me.  I have an organic chemistry final that I really need to study for so that takes priority…unfortunately.  In the meantime: yes, I read those papers.  Otherwise I would not have posted them.  You are right Halothane, your knowledge and experience dwarfs mine.  I presume that applies to a few others here as well.  Based upon the vernacular within your posts, in addition to the list of work experience, I presume that you are a CRNA.  I freely admit that the attribute I respect most of CRNAs, AAs, and anesthesiologists is the in-depth knowledge that they possess of physiology, pathophysiology, and pharmacology.  I can't really blame you for getting a little snippy at the end either.  We're getting awfully close to Godwin's Law.  Hopefully I can put it back on track.  I'm sure most don't even care anymore, but apathy can be a terrible thing.  Based upon your description of your experience, for all I know I could be arguing with my partner’s husband…he took the same route as you.  

To the OP: intubation itself is not a painful procedure...I myself have had surgery and the only painful part was the burn of the propfol going into my arm.  Now, this was in a controlled environment and performed by an individual that has thousands of intubations under her belt.  This doesn't describe our practice.  Any pain inflicted from intubation is a response to our poor technique or, in the absence of this, the fact that a piece of plastic is irritating the mucosal lining.  The bougie and ET tube is not the time to practice form for muzzleloader season.  I don't hunt so this could be an incorrect analogy.  The thing is, pain is subjective and anxiety or poor sedation increases this perception to pain.  Does adequate sedation treat the pain or does it inhibit the recall of the pain actually ever occurring?  I think the latter, mainly for the exact reasons that Halothane cites: it puts to sleep the higher brain centers that are responsible for memory formation and recall.  

I think the response to intubation that your OMD is concerned about masking is indeed hypotension.  I also think your educator muddies the water here.  What causes the hypotension?  Physiologically, people suck and ventilators (BVMs) blow.  This is why it is called “positive pressure” ventilation.  The respiratory cycle is turned on its head, in essence, although not from intubation itself but rather from the transition to positive pressure ventilation.  Intrathoracic pressure increases, which translates to a lower cardiac output.  All of the medications used for induction, and post intubation care for that matter, can cause vasodilation.  As Paracelsus said, “the dose makes the poison.”  This is where I tip my hat to Halothane and his profession, because they comprehend this concept much better than any of us here.  Read up on it, this forum is certainly not capable of explaining it well enough.  If you are performing this procedure, I think it is your responsibility for knowing it.  Or, at the very least, recognizing how complex of a topic it actually is.  It is not as black and white as it may seem.    This is probably the main source of Halothane’s frustration, although not the sole source either.   

Regardless of my opinion, Halothane is again correct in stating that ketamine provides analgesia at the doses you describe.  The subdissociative, pain management dose for ketamine is generally accepted to be 0.2mg/kg IV. Dissociation occurs around 2mg/kg.  Ketamine is a versatile drug, but again, it is not the panacea of post intubation care.  It is a bit more forgiving, although this characteristic is again dependent upon the patient’s underlying physiology and the pathophysiology of their illness.  I realize I am a broken record here, but this cannot be stressed enough.  

So a well sedated patient, absent a painful injury or procedure is not experiencing pain.  This is the point that Halothane is really trying to make, I think.  This is true.  The stimuli of the transport environment are not present in an ICU, which increases the sedative requirements.  The presence of an injury increases analgesic requirements.  The KISS approach is accurate, but at some point it has its limitations.  My main point, particularly by posting the ICU sedation article, is that even in controlled environments it would appear that we aren't as good as we think we are at inducing the level of sedation that Halothane refers to.  This is a slippery slope for EMS as illustrated by our general lack of understanding of the process.  Until later...


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## Carlos Danger (May 7, 2014)

I appreciate the hat-tip, VPIMedic. 



VPIMedic said:


> So a well sedated patient, absent a painful injury or procedure is not experiencing pain.  This is the point that Halothane is really trying to make, I think.  This is true.



That is indeed the main point I was trying to make. Even if there is some nociceptor activation (pain) involved, if they are indeed well-sedated, they should not be _feeling_ the pain. 

Nociceptor activation has two basic effects: 1) it causes an autonomic (sympathetic) response which manifests clinically as tachycardia and hypertension, and 2) it causes an unpleasant conscious experience, which we call pain.

One way to limit the effect of nociceptor activation is to administer opioids which block pain impulse transmission primarily in the spinal cord, keeping the pain impulse from reaching the upper spinal cord, where the reflex sympathetic stimulation is generated, and also from reaching the brain, where the pain experience is generated. Think of giving fentanyl as "blocking the road" that pain signal has to travel up the spinal cord in order to get to the brain.

When you adequately sedate someone, you do nothing to "block the road" that goes up the spinal cord, so the impulse is able to reach the parts of the spinal cord where a sympathetic response is generated. However, sedation shuts down the parts of the brain that turn that electrical "pain" stimulus into an unpleasant experience. This explains why giving fentanyl works so well to blunt the sympathetic response to intubation. It's not that the patient _feels_ any less - after an adequate dose of propofol or etomidate, they weren't going to _feel_ the intubation anyway. But the fentanyl blocks the signal much earlier in it's travels towards the brain before it can elicit a sympathetic response. 

In addition to blocking pain transmission in the spinal cord, opioids also have sedative effects in the brain (same basic mechanism as etomidate or propofol or versed, just different receptors), and also blunt the respiratory drive.

So when your vent patient on a propofol drip is still breathing against the vent and tachycardic, and you give them 100 mcg of fentanyl and they stop fighting the vent and their HR comes down, it probably isn't because they were _experiencing_ pain before the fentanyl, it's probably because the fentanyl further sedated them, slowed their respiratory drive, and blocked any sympathetic response that was occurring in response to inadequate sedation. You would likely have had similar results just by increasing the propofol infusion significantly, though there are obviously downsides to that.

As you can imagine, the neurophysiology of all this is actually pretty complex, but this is kind of the down-and-dirty about the differences between using opioids and sedatives for post-intubation patient comfort.

The reason you hear things lately on blogs like EMCrit about how much better "analgo-sedation" is as compared to benzo- or propofol- based sedation, has less to do with short-term patient comfort and more to do with vent weaning and long-term cognitive outcomes of patients who are on a vent for several days or longer. I'm not aware of any studies that show superior patient comfort with a narcotic-based technique, or that the outcomes are affected at all by a very short-term regimen of benzo-based sedation in the prehospital or ED setting.  

A post-intubation cocktail of versed *and fentanyl or morphine* is a really good way to go. It's simple, safe, and effective, and it covers all the bases and is pretty hemodynamically stable.

But if for some reason your protocols don't allow opioids, or only allow very small doses of them, do not fret about being "cruel" to your patients. As long as you can give adequate sedation (the "adequate" part is important, mind you), your patients are probably not suffering.


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## 18G (May 7, 2014)

And just like a recent discussion that occurred on Facebook regarding abd pain and treating it with narcotics by EMS. A Medical Doctor (like yourself having completed thousands and thousands of hours of medical training) was advocating an incorrect and outdated practice of withholding analgesia despite tons of evidence to the contrary. Education doesn't automatically make you right (not saying you're totally wrong). 

The common sedatives that are given lack analgesic properties. Yeah, if you're giving high doses the patient won't be feeling anything. But 2mg of Ativan or 1-5mg of Versed every 30-45mins??? It's not gonna achieve that effect.  So yes, these patient's feel pain and remember it. The body responds to this painful stimuli negatively. I see it all the time. Maybe not in an OR, but in an ED, ICU, and field environment where sedation often lacks, pain control is necessary. Treat the pain, achieve some sedation at the same time, and pack on the sedative as a bonus. 

That's just coming from a dumb Paramedic on a 10th grade level so take it for what its worth.


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## FLdoc2011 (May 7, 2014)

In an ICU where I have patients on vents for days I just don't see these folks needing lots of opioids for pain control while in the vent. 

Usually if adequately sedated they may not need any.  Even in the patients lightly sedated who can still follow commands they usually tolerate the tube well without much if any pain. 

Do I still have something available for pain if needed?  Of course.    But in practice it just hasn't been a bug issue like it seems to have been made here, though granted these are different environments with somewhat of a different patient population I'm sure.  

All drugs have side effects and there may be times when I would like to avoid any opiates.


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## Nova1300 (May 8, 2014)

I think you owe a patient (who is not in shock) analgesia after intubation.

3 points

1.  The endotracheal tube may not cause pain, but it is highly stimulating.  The sympathetic surge can be detrimental to some patients, especially those with ongoing myocardial ischemia or those with increased ICP.  Which account for a good number of patients who get intubated in the prehospital world.  Benzos do very little to blunt this response.  

2. Again, while the tube does not hurt, you know what probably does?  Being hand-ventilated in a fast-moving vehicle.  We overventilate, we over-distend, we move the tube around;  At least ICU/ER patients have a nice steady ventilator rate, or they set their own.  And their tube is sitting still.  

3. Heavy drinkers and patients on chronic benzos can often require huge doses of versed before you start to see clinical effect.  If your patient falls into this category, when your induction drug wears off you have a paralyzed patient with little to no sedation.  And no analgesia.  That kinda makes you a jerk

I will always advocate for analgesia before sedation.  Pain only makes patients combative and delirious. And throwing benzos at it only worsen the problem.  I treat the pain, and if that doesn't work I move on to sedation.


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## Sublime (May 9, 2014)

I want to thank everyone for their posts so far. I really do appreciate your input and opinions. However Halothane you have really persuaded me and changed my perspective on this topic. Posts like your last one are why I continue to use these forums. I really do feel enlightened on the topic.

Now if you don't mind I would like to further pick your brain.

In your first post you recommended 0.1mg/kg of versed as a post intubation dose. This seems like a pretty fair dose to me. Our protocol as I stated is 2.5 mg IV q10 to a max of 10mg. I'd say this is a rather small post intubation sedation dose. I'll admit though I have only been a medic a couple years and have very limited experience with this. If I was going to present to the education department and my medical director about increasing our flexibility with the dose or adding ketamine for post intubation purposes, what is your opinion on how to best approach this? I've googled for some papers or research I might use but I have found anything specific enough to apply to my argument. Not asking you to do the work for me, I just would like to hear your opinion, you obviously have much more experience and knowledge about this than I do.

Thanks!


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## 18G (May 12, 2014)

There is an article in this months issue of Emergency Physicians monthly on post-intubation sedation and advocates goal #1 being treating pain with fentanyl.


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## Carlos Danger (May 13, 2014)

Sublime said:


> Now if you don't mind I would like to further pick your brain.
> 
> In your first post you recommended 0.1mg/kg of versed as a post intubation dose. This seems like a pretty fair dose to me. Our protocol as I stated is 2.5 mg IV q10 to a max of 10mg. I'd say this is a rather small post intubation sedation dose. I'll admit though I have only been a medic a couple years and have very limited experience with this. *If I was going to present to the education department and my medical director about increasing our flexibility with the dose or adding ketamine for post intubation purposes, what is your opinion on how to best approach this?* I've googled for some papers or research I might use but I have found anything specific enough to apply to my argument. Not asking you to do the work for me, I just would like to hear your opinion, you obviously have much more experience and knowledge about this than I do.
> 
> Thanks!



Well, to my knowledge there is unfortunately no research that shows that prehospital post-intubation sedation practices have any impact on outcomes, so you probably can't approach it from an EBM perspective.

I'd say, try to point out that the overall trend in EM is towards much better post-intubation comfort measures, for purely humane reasons. We are supposed to do what we can to make our patients comfortable. What would your medical director want his wife or daughter to have after intubation? 

Increasing the dose of versed, adding fentanyl, repeating the ketamine, all are good options.

Honestly, I'd comb through the physician-led blogs and find the articles and podcasts that argue for better sedation practices and find a way to present those arguments. EMCRIT is a good place to start. 

Feel free to PM me if you want. Good luck.  



18G said:


> There is an article in this months issue of Emergency Physicians monthly on post-intubation sedation and advocates goal #1 being treating pain with fentanyl.



I saw that a few days ago and wondered whether someone would mention it in this thread. 

Fentanyl for sedation is the hot thing right now in the "ED critical care"/FOAMed/EM blogoshpere. Last year it was ketamine. I understand why....fentanyl is a good drug, and it's cheap. It's sympatholytic properties certainly make us feel better, too, similar to how we feel better when we give a bunch of fluids to bring a trauma patient's SBP up to 100. 

However, the article presented no evidence that fentanyl-based sedation provides better patient comfort that hypnotic-based sedation. It doesn't really address anything that has been discussed in this thread.


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## MSDeltaFlt (May 19, 2014)

It's about time I read a thread here that peaked my interest.  Good stuff guys except for the SIMV bit which makes my skin crawl so I won't hijack.  Keep it coming.


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## FiremanMike (May 22, 2014)

MSDeltaFlt said:


> It's about time I read a thread here that peaked my interest.  Good stuff guys except for the SIMV bit which makes my skin crawl so I won't hijack.  Keep it coming.



Can you elaborate? I took a pretty decent airway class that made me a believer in SIMV>AC, I'd love to hear some counterpoints..


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## VFlutter (May 23, 2014)

18G said:


> *So yes, these patient's feel pain and remember it. *The body responds to this painful stimuli negatively. I see it all the time. Maybe not in an OR, but in an ED, ICU, and field environment where sedation often lacks, pain control is necessary. Treat the pain, achieve some sedation at the same time, and pack on the sedative as a bonus.



Just some anecdotal observations. Most of our ICU patients have intermittent Fentanyl (50mcg q30 or 100mcg q1hr) orders but the majority of our post intubation care is sedative based (Intermittent Versed, Diprivan, Precedex). Most patients receive very little, if any, Fentanyl. We turn off all sedation and narcotics prior/during weans. I have never had a patient get extubated and tell me that they were in extreme pain or being tortured. Nor has anyone told me they remember their intubation or time after. Was it uncomfortable? Of course. But it is usually tolerated. 

It would be great to snow every patient so there is absolutely no chance they would feel any sort of pain or discomfort. We would also be traching a lot of patients for failing to wean.


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## Carlos Danger (May 23, 2014)

MSDeltaFlt said:


> It's about time I read a thread here that peaked my interest.  Good stuff guys except for the SIMV bit which makes my skin crawl so I won't hijack.  Keep it coming.





FiremanMike said:


> Because then we'd be sitting around and twiddling our thumbs for 10 minutes instead of 5...
> 
> As for your vec opinion, I'm only a fan of vec if you're doing hypothermia protocol or don't have a vent.  IMHO, a vent patient should really be on SIMV as much as possible..



Let's move this part of the discussion to the mechanical ventilation discussion I recently started. I copied these posts over there, hope no one minds.


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## 18G (May 24, 2014)

I'm talking about post-intubation analgesia in the pre-hospital, ED, and inter-facility transport setting. ICU care is a little different. 





Chase said:


> Just some anecdotal observations. Most of our ICU patients have intermittent Fentanyl (50mcg q30 or 100mcg q1hr) orders but the majority of our post intubation care is sedative based (Intermittent Versed, Diprivan, Precedex). Most patients receive very little, if any, Fentanyl. We turn off all sedation and narcotics prior/during weans. I have never had a patient get extubated and tell me that they were in extreme pain or being tortured. Nor has anyone told me they remember their intubation or time after. Was it uncomfortable? Of course. But it is usually tolerated.
> 
> It would be great to snow every patient so there is absolutely no chance they would feel any sort of pain or discomfort. We would also be traching a lot of patients for failing to wean.


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## TransportJockey (May 24, 2014)

Our protocols are rather lax. They are: BIS readings of 40-60. That's it. We have our choice of medications (Propofol, Versed, Valium, Ketamine, Fentanyl) to use for it, with standard dosing of each. But the primary thing is a BIS of 40-60, we titrate meds to it, along with our other vital signs.


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## Carlos Danger (May 24, 2014)

TransportJockey said:


> Our protocols are rather lax. They are: BIS readings of 40-60. That's it.



I'm suprised to hear that. Lots of research questioning the utility of the BIS - even in more controlled settings - while clinical signs are simple and reliable.

http://www.ncbi.nlm.nih.gov/m/pubmed/23708914/


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## TransportJockey (May 24, 2014)

Halothane said:


> I'm suprised to hear that. Lots of research questioning the utility of the BIS - even in more controlled settings - while clinical signs are simple and reliable.
> 
> http://www.ncbi.nlm.nih.gov/m/pubmed/23708914/



We use the other clinical signs but we are doing a trial on the BIS.


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## chaz90 (May 24, 2014)

TransportJockey said:


> We use the other clinical signs but we are doing a trial on the BIS.



Is this a separate device that's able to monitor BIS in the field? Being mostly ignorant in the ways of CCT and IFT I hadn't even heard of this being done pre-hospitally before.


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## TransportJockey (May 24, 2014)

Its made by covidien. Its a four channel monitor if I remember right.


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## Handsome Robb (May 25, 2014)

Are there any toys y'all don't have? 

I spent a while earlier trying to find the closest commercial airport is in relation to Pecos and figure out how much it'd cost every week to fly in and rent a car :rofl: definitely not an option but I got way too much time on my hands anyways.


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## TransportJockey (May 25, 2014)

Robb said:


> Are there any toys y'all don't have?
> 
> I spent a while earlier trying to find the closest commercial airport is in relation to Pecos and figure out how much it'd cost every week to fly in and rent a car :rofl: definitely not an option but I got way too much time on my hands anyways.



Ultrasound... but that'll be here in a month. And istats. But we just got our quote to equip ground units.

Yiu could always fly to ABQ and carpool with me lol


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