# Versed vs. Ativan



## Emtpbill (Jan 30, 2012)

So Friday night I am 20 hours into a 24 hour tour. Get hit out for seizures. Arrive o/s with 3 pd officers to find a 50 yom sitting on a computer desk chair that is on wheels. Family sts that they were awakened by pt not acting right and talking disoriented. Wife says she had to "wrestle with pt to get him to sit". He is leaning against a wall. Family sts he is a IDDM who also has dialysis 3 times a week but didn't go today cause his ride never came. When I try to talk to pt all he says is I want a drink of water.
   Glucometer shows BS at Hi, doesn't give a number. Try to wheel chair to steps but it doesn't move. Get the reeves set up an pt onto it, pt starts to seize, approx 15 seconds grand mal.  
    Expedite to MICU . Hi flo 02, vitals EKG. All wnl.
   Pt arms are scarred from years of IV drug use. Finally am able to thread a 20 in the right internist vein. 
  NSS wide to try to dilute the sugar(I know not really helpful, but he needs insulin and I don't have any).
    Anyways halfway into a 25 minute transport time he starts to become combative. I am alone in back and PD is too far to rendezvous.
   So I give Ativan. 1mg, vitals. Another 1mg and so on. Call command and give report. Total of 4mg ativan and this guy is still combative.
   Would I have been better to have gone with versed. I have only used versed to facilitate intubation an that was about 10 years ago. Worked great 5mg but that was on a 100 lb. woman.
    What's is everyone's experience with using versed for seizures or to settle down combativeness.


---
I am here: http://maps.google.com/maps?ll=40.089019,-74.979306


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## mycrofft (Jan 30, 2012)

2 preliminary questions:

1. What is your working diagnosis (yeah, I know, "assessment"). 
2. What are your protocols for this assessment?


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## Shishkabob (Jan 30, 2012)

Anecdotally, i much prefer versed to Ativan.   I like that it can be given IN, IM, and IV and still haven't a good rate of onset, and for me atleast, I've been better able to control people with it.   It's my personal first line benzo that I go to between the two. 

Obviously each patient is different.   If I've given one benzo and it's not working, I'm doing the other.


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## Emtpbill (Jan 30, 2012)

mycrofft said:


> 2 preliminary questions:
> 
> 1. What is your working diagnosis (yeah, I know, "assessment").
> 2. What are your protocols for this assessment?



   Well I have several problems I have to work with. First is the elevated blood sugar. I'm not sure what the cutoff for the hluceter is to read just "hi" but I have been told 500. Secondly is the missing dialysis. If his kidneys are completely shot then even missing 1 dialysis could cause seizures. Also ther is a hx of drug abuse and from what PD told me the whole family has an abuse hx. So besides what they have told me, what else could I be dealing with that they haven told me.
    Protocols are pretty standard for altered mental status.   I called command when I needed more Ativan than usual.


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## Aidey (Jan 30, 2012)

Well, ativan can become toxic in high doses in renal patients so I would have gone with versed. I also question the value of high volume fuid administration in a dialysis pt who skipped dialysis. Especially if he doesn't have signs of dehydration. Chances are he is going to become fluid overloaded long before there is any impact on his blood sugar.


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## Emtpbill (Jan 30, 2012)

Aidey said:


> Well, ativan can become toxic in high doses in renal patients so I would have gone with versed. I also question the value of high volume fuid administration in a dialysis pt who skipped dialysis. Especially if he doesn't have signs of dehydration. Chances are he is going to become fluid overloaded long before there is any impact on his blood sugar.



  I was thinking about that also, but the amount of fluid I could get into him with a 20g wasn't gonna overload him. Thats a good point about the Ativan in hi doses. That's exactly why I threw this call out there.  Good point.


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## STXmedic (Jan 30, 2012)

Emtpbill said:


> I was thinking about that also, but the amount of fluid I could get into him with a 20g wasn't gonna overload him.



Que? 

A standard 20g cath can flow about 65ml/min. In a 15 minute transport, that's just shy of 1L. That's a decent amount of fluid in a dialysis patient...


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## Emtpbill (Jan 30, 2012)

PoeticInjustice said:


> Que?
> 
> A standard 20g cath can flow about 65ml/min. In a 15 minute transport, that's just shy of 1L. That's a decent amount of fluid in a dialysis patient...



In a patient who is calm and keeping his arm straight so the fluid could flow freely, yes. 
   Ok, let's focus on my Ativan versed part. I didn't fluid overload this guy, he maye got 150cc total after fighting me.


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## Veneficus (Jan 30, 2012)

Fluid issues already addressed, so I will not harp on it.

I am rather fond of versed myself, for the ever important reason of "provider comfort."

One of my mentors in anesthesia likes to say: 

"there are so many ways to do the same thing that its best to pick only a handful and be good at them rather than inexperienced with a bunch."

I cut it down to 4.

Plan A
Plan B
Plan C
Call for help

In any renal failure patient, toxicity and potentiation can be an issue in any medication excreted by the renal system. 

If it was that much of an issue, why not just use fentynal to knock the guy down? It is excreted by fecal route and you can get anesthetic dosage out of it.


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## Emtpbill (Jan 30, 2012)

Only have 200mcg of fentanyl on truck, normally we have 4-500 mcg but the ALS coordinator had not been to pharmacy.


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## Aidey (Jan 30, 2012)

Plan A - Versed
Plan A.1 - Physical restraints. 
Plan B - Fent
Plan C - Etomidate
Plan C.1 - Just RSI already, avoiding succs. 
Plan D - Call the specialist with way more drugs than I have.

Edit - yes Etomidate is excreted in urine, but it has a half life of about an hour and a half vs 14 hrs for ativan.


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## Shishkabob (Jan 30, 2012)

200 of fentanyl should slow him down a bit.   I premeditated my RSI patients with 250 of fentanyl and they went out, almost negating etomidate.   Plus you have the benefit of intra-nasal route and using narcan if something goes wrong. 

Bebadryl is another decent one, if your protocols allow?   Same with haldol if need be.


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## mycrofft (Jan 30, 2012)

*Parsing*

Busy thread! Good one.

So your assessment is altered mental state (obtunded or not oriented/reactive to verbal stimuli), and you have elevated blood glucose.

Don't answer these unless you want to, a mental exercise.

You also have bystander history of diabetes and noncompliant dialysis, unconfirmed hx of IVDU (IV drug use), and bystander account of seizure.

FOG hint #1: bystanders call everything from waking up from a faint to a  grand mal, to orgasm, a seizure. If active seizing is not observed/present, it is a "subjective", not "objective". Good call on dialysis predisposing pt for a seizure, but once the pt is breathing and assessed for incidental injuries (falling down, etc.) be ready and mindful of potential for seizures, get a line started. Was there a line in  place before attempting to move?

Question: is "diluting the sugar" a standard or improvised treatment? (I'm thinking "no", but that's because I've never heard of it before now; also, no place for that much fluid to go since kidneys aren't working, if that is true, right?).

Q: Was there a pulse ox or clinical sign indicating hypoxia and need for "hi flow" O2?  (I'm thinking yes there was postictal, but not needed once seizures done and pt is pink).

Q: What is pt approx, weight (to determine dosage) and, how long will your ativan, via it's administration route (IV, IM, intratracheal?) take to work? (Issue: if you are using ativan to snow the pt and you go past the dosage because it isn't working fast enough* you may be overdosing and probably again outside the protocols. The pt may have simply been postictal. Or a combative bozo).

Being in your care and having benzodiazepine titration to vitals,  was  the best way that scenario could evolve.

I've no idea about versed other than looking it up.

*I call that sort of drug dosage the "Thermostat Effect"; some people don't understand that turning the thermostat further does not make it cool or heat faster, it makes it run longer. I've seen it with Ativan, Valium, and Glucagon a number of times.


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## Akulahawk (Jan 30, 2012)

My own experience with Ativan in sz situations, granted only a couple times I've seen it used, is that it doesn't seem to be all that effective. I have seen Versed and Valium used in sz management and they seem to be more effective, longer. One patient I had would have breakthrough sz after about 10 min with the Ativan, while the Valium we gave lasted >1 hour before physical seizing started up again. I don't doubt that ativan works, I just don't think it's well suited for this usage, based on my (very) limited experience with it.


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## 18G (Jan 30, 2012)

Overall, it sounds like you did the best you could especially with being by yourself trying to handle a combative patient. This guy had quite a few issues going on it sounds like and you addressed them all. 

First is the blood sugar issue. Most glucometers from my experience read "HI" between 500-600mg/dl. How long has the patient been "HI" is the question. Any blood sugar this high is gonna make me think DKA with profound dehydration and electrolyte abnormalities. Now given the renal failure and being a dialysis patient, this creates other issues with the DKA and the patient probably won't be able to output enough urine to become dehydrated and will be already overloaded. 

Fluid replacement is important in the DKA patient to treat the profound dehydration that is normally present. The renal threshold for glucose spilling over into the urine is commonly stated at 180mg/dl. When this happens, it pulls water with it and causes frequent urination. Polyuria = dehydration. Yes, IV fluids can cause dilution of the glucose and lower blood sugar but that is not the primary reason for fluid administration. In this case a good point for fluid restriction is made. 

All seizure patients should have high-flow oxygen during the active phase and during the postictal phase. The diaphragm is impaired during tonic-clonic seizures with reduced ventilation (sometimes apnea) and reduced oxygen delivery to the brain. I have noticed faster recovery time with high-flow oxygen and I believe I have read some evidence supporting this also. 

I really like Versed. It works fast and very well. Ativan is good too but has a little longer onset. So for quick action in your case, Versed probably would have been a little better choice. Versed is shorter acting though compared to Ativan. Our protocols allow 1-2mg of Ativan or 1-5mg of Versed for seizures. Chemical restraint we have to call. 

Definitely sounded like a case for online consult with the doc.


Here is a great article outlining how to handle your patient type... suspected DKA with renal/dialysis patient. 

http://www.cjem-online.ca/v6/n4/p281


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## NYMedic828 (Jan 30, 2012)

To the OP, be happy you are permitted to standing order administer benzos on your own judgement.

Id have to get on the phone to call the doctor while fighting the patient...

Only standing order is for an active seizure.


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## STXmedic (Jan 30, 2012)

NYMedic828 said:


> To the OP, be happy you are permitted to standing order administer benzos on your own judgement.
> 
> Id have to get on the phone to call the doctor while fighting the patient...
> 
> Only standing order is for an active seizure.



That sucks. We've got standing orders for valium and midaz for several circumstances, which is great when you don't want to fight with one hand and call with the other! Get a good relationship between you and your med director going. They tend to be a lot more forgiving when you ask for "forgiveness" rather than permission  That, or get them to fix your protocols!


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## NYMedic828 (Jan 30, 2012)

PoeticInjustice said:


> That sucks. We've got standing orders for valium and midaz for several circumstances, which is great when you don't want to fight with one hand and call with the other! Get a good relationship between you and your med director going. They tend to be a lot more forgiving when you ask for "forgiveness" rather than permission  That, or get them to fix your protocols!



When you have over 20 medical directors, its tough to get a good relationship going. Never know who is going to answer that phone. Some people are so incompetent that the doctors will get fed sometimes and assume everyone is that way.


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## STXmedic (Jan 30, 2012)

NYMedic828 said:


> When you have over 20 medical directors, its tough to get a good relationship going. Never know who is going to answer that phone. Some people are so incompetent that the doctors will get fed sometimes and assume everyone is that way.



Ahh... Yes, I could see how that would be an issue...


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## Conanboris (Feb 15, 2012)

Veneficus said:


> If it was that much of an issue, why not just use fentynal to knock the guy down? It is excreted by fecal route and you can get anesthetic dosage out of it.



Was just wondering on this? It's the first time I'd heard that and I best of my recollection, fentanyl is excreted predominantly in the urine (somewhere around 70-75%). Fecal excretion is much lower (around 10%)..

As always, I stand correctly and am really just here to learn...


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## systemet (Feb 15, 2012)

We also need to consider the possibility of hyperkalemia in this patient (assuming hemodialysis).  The "ECG wnl" is reassuring... but is this a 12-lead or 3-lead, and how are our T waves looking?

I would argue that sedation/analgesia should be to facilitate transport in as small a dose as possible, and we should avoid upsetting the apple cart unless we have a very long transport time, e.g. hours + to dialysis, or strong evidence of critical hyperkalemia.


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## Conanboris (Feb 15, 2012)

Conanboris said:


> Was just wondering on this? It's the first time I'd heard that and I best of my recollection, fentanyl is excreted predominantly in the urine (somewhere around 70-75%). Fecal excretion is much lower (around 10%)..
> 
> As always, I stand correctly and am really just here to learn...



stand CORRECTED ... not correctly... d'oh


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## Jon (Feb 18, 2012)

Interesting discussion.

I wouldn't have thought of Fentanyl - and these days, it's damn near non-existent on our rigs anyway.

PA has some decent protocols - including the "combative patient" option where we can snow the heck out of the guy to keep them and us safe.


I'd have discussed switching to Versed w/ the doc after 2mg Ativan didn't stop it. And yeah, if I had a longer transport, considering opioids and Benadryl to attempt to make the situation safe for me and the pt. makes sense.


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## Veneficus (Feb 18, 2012)

Conanboris said:


> Was just wondering on this? It's the first time I'd heard that and I best of my recollection, fentanyl is excreted predominantly in the urine (somewhere around 70-75%). Fecal excretion is much lower (around 10%)..
> 
> As always, I stand correctly and am really just here to learn...



just found this, sorry for the delay.

The numbers are different depending on whether you are measuring metabolites, unmetabolized, oral, or transdermal routes.

Honestly I have been told in the clinical environment that fent is better for dialysis patients because it is excreted fecally. I can find no literature on this.

After looking into it deeper, after seeing this post, it appears to be metabolized into inert metabolites faster and in greater quantity, so I am of the mind that it is the metabolism and not the excretion that makes a difference.

Please forgive my earlier statement as not entirely accurate. 

Fent is still going to be superior to other agents in terms of toxicity in the renal compromised.


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## Basermedic159 (Feb 20, 2012)

Emtpbill said:


> So Friday night I am 20 hours into a 24 hour tour. Get hit out for seizures. Arrive o/s with 3 pd officers to find a 50 yom sitting on a computer desk chair that is on wheels. Family sts that they were awakened by pt not acting right and talking disoriented. Wife says she had to "wrestle with pt to get him to sit". He is leaning against a wall. Family sts he is a IDDM who also has dialysis 3 times a week but didn't go today cause his ride never came. When I try to talk to pt all he says is I want a drink of water.
> Glucometer shows BS at Hi, doesn't give a number. Try to wheel chair to steps but it doesn't move. Get the reeves set up an pt onto it, pt starts to seize, approx 15 seconds grand mal.
> Expedite to MICU . Hi flo 02, vitals EKG. All wnl.
> Pt arms are scarred from years of IV drug use. Finally am able to thread a 20 in the right internist vein.
> ...



Versed or Valium ALL DAY! I hate Ativan and I think it should be take off the truck!


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## Aidey (Feb 20, 2012)

Is there a basis for your statement or is it simply opinion?


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## Basermedic159 (Feb 23, 2012)

Aidey said:


> Is there a basis for your statement or is it simply opinion?



I've read that IV ativan can cause residual anxiety. It is my opinion that Versed and Valium are more effective than Ativan.


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## Basermedic159 (Feb 23, 2012)

Basermedic159 said:


> I've read that IV ativan can cause residual anxiety. It is my opinion that Versed and Valium are more effective than Ativan.



Also, I think fentanyl should be in the mix as well. Mix and titrate to effect.


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## systemet (Feb 23, 2012)

Basermedic159 said:


> Also, I think fentanyl should be in the mix as well. Mix and titrate to effect.



Why?


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## Basermedic159 (Feb 25, 2012)

systemet said:


> Why?



Because the Versed/Valium will "relax" them, added with Fentanyls euphoric effect, makes for a more calm, happier patient. 

Like I said this is just an opinion and a preference. To each their own...


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## Canadian Travel Medic (Feb 25, 2012)

Hi all, new here so bare with me haha

But i've given Versed IM before and it worked fast and had the desired effect, the only down side i'd say is the short half life, we had a 25min transport and had to give a repeat dose a couple of times.


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## EMSrush (Oct 21, 2012)

Hope I don't get scolded for dredging up an old thread, but I didn't see much point in creating a new one. This is a good thread. 

For those who give Versed for chemical restraint, does anyone have any experience or feedback with regards to periods of apnea, s/p administration?


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## Shishkabob (Oct 21, 2012)

Off the normal 2.5-5mg doses I've given for combative people, I've not really  experienced a severely depressed respiratory drive.


If it happens, they get bagged for a few minutes.


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## EMSrush (Oct 21, 2012)

Linuss said:


> Off the normal 2.5-5mg doses I've given for combative people, I've not really  experienced a severely depressed respiratory drive.
> 
> 
> If it happens, they get bagged for a few minutes.



Right. I just was wondering how often it happens. An RN told me it was quite common.


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## systemet (Oct 21, 2012)

EMSrush said:


> For those who give Versed for chemical restraint, does anyone have any experience or feedback with regards to periods of apnea, s/p administration?



Not sure what "s/p" means? 

I've used it quite a lot, and have had no problems (I have made a couple of people apneic with IV lorazepam).  If you're giving it IV, the onset is fairly rapid, and it's quite titratable, so if you keep in mind that the goal is to facilitate appropriate physical restrain, and limit physiologic stress to the patient, verus knocking them completely out, then I think you're going to be ok.

Unfortunately, like anything, when the patient's taken other agents, prescribed or not, it becomes less predictable, but that's a given, right?


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## Shishkabob (Oct 21, 2012)

systemet said:


> Not sure what "s/p" means?



Status post


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## usalsfyre (Oct 21, 2012)

EMSrush said:


> Right. I just was wondering how often it happens. An RN told me it was quite common.



How much are they giving? Our system regularly gives 5 of versed, 5 of haloperidol and 50 of diphenhydramine for sedation (in the elderly population mind you) and we've yet to experience a respiratory arrest. I've been giving benzodiazepines and opiates together for years and haven't done this.

I HAVE seen a lot of respiratory rates to down significantly, but mostly this was simply a return to an acceptable range, no apnea observed


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## EMSrush (Oct 21, 2012)

5mg IM. ETOH on board.


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## bigbaldguy (Oct 21, 2012)

mycrofft said:


> FOG hint #1: bystanders call everything from waking up from a faint to a grand mal, to orgasm, a seizure.



Awesomely quotable


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## EMSrush (Oct 21, 2012)

I understand that ETOH will potentiate the effects, but this is the first time I've seen apnea. Was just looking for some feedback on experiences.


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## usalsfyre (Oct 21, 2012)

EMSrush said:


> 5mg IM. ETOH on board.



ETOH changes the while equation. A bit on how benzodiazepines work...

Benzo's work on the GABA receptor sites. That is NOT to say the directly activate the sites...you'll see why this is important in a second. A benzodiazepine increases the binding potential of the GABAa neurotransmitter, thereby increasing GABA activity and inhibitory action. Alone, this is VERY safe, as its action is limited by the amount of endogenous GABAa you have floating around. You'll get to a point where it doesn't matter how much more medication you give, there's not enough neurotransmitter to depress things anymore. However...

There ARE compounds that directly activate the GABA receptor, one of the more common ones being ethanol. As such if your intoxicated patient consumes a benzo, not only does he have his own GABAa to worry about, he's got a whole crapload of extra stuff that directly acts on that receptor floating around to knock him further towards a coma.

Most "benzodiazepine" ODs are really polysubstance ODs.


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## Aidey (Oct 21, 2012)

usalsfyre said:


> ETOH changes the while equation. A bit on how benzodiazepines work...
> 
> Benzo's work on the GABA receptor sites. That is NOT to say the directly activate the sites...you'll see why this is important in a second. A benzodiazepine increases the binding potential of the GABAa neurotransmitter, thereby increasing GABA activity and inhibitory action. Alone, this is VERY safe, as its action is limited by the amount of endogenous GABAa you have floating around. You'll get to a point where it doesn't matter how much more medication you give, there's not enough neurotransmitter to depress things anymore. However...
> 
> ...




The moral of the story? Always eat Chinese food before getting drunk and taking your xanax.


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## Jon (Oct 21, 2012)

I had it happen once. Gave a full 5mg for sedation for pacing.

10 minutes later, patient goes from alert and oriented to unresponsive and apneic. Not proud, but I kinda freaked out. Didn't really occur to me that the apnea was related to the versed.

Lesson? Don't give lots of Versed. It's far easier to add more than try to take it away.


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## EMSrush (Oct 21, 2012)

usalsfyre said:


> ETOH changes the while equation. A bit on how benzodiazepines work...
> 
> Benzo's work on the GABA receptor sites. That is NOT to say the directly activate the sites...you'll see why this is important in a second. A benzodiazepine increases the binding potential of the GABAa neurotransmitter, thereby increasing GABA activity and inhibitory action. Alone, this is VERY safe, as its action is limited by the amount of endogenous GABAa you have floating around. You'll get to a point where it doesn't matter how much more medication you give, there's not enough neurotransmitter to depress things anymore. However...
> 
> ...



Thank you so much for this. I just had an "a-ha!" moment after reading what you wrote. I had a psych Pt to transport, who remained absolutely combative, despite somewhere in the range of 30-35mgs of Versed given PTA. I never knew what, if any medications she was already on, but I couldn't believe how active she was, despite the Versed. She was literally eating her way out of restraints when we arrived to pick her up. Before we left, because things still weren't under control enough to transport the Pt safety, an RN gave an additional 5 of Versed. I remember saying to myself, "Gees... like another 5mg is going to help at this point..?" No surprise, the extra 5 did nothing for the Pt.

So I take it we were out of neurotransmitters to cause any further effect on this psych Pt. I believe she had been given some Ativan too, around 5mg. I could not, and I cannot figure out why the pharmaceutical interventions didn't even touch her.

On another note, I wonder why ETOH in itself is not a contraindication to the administration of Versed. It is used cautiously here, considering that a good portion of our dangerous psych Pts are already ETOH+. With regard to ETOH intoxication, I wonder at what point, if any, is Versed no longer an option.


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## Aidey (Oct 21, 2012)

Versed is always an option if you have a way to control the airway.


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## Frozennoodle (Oct 22, 2012)

Idk if anyone has said this but the fluid bolus recommended for hyperglycemia is for dehydration secondary to glucose drawing water into the vasculature and then into the kidneys for elimination.  Oncotic pressure and what not.  It's not for sugar dilution.  The amount of fluid required to dilute CBG would likely kill the patient and since this guy isn't producing urine he's not losing fluid and net flirtation is probably causing edema in bad places.  This man needs dialysis, insulin, and common sense!  IV, o2, monitor for potential dysrthmia, transport.  Treat seizures as needed per protocol and restrain for combative behavior.  Also, don't forget to check the pupils!


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## Melclin (Oct 22, 2012)

Linuss said:


> I *premeditated* my RSI patients with 250 of fentanyl and they went out, almost negating etomidate.



If they meditate really well before you tube them, do you even need drugs? 





usalsfyre said:


> I HAVE seen a lot of respiratory rates to down significantly, but mostly this was simply a return to an acceptable range, no apnea observed



This.

I have limited experience with benzos and reasonable experience with opiates and I would say this of both. 

Anecdotally, usually the stories that start with "I gave this dude some midaz/morph/fent/Nitro and he totally pegged out on me", finish with me trying to politely hint that just because you are technically _allowed_ to give a particular drug at a certain dose, doesn't make that drug or that dose the most appropriate. 

Incidentally, I'm also a big fan of fentanyl as a mild sedative. Especially in children. If the local muay thai champion is trying beat my head in with my own foot, they will promptly become the owner of a sizeable portion of midaz. However, for the average mildly agitated pt who needs to chill out, esp when its medically related mild agitation and not because they disagree with my face being this shape (it should be obvious, but I'll say it anyway. If their agitation is because they're in pain or might be in pain but cannot express it, then fentanyl is also the way to go). I've never considered it in larger doses for major agitation. Not a bad idea, but aren't larger single doses of fent more closely associated with diaphramatic rigidity?


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## Akulahawk (Oct 22, 2012)

The few times I've given diazepam, Ativan, or midaz, I never saw apnea if that's the only substance on board. I'd expect that could occur far more readily if given with an opiate or if there was ETOH on board, as discussed above.


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