# Rapid Dosing of meds in RSI



## Craig Alan Evans (Sep 1, 2012)

What are everyone's thoughts on this method of dosing for RSI?

http://craigalanevans.blogspot.com/2012/09/rsi-part-1rapid-dosing-for-rsismlxl.html


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## Veneficus (Sep 1, 2012)

I like it.

The only thing I would change is the small adult weight from 60kg to 70kg.


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## usalsfyre (Sep 1, 2012)

I do something similar. Small adults gets 150mcg of fent and 20mg of etomidate, average 200 and 30, and large 250 and 40. Nearly everyone gets 150mg of sux or 10mg of rocc  (simply to facilitate a fast onset) and a 5-10mg chaser of midaz. 

I use the syringe idea as well, but I tend to mix my narcs in flushes, so I've got to be a bit careful there.


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## NYMedic828 (Sep 1, 2012)

I've done something similar, in my dreams because NYC has garbage protocols.

Fentanyl hasn't been opened once in all of NYC for an actual patient.


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## Craig Alan Evans (Sep 1, 2012)

That's too bad NY. I'm sure you see far more patients that need it than I do.


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## usalsfyre (Sep 1, 2012)

Craig Alan Evans said:


> That's too bad NY. I'm sure you see far more patients that need it than I do.



Craig, have y'all switched to etomidate for induction?


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## Craig Alan Evans (Sep 1, 2012)

Yes, we still use versed post intubation but initially it 's Etomidate .3mg/kg


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## Craig Alan Evans (Sep 1, 2012)

Kyle,

We have also started using Ketamine to control combative psychotic patients.  Works like a dream.  We used to throw buckets of Versed, Benadryl, and Haldol  and they took a goo nap later but it never controlled the acute behavior.  One dose of Ketamine and they start starring at the walls.  It's a life saver.


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## Aidey (Sep 1, 2012)

usalsfyre said:


> I do something similar. Small adults gets 150mcg of fent and 20mg of etomidate, average 200 and 30, and large 250 and 40. Nearly everyone gets 150mg of sux or 10mg of rocc  (simply to facilitate a fast onset) and a 5-10mg chaser of midaz.
> 
> I use the syringe idea as well, but I tend to mix my narcs in flushes, so I've got to be a bit careful there.



Have I ever mentioned how much I hate you? :angry:


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## Craig Alan Evans (Sep 1, 2012)

Don't be bitter!


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## Aidey (Sep 1, 2012)

We've been out of etomidate for months. I can't give fentanyl with versed and Roc is only allowed to be used in patients with absolute contraindications to sux. I'm allowed to hate him


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## Craig Alan Evans (Sep 1, 2012)

LMAO. I concur.


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## Handsome Robb (Sep 1, 2012)

I like it. 

No RSI for Nevada paramedics though. Unless you're in the middle of BFE then maybe, mostly what I've seen is Etomidate and a prayer that they don't trismus out.


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## Craig Alan Evans (Sep 1, 2012)

That's too bad NV. Not using a paralytic increases the difficulty of the intubation tremendously.


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## NomadicMedic (Sep 1, 2012)

Our formula is pretty simple. Evey RSI gets 20mg of Etomidate, 2mg/kg of Sux. Up to 100mcg of Fent... Then 0.1mg/kg vec and up to 10mg of versed. 

Adults are either 70kg or 100kg. They come in big or small.  That makes it simple.


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## Craig Alan Evans (Sep 1, 2012)

Sounds very similar.


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## NomadicMedic (Sep 1, 2012)

Great minds?


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## NYMedic828 (Sep 1, 2012)

Craig Alan Evans said:


> That's too bad NV. Not using a paralytic increases the difficulty of the intubation tremendously.



Had a patient react to etomidate with trismus 2 weeks ago... 

What a waste to even have our "sedation" protocols. We don't have paralytics and the strictness behind our narcotics turns most people off from even attempting to get orders.

Things like this is what keeps EMS a taxi service because "we may as well just go to the hospital and let them do it." Results in us doing well, nothing but being a taxi that takes vitals...


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## Doczilla (Sep 2, 2012)

Craig Alan Evans said:


> Kyle,
> 
> We have also started using Ketamine to control combative psychotic patients.  Works like a dream.  We used to throw buckets of Versed, Benadryl, and Haldol  and they took a goo nap later but it never controlled the acute behavior.  One dose of Ketamine and they start starring at the walls.  It's a life saver.



Did we just become best friends? 

Wanna do karate in my garage?


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## Doczilla (Sep 2, 2012)

NYMedic828 said:


> Had a patient react to etomidate with trismus 2 weeks ago...
> 
> What a waste to even have our "sedation" protocols. We don't have paralytics and the strictness behind our narcotics turns most people off from even attempting to get orders.
> 
> Things like this is what keeps EMS a taxi service because "we may as well just go to the hospital and let them do it." Results in us doing well, nothing but being a taxi that takes vitals...



Lol poor guy. Might as well bring ether to work.


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## Merck (Sep 2, 2012)

n7lxi said:


> Our formula is pretty simple. Evey RSI gets 20mg of Etomidate, 2mg/kg of Sux. Up to 100mcg of Fent... Then 0.1mg/kg vec and up to 10mg of versed.
> 
> Adults are either 70kg or 100kg. They come in big or small.  That makes it simple.



I just can't get on board with a one-size-fits-all approach to airway management.  I advocate for appropriate drugs, appropriate knowledge, some experience, and then the freedom to choose the most appropriate method of induction/intubation for a particular patient.

Up to 100mcg of fentanyl isn't much analgesia, especially if you're then going to a longer-acting paralytic and just midaz.  Can you give more fent post-intubation?  And can you just use vec if you want or do you have to use sux?


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## NomadicMedic (Sep 2, 2012)

You may add more fent after a consult, the 100mcg is what is in the RSI standing orders. We only use the vec as a paralytic for anticipated long transports (the helo). And sux is the only paralytic allowed for the initial intubation. 

Do I wish we carried Roc as well? Yes. Do I wish we used Ketamine as an induction med? YES!

However, this sedation/paralytic algorithm works well for most of our adult RSI cases, and for those that may require a deviation, our docs are very flexible with medics making changes, as long as they can justify why they want to go off the page. With more and more services losing RSI, and even basic intubation, having any flexibility in protocols is a good thing. Having medics smart enough to identify these situations is even better.


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## Veneficus (Sep 2, 2012)

Doczilla said:


> Lol poor guy. Might as well bring ether to work.



Would probably work better actually.


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## Merck (Sep 2, 2012)

Nice to hear there's some leeway. I consider the SAH or similar situation. Sleepy-time drugs are fine but there must still be one hell of a headache. I get especially nervous with long-acting patalytics. Analgesia=good in my books. But then, I've actually heard the line from the sending facility, "yep, he's being sedated with pavulon"......


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## usalsfyre (Sep 2, 2012)

Craig Alan Evans said:


> Yes, we still use versed post intubation but initially it 's Etomidate .3mg/kg



When I left it was still Versed and sux only. 

The crazy thing is I'm actually using fent and midazolam more often than etomidate due to the patient population I RSI now.


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## usalsfyre (Sep 2, 2012)

Craig Alan Evans said:


> Kyle,
> 
> We have also started using Ketamine to control combative psychotic patients.  Works like a dream.  We used to throw buckets of Versed, Benadryl, and Haldol  and they took a goo nap later but it never controlled the acute behavior.  One dose of Ketamine and they start starring at the walls.  It's a life saver.



Working on getting ketamine protocols written and approved at the moment, I'm hoping to do a Nov-Dec rollout. I've heard more good things about ketamine than any drug in recent memory.


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## Veneficus (Sep 2, 2012)

Merck said:


> I just can't get on board with a one-size-fits-all approach to airway management.  I advocate for appropriate drugs, appropriate knowledge, some experience, and then the freedom to choose the most appropriate method of induction/intubation for a particular patient.
> 
> Up to 100mcg of fentanyl isn't much analgesia, especially if you're then going to a longer-acting paralytic and just midaz.  Can you give more fent post-intubation?  And can you just use vec if you want or do you have to use sux?



I must fully agree with this.

First, if you are using RSI, you generally know what you are doing, why, have some experience, and hopefully some considerable QA/QI.

It seems the very nature of taking highly advanced prehospital providers, such as those capable of RSI, and restricting them to a formula is self defeating. 

But that gets me started on my anti-protocol podium so I won't go there.

I understand the use of succs is selected more for its duration than actual purpose, which is to reduce the amount of opioids for anesthesia. 

Some might argue that you are not inducing anesthesia, but if that is the case, what is the point of a sedative with a pain reliever?


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## AeroClinician (Sep 10, 2012)

Craig Alan Evans said:


> Yes, we still use versed post intubation but initially it 's Etomidate .3mg/kg



I have given Etomidate so much that I made my own street formula for it ---->  3mgs for every 10kgs the pt. weighs.

Example: 80kg pt. gets 24mgs

Its accurate and hard to mess up when your tubing someone at 2am. :beerchug:


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## usalsfyre (Sep 10, 2012)

Firehazmedic said:


> I have given Etomidate so much that I made my own street formula for it ---->  3mgs for every 10kgs the pt. weighs.
> 
> Example: 80kg pt. gets 24mgs
> 
> Its accurate and hard to mess up when your tubing someone at 2am. :beerchug:



Doesn't that pretty much match the 0.3mg/kg guideline that's the standard dosing? Not to mention its a pain to draw up something like 27mgs for say a 90kg patient?


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## AeroClinician (Sep 10, 2012)

usalsfyre said:


> Doesn't that pretty much match the 0.3mg/kg guideline that's the standard dosing? Not to mention its a pain to draw up something like 27mgs for say a 90kg patient?



Yes, that's what makes it great. I am saying its easier mental math to do it that way without pulling out the pen and paper. When your Etomidate is provided in a 20cc prefilled syringe with 40mgs, it's easy to give 13.5mLs and achieve 27mgs. How is that difficult?


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## Aidey (Sep 10, 2012)

Well, frankly, moving the decimal point one place over isn't all that mind blowing.


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## usalsfyre (Sep 10, 2012)

Firehazmedic said:


> Yes, that's what makes it great. I am saying its easier mental math to do it that way without pulling out the pen and paper. When your Etomidate is provided in a 20cc prefilled syringe with 40mgs, it's easy to give 13.5mLs and achieve 27mgs. How is that difficult?



Probably because 20ml syringes (at least the ones I've used) don't tend to have half ml marks. Furthermore since the dosing range is 0.1-0.6 why not just give 30 and make it really easy?


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## AeroClinician (Sep 10, 2012)

usalsfyre said:


> Probably because 20ml syringes (at least the ones I've used) don't tend to have half ml marks. Furthermore since the dosing range is 0.1-0.6 why not just give 30 and make it really easy?



Don't need half mL marks, just approximate inbetween the 2 marks. The reason why is because Etomidate can cause ARDS in the pt's recovery later. So I want to give as little as I can to help minimize it.


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## AeroClinician (Sep 10, 2012)

Aidey said:


> Well, frankly, moving the decimal point one place over isn't all that mind blowing.



Some don't know this.... I have seen a medic pull out a pen and paper to calculate Etomidate on scene.


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## Aidey (Sep 10, 2012)

Just because some people are complete idiots does not mean that something normal suddenly becomes brilliant.


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## usalsfyre (Sep 10, 2012)

Firehazmedic said:


> Don't need half mL marks, just approximate inbetween the 2 marks. The reason why is because Etomidate can cause ARDS in the pt's recovery later. So I want to give as little as I can to help minimize it.



Do you understand the mechanism by which etomidate is going to possibly cause ARDS? 3mgs isn't going to make that big of a difference. The big thing is watching the patient population your using it in and selecting a different agent in poor candidates.


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## AeroClinician (Sep 11, 2012)

usalsfyre said:


> Do you understand the mechanism by which etomidate is going to possibly cause ARDS? 3mgs isn't going to make that big of a difference. The big thing is watching the patient population your using it in and selecting a different agent in poor candidates.



Study --->http://www.ncbi.nlm.nih.gov/m/pubmed/19590307/


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## AeroClinician (Sep 11, 2012)

Aidey said:


> Just because some people are complete idiots does not mean that something normal suddenly becomes brilliant.



Never claimed it was brilliant.....


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## usalsfyre (Sep 11, 2012)

Firehazmedic said:


> Study --->http://www.ncbi.nlm.nih.gov/m/pubmed/19590307/



I've seen the literature, but do you understand WHY it impacts ARDS rates and why it may be better to chose a different agent in the septic and severe trauma patient, what those agents may be and what can be done post induction to counteract etomidate administration? Shaving 3mgs off your dose isn't going to help, avoiding etomidate entirely will.


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