# Versed dosing for RSI



## Aidey (Oct 9, 2013)

If Versed is in your RSI protocol, what dose are you using?


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## Tigger (Oct 9, 2013)

Not sure if you mean for post-procedure sedation or as a replacement for etomidate, both are in the protocols though the latter is rarely if ever used. 

For sedation 2mg over 2 minutes for patients 13-55yo, max of 4mgs. If used with fentanyl the dose is halved. 

If etomidate is not available Versed can be given at 0.1 mg/kg prior to giving succinylcholine.


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## Aidey (Oct 9, 2013)

If etomidate isn't available is there a max dose?


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## Tigger (Oct 9, 2013)

I believe that is the maximum dose.


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## Christopher (Oct 9, 2013)

Tigger said:


> I believe that is the maximum dose.



We have the 1-2-3 rule in effect for RSI dosing:

0.1 mg/kg Midazolam
2 mg/kg Succinylcholine
0.3 mg/kg Etomidate

Also in our local 1-2-3 rule is 1 mg/kg Rocuronium (I don't know why they didn't do 1.2) and 2 mg/kg Ketamine (although we don't have it).


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## blindsideflank (Oct 9, 2013)

0.1mg/kg some say to a max of 5mg

Maintenance 0.05mg/kg ( and I time it prn)


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## lightsandsirens5 (Oct 9, 2013)

I've got it for PIM. Up to 5mg. Though I miss my Ativan. I like that stuff much better for...well, everything.

Not sure why I would ever need to use Versed as an "induction" agent as I have both Etomidate and Ketamine at my disposal for that. 0.3mg/kg and 1.5mg/kg, respectively.


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## Carlos Danger (Oct 9, 2013)

blindsideflank said:


> 0.1mg/kg some say to a *max of 5mg*





lightsandsirens5 said:


> I've got it for PIM. *Up to 5mg.* Though I miss my Ativan. I like that stuff much better for...well, everything.



This is why I hate seeing versed used for induction....people rarely give doses that even begin to approach adequate. 5 mg isn't even close to the amount of versed needed to induce anesthesia in a decent sized (80 kg+) adult. I couldn't even imagine giving 5mg of versed to a conscious person and then pushing a NMB.

0.2 - 0.35 mg/kg is a much more appropriate dose range, IMO.


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## Christopher (Oct 9, 2013)

Halothane said:


> This is why I hate seeing versed used for induction....people rarely give doses that even begin to approach adequate. 5 mg isn't even close to the amount of versed needed to induce anesthesia in a decent sized (80 kg+) adult. I couldn't even imagine giving 5mg of versed to a conscious person and then pushing a NMB.
> 
> 0.2 - 0.35 mg/kg is a much more appropriate dose range, IMO.



Yeah, the lack of a max seems to be our systems' way of saying, "you'll need a lot". Although I haven't heard of a time where it was used for induction pre-hospitally.


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## EMT B (Oct 9, 2013)

The flight surgeon on my pedi trauma the other day used 2mg versed 50mg fentanyl to induce


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## NomadicMedic (Oct 9, 2013)

EMT B said:


> The flight surgeon on my pedi trauma the other day used 2mg versed 50mg fentanyl to induce



How big was the kid?


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## EMT B (Oct 9, 2013)

about 21kg i transported to the LZ so he hadn't gotten any pain meds on board yet


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## VFlutter (Oct 9, 2013)

We use 2-4mg of versed for moderate sedation during cardiac Caths. I can't imagine trying to RSI someone with 5mg.


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## Carlos Danger (Oct 9, 2013)

EMT B said:


> about 21kg i transported to the LZ so he hadn't gotten any pain meds on board yet



That works out to about .1 mg/kg which seems inadequate to me (though the 2 mcg/kg of fentanyl certainly would have helped some), but it's still a much better dose than 5 mg for a 100 kg patient, which works out to about half what this kid got, per kg.


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## EMT B (Oct 9, 2013)

what do you think he should have gotten? maybe thats not all he got, maybe he got more in the chopper?

thats still a decent amt. thats like giving a 105kg pt 10mg....


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## Christopher (Oct 9, 2013)

EMT B said:


> what do you think he should have gotten? maybe thats not all he got, maybe he got more in the chopper?
> 
> thats still a decent amt. thats like giving a 105kg pt 10mg....



0.1 mg/kg - 0.3 mg/kg is the textbook range for induction, although >0.1 mg/kg produces moderate hypotension (~20% drop in SBP). However, the lower dose may produce less than adequate sedation.

I seem to remember a paper (but cannot find it) which noted that ED's routinely gave 0.05 mg/kg midazolam for induction due to mistaking the conscious sedation dose for the induction dose!


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## NomadicMedic (Oct 9, 2013)

0.2ng/kg of versed is our sedation dose for peds, and 0.3mg/kg of etomidate for pedi RSI. I haven't had to RSI a kid, and hope I don't have to. Curious why the doc chose  to use versed over etomidate or ketamine.


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## blindsideflank (Oct 9, 2013)

We aren't talking versed only are we?

Versed and opiates have a synergistic effect so that 4 of versed used for cath is different. I've given 30 of morphine for gall stones (I don't believe the biliary spasm) and the person is still conscious but I guarantee if I added 2 of versed he would be out.


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## EMT B (Oct 9, 2013)

DEmedic said:


> 0.2ng/kg of versed is our sedation dose for peds, and 0.3mg/kg of etomidate for pedi RSI. I haven't had to RSI a kid, and hope I don't have to. Curious why the doc chose  to use versed over etomidate or ketamine.



not sure..im just a scrub emt ^_^


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## FiremanMike (Oct 9, 2013)

I really dislike versed for induction or even pre induction, there are so many better options.  My order of preference is ketamine then etomidate, each has their ups and downs and times when one is better than the other.  For paralyzing I prefer 0.6mg/kg of roc over succs, but either will do.  For post intubation I like to alternate 2-2.5 of versed and 50 of fent, seems to work well to keep the patient snowed enough to not remember but awake enough to breath on their own.  Of course if you don't have a vent with SIMV, then vec post intubation seems like a better choice.


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## EMT B (Oct 9, 2013)

who actually carries the drug to reverse sux in the field?


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## VFlutter (Oct 9, 2013)

EMT B said:


> who actually carries the drug to reverse sux in the field?



Who carries Romazicon?


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## EMT B (Oct 9, 2013)

maybe? im not sure what it is. the cct medic at my squad down at school doesn't like to use succs for RSI because he said that the companies he works for dont have the drug to reverse its effects


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## STXmedic (Oct 9, 2013)

EMT B said:


> maybe? im not sure what it is. the cct medic at my squad down at school doesn't like to use succs for RSI because he said that the companies he works for dont have the drug to reverse its effects



To my knowledge, there isn't a drug to reverse succinylcholine... Suggamadex is the reversal agent for agents like Vec and Roc, but I don't know how readily available it is (or if its even FDA approved yet...).

I hope nobody is carrying Romazicon...


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## EMT B (Oct 9, 2013)

well theres the answer. my mom said there is no antidote. it is metabolized by an enzyme called pseudocholinesterase. one of the reasons she things sux is dangerous and doesnt like to use it is because if someone is pseudocholinesterase deficient, the drug doesn't get metabolized for a LONG time.

Edit: Shes a former Critical Care Tech, current CRNA


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## MSDeltaFlt (Oct 9, 2013)

EMT B said:


> well theres the answer. my mom said there is no antidote. it is metabolized by an enzyme called pseudocholinesterase. one of the reasons she things sux is dangerous and doesnt like to use it is because if someone is pseudocholinesterase deficient, the drug doesn't get metabolized for a LONG time.
> 
> Edit: Shes a former Critical Care Tech, current CRNA



The worst side effect of succinylcholine is malignant hyperthermia.  Antidote?  Dantrolene.  Where can you get Dantrolene?  Surgery.  Can't use Succs in surgery without it.


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## blindsideflank (Oct 9, 2013)

Perhaps he meant neostigmine (and subsequently glycopyrrolate ) for ndnmba like rocoronium? It has to already be wearing off before you can reverse it.
Suggamedex is also for roc and rapid acting (and I think expensive), maybe we will see it. It's used in some provinces here I think (by anesthetists)


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## EMT B (Oct 9, 2013)

maybe antidote was the wrong word. i was thinking more along the lines of naloxone reverses narcotics


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## triemal04 (Oct 10, 2013)

Chase said:


> EMT B said:
> 
> 
> > who actually carries *the drug to reverse sux* in the field?
> ...


Somebody needs to brush up on their pharmacology...:rofl:


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## Christopher (Oct 10, 2013)

triemal04 said:


> Somebody needs to brush up on their pharmacology...:rofl:



I doubt very seriously Chase confused the two, instead asking a different question to make a point.

Besides I do not believe there is a reversal agent for succ akin to sugammadex for roc. Edrophonium and neostigmine can indirectly shorten succ time (phase II issues if memory serves), but nothing like sugammadex.


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## VFlutter (Oct 10, 2013)

triemal04 said:


> Somebody needs to brush up on their pharmacology...:rofl:



Ya, I was trying to make a point since the original topic was Versed. I do not think there is a need for it in EMS but I was curious if anyone carried it. It usually causes more problems than it solves but it does have it uses in extreme cases. I guess if you are using high dose Benzos as your main RSI drug then it might be a consideration.

I have only given Romazicon once during a code.


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## usalsfyre (Oct 10, 2013)

I'll say this with the disclaimer that I'm well aware there are numerous exceptions to the rule, BUT

If you're going into a field RSI and "let the patient wake up and breathe on their own" is a viable option for a failed intubation I SERIOUSLY worry about your candidate selection.


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## FiremanMike (Oct 10, 2013)

MSDeltaFlt said:


> The worst side effect of succinylcholine is malignant hyperthermia.  Antidote?  Dantrolene.  Where can you get Dantrolene?  Surgery.  Can't use Succs in surgery without it.



While probably not considered a "side effect", in my mind the most dangerous effect of succs would be death in patients who are already hyperkalemic prior to administration, as evidenced by lab values or burns over 24 hours, evidence of rhabdo, etc.. (in fairness, I've heard anecdotally that this is blown out of proportion)

But alas, somehow this discussion has led us to succs.  Since it has, can I get a "goooooooo rocuronium" and a "down with succs" from my homies?


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## Carlos Danger (Oct 10, 2013)

blindsideflank said:


> We aren't talking versed only are we?
> 
> Versed and opiates have a synergistic effect so that 4 of versed used for cath is different. I've given 30 of morphine for gall stones (I don't believe the biliary spasm) and the person is still conscious but I guarantee if I added 2 of versed he would be out.



I don't know about that. Their actions are synergistic but it's not necessarily that dramatic. Of course it depends on the patient and the situation, but generally if someone is tolerating 30mg of morphine well, I would probably not expect them to go "out" with the addition of just 2 of versed.

What do you mean you don't "believe" the biliary spasm?




FiremanMike said:


> can I get a "goooooooo rocuronium" and a "down with succs" from my homies?



Meh, I think sux is a great drug and the side effects / risks are blown out of proportion.

There are some populations that it shouldn't be used in, but outside of that I think the benefits easily outweigh the risks in the vast majority of emergent patients. 

In the OR with an elective patient it's a different ballgame. But in the field with a critical patient, sux is definitely where it's at.


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## VFlutter (Oct 10, 2013)

Halothane said:


> I don't know about that. Their actions are synergistic but it's not necessarily that dramatic. Of course it depends on the patient and the situation, but generally if someone is tolerating 30mg of morphine well, I would probably not expect them to go "out" with the addition of just 2 of versed..



Our usual dosing is 2-4mg Versed and 50-100 Fentanyl. Patients are generally very comfortable but arousable enough to answer simple questions. I rarely have patients "go out".


On a side note the CRNA in the Cath Lab seems to have it made. Providing sedation for TEE/Cardioversions all day with the occasional RSI during a Cath.


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## FiremanMike (Oct 10, 2013)

Halothane said:


> Meh, I think sux is a great drug and the side effects / risks are blown out of proportion.
> 
> There are some populations that it shouldn't be used in, but outside of that I think the benefits easily outweigh the risks in the vast majority of emergent patients.
> 
> In the OR with an elective patient it's a different ballgame. But in the field with a critical patient, sux is definitely where it's at.



<shrug> to me, succs is a great drug but has scenarios where it absolutely cannot be used.  Roc is a great drug that doesn't really have any scenarios where it can't be used (that I'm aware of).  I'd rather have a drug that gives me one less thing to think about, and roc does that.


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## blindsideflank (Oct 10, 2013)

Halothane said:


> What do you mean you don't "believe"



Poor wording on my part. I was just mentioning that I feel morphine is appropriate for pain control on gall stones 

And I agree, sux effects are overhyped in situations like burns (hyperkalemia) malignant hyperthermia, etc.


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## Aidey (Oct 10, 2013)

Ok, since this is my thread I'm going to be snippy and picky. I'm looking for versed doses period. Not opinions on the best RSI drugs or anything else about RSI or sedation. If you use high dose, I especially want to hear from you.


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## VFlutter (Oct 10, 2013)

blindsideflank said:


> Poor wording on my part. I was just mentioning that I feel morphine is appropriate for pain control on gall stones .



Appropriate, maybe. But most effective or best practice, No. 

Why snow a patient with 30mg of Morphine when you can get better pain management with other options? I have had many patients get 1-2mg of Dilaudid from EMS or the ER with minimal relief and then finally get Benytl or IV Toradol on the floor with nearly complete relief. 

And if you really want to use Opiods then Dermol is a better choice IMO due to the possible antispasmodic effects.

And if IRRC Morphine may actual increase sphincter tone and cause worsening spasms.


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## FiremanMike (Oct 11, 2013)

Aidey said:


> Ok, since this is my thread I'm going to be snippy and picky. I'm looking for versed doses period. Not opinions on the best RSI drugs or anything else about RSI or sedation. If you use high dose, I especially want to hear from you.



Ok, fair enough..


We used to just use versed and etomidate.  Our dose was 2mg of versed followed by 0.3mg/kg of etomidate (max of 20mg......).  When it worked, it did fine, when it didn't it was because they were under dosed on etomidate and needed more.

I currently work under a protocol that allows versed as a third line to etomidate and ketamine, it's dose is also 0.3mg/kg (no max).


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## Aprz (Oct 11, 2013)

Chase said:


> Ya, I was trying to make a point since the original topic was Versed. I do not think there is a need for it in EMS but I was curious if anyone carried it. It usually causes more problems than it solves but it does have it uses in extreme cases. I guess if you are using high dose Benzos as your main RSI drug then it might be a consideration.
> 
> I have only given Romazicon once during a code.


I'll bite. We carry it, but on CCT for IFT, and I've never seen it used. I only what it is used for, reversal of benzodiazepine (eg Midazolam (Versed), Diazepam (Valium), Lorazepam (Ativan)), and I think the dose 1st attempt 0.2 mg/kg over 15 seconds, 2nd attempt 0.3 mg/kg over 30 seconds, and 3rd attempt 0.5 mg/kg over 30 seconds.

I've heard it's bad, but when I asked why, I was told "cause it just is, trust me". I've never really been told or know why Flumazenil (Romazicon) is really bad? What's really the con with it? I get we can just ventilate the patient if they are hypoventilating if they are overdosed on a benzo, and it's contraindicated if you are trying to reverse it for somebody who has overdosed on multiple drugs (likely intentionally, they don't want it to be pushed similarly to naloxone (narcan)).


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## Carlos Danger (Oct 11, 2013)

Aprz said:


> I've heard it's bad, but when I asked why, I was told "cause it just is, trust me". I've never really been told or know why Flumazenil (Romazicon) is really bad? What's really the con with it? I get we can just ventilate the patient if they are hypoventilating if they are overdosed on a benzo, and it's contraindicated if you are trying to reverse it for somebody who has overdosed on multiple drugs (likely intentionally, they don't want it to be pushed similarly to naloxone (narcan)).



I bet most of the people who say "flumazenil is bad - trust me" have never used it, and are just repeating the urban legends that were passed down to them.

Just like nalaxone and _every_ other med, flumazenil is not inherently "good" or inherently "bad". It is a chemical with indications, contraindications, precautions, and adverse effects. When used inappropriately it can be harmful. When used properly it can be potentially life saving. Remember that intubation and mechanical ventilation carry significant risks, too, especially in the field.

The big things to keep in mind about flumazenil that might get people into trouble are that it doesn't last as long as some of the benzos - meaning re sedation can occur after it wears off - and if the benzos were given for seizures and you then use flumazenil to reverse the benzos, then seizures can start again if no other anti-seizure meds were given.



Aidey said:


> Ok, since this is my thread I'm going to be snippy and picky. I'm looking for versed doses period. Not opinions on the best RSI drugs or anything else about RSI or sedation.* If you use high dose, I especially want to hear from you.*



What do you mean by "high dose"? 

I previously had midazolam in my protocols as an option (or adjunct) for induction. The dose was 0.15 - 0.3 mg/kg, if I recall correctly. I use midazolam on a daily basis and have access to many anesthesia and pharm references, so I might be able to help you find the specific info you are looking for.


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## Aidey (Oct 11, 2013)

Halothane said:


> What do you mean by "high dose"?
> 
> I previously had midazolam in my protocols as an option (or adjunct) for induction. The dose was 0.15 - 0.3 mg/kg, if I recall correctly. I use midazolam on a daily basis and have access to many anesthesia and pharm references, so I might be able to help you find the specific info you are looking for.



That qualifies. Anything where the pt gets say more than 2mg as an induction dose.


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## Christopher (Oct 11, 2013)

Halothane said:


> I bet most of the people who say "flumazenil is bad - trust me" have never used it, and are just repeating the urban legends that were passed down to them.
> 
> Just like nalaxone and _every_ other med, flumazenil is not inherently "good" or inherently "bad". It is a chemical with indications, contraindications, precautions, and adverse effects. When used inappropriately it can be harmful. When used properly it can be potentially life saving. Remember that intubation and mechanical ventilation carry significant risks, too, especially in the field.
> 
> The big things to keep in mind about flumazenil that might get people into trouble are that it doesn't last as long as some of the benzos - meaning re sedation can occur after it wears off - and if the benzos were given for seizures and you then use flumazenil to reverse the benzos, then seizures can start again if no other anti-seizure meds were given.



I'm reminded of Kreshak's review of 10 years of poison control data, with 904 patients receiving flumazenil. 13 ended up seizing, and one died (causal? possibly).

Most likely cause of seizing after flumazenil administration? Coingestion or presence of pro-convulsant medications.

I rank Kreshak's article up there with Levine's "Stone Heart" myth buster.


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## Aprz (Oct 11, 2013)

So in the end, Flumazenil (Ramazicon) is probably not as bad as what people make it sound? Pretty much indicated for people you want to wake up/have breathing on their own if given solely too much of a benzodiazepine. May have shorter half life than the benzodiazepine, and problems the patient had prior to having the benzodiazepine, may reoccur.


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## Smash (Oct 12, 2013)

Aprz said:


> I'll bite. We carry it, but on CCT for IFT, and I've never seen it used. I only what it is used for, reversal of benzodiazepine (eg Midazolam (Versed), Diazepam (Valium), Lorazepam (Ativan)), and I think the dose 1st attempt 0.2 mg/kg over 15 seconds, 2nd attempt 0.3 mg/kg over 30 seconds, and 3rd attempt 0.5 mg/kg over 30 seconds.
> 
> I've heard it's bad, but when I asked why, I was told "cause it just is, trust me". I've never really been told or know why Flumazenil (Romazicon) is really bad? What's really the con with it? I get we can just ventilate the patient if they are hypoventilating if they are overdosed on a benzo, and it's contraindicated if you are trying to reverse it for somebody who has overdosed on multiple drugs (likely intentionally, they don't want it to be pushed similarly to naloxone (narcan)).



You sir, are awarded eleventy billion internets for the use of proper drug names.  God bless you.


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