# Sedation/Anesthesia in the Field



## Fox800 (Oct 26, 2010)

Just curious if you guys are allowed to give medications such as etomidate, ketamine (or anything similar) to manage a patient with severe injuries to induce amnesia/unconsciousness. The scenario I'm thinking of is an arm or leg "bent the wrong way" or a patient entrapped with severe injuries. I'd love to have something similar but at the moment my service doesn't.


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## Fox800 (Oct 26, 2010)

We do have midazolam and diazepam but according to our new protocols they are not authorized for anxiety or to induce amnesia (for midazolam). Only for seizures, violent patient sedation, induced hypothermia (post-ROSC), and sedation for cardioversion.


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## MrBrown (Oct 26, 2010)

Yes, we have a rapid sequence intubation program for Intensive Care Paramedics using fentanyl, ketamine, suxamethonium and vecuronium; they are also able to use midazolam for conscious sedation.

We also have PRIME Doctors capable of RSI (sort of like BASICS in the UK) who are able to anaesthetise and I suspect they would be more likely to knock somebody out for traumatic injury in the absense of neurological or oxygenation defecit since they have more medicolegal flexibility.


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## medic6578 (Oct 26, 2010)

We have all the meds you mentioned. Now for ROSC we give Rocs to stop shivering. W can give versed for anxiety.  Because of the shortages of sucs we only use rocs for RSI. Our Med director is pretty aggressive and let's us do just about everything without calling for orders which us great. More time pro-longing death and less time talking to the Doc on the box. 

Sent from my HTC-EVO


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## Melclin (Oct 26, 2010)

Not as such. 

However, you can just keep dropping morphine or fentanyl on the person until you don't have a problem pain wise. Then you deal with any conscious state/airway issues when you get to them. I suppose you are limited by BP.  

I have a picture in my head of attending a pt with severe, extensive burns and drawing 600mcg of fentanyl into a 60ml syringe and just keep pushing it slowly into a free flowing IV line until the pain drops off. After a quick chat to a more experienced paramedic on the radio of course. 

I'd be interested to what extent MICA have the ability do this and tube to deal with the airway consequences.


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## usalsfyre (Oct 26, 2010)

Fox800 said:


> Just curious if you guys are allowed to give medications such as etomidate, ketamine (or anything similar) to manage a patient with severe injuries to induce amnesia/unconsciousness. The scenario I'm thinking of is an arm or leg "bent the wrong way" or a patient entrapped with severe injuries. I'd love to have something similar but at the moment my service doesn't.



Nothing here, other than the note in our protocols that management of severe pain is an indication for RSI. 

In the case of the patient trapped I would think long and hard about going ahead and securing an airway while the patient was trapped as long as it could be safely/effectively done. Many of these patients crap out the moment they get disentangled, and your now behind the curve if you don't have one. With an airway secure I could give fentanyl till it ran out the patients ears with the only caveat of I must not completely knock out sympathetic stimulation. It's highly situation dependent though. 

Ketamine would seem to be ideal for the situation with the broken limb, but there's still a lot of people scared to death of it.


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## Melclin (Oct 26, 2010)

usalsfyre said:


> Ketamine would seem to be ideal for the situation with the broken limb, but there's still a lot of people scared to death of it.



I don't know that I'd care to use it in smaller analgesic doses without the option for the addition of some midaz. But I have no hands on experience with it. 

Anyone ever had trouble with ketamine analgesia?

Paging Doc Brown, some idiot paramedic call Oz has Ketamined a bi-lat femure fracture and now he's higher than you on promethazine. We need a doc for sedation.


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## MrBrown (Oct 26, 2010)

We use ketamine in low (10-20mg bolus) doses for analgesia and big (1.5mg/kg) doses for anaesthesia.

Now interestingly here you cannot give ketamine to somebody who has been given midaz but you can give midaz for post-ketamine sedation management.

I am not a fan of just pouring morphine into people hoping the pain goes away because the pain is likely to stay and thier blood pressure is the only thing thats going to go away.

After 20mg of morphine if it is having no effect then its time to try something else.

Oh and Oz you clean your own mess up, Brown is at his friends house in Box Hill making lunch.  If memory serves MICA 5 is just round the corner.


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## usalsfyre (Oct 26, 2010)

MrBrown said:


> We use ketamine in low (10-20mg bolus) doses for analgesia and big (1.5mg/kg) doses for anaesthesia.
> 
> Now interestingly here you cannot give ketamine to somebody who has been given midaz but you can give midaz for post-ketamine sedation management.
> 
> ...



Fent is a lot more hemodynamicly stable, and the patient's LOC will go away before B/P normally. 

My understanding of ketamine anaesthesia is that it doesn't induce unconsciousness so much as disassociation (please correct me if I'm wrong, it's a drug I'm only aware of, not intimately familiar with). This would seemingly be ideal for the situation stated above, as the patient could be awake and protecting their own airway, have an arm that hurt like hell, was bent the wrong way, but really doesn't give a crap and won't remeber it when the med wears off.


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## MrBrown (Oct 26, 2010)

Ketamine is not a traditional anaesthetic so to that end you are correct sir; it is an NMDA inhibitor whereas propofol for example inhibits GABA.

The result however is the same - the patient does not remember, which if Brown is treating them is a really good thing


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## Smash (Oct 26, 2010)

usalsfyre said:


> Fent is a lot more hemodynamicly stable, and the patient's LOC will go away before B/P normally.
> 
> My understanding of ketamine anaesthesia is that it doesn't induce unconsciousness so much as disassociation (please correct me if I'm wrong, it's a drug I'm only aware of, not intimately familiar with). This would seemingly be ideal for the situation stated above, as the patient could be awake and protecting their own airway, have an arm that hurt like hell, was bent the wrong way, but really doesn't give a crap and won't remeber it when the med wears off.



Exactly right.  The way it was once described to me was that it chemically amputates the limbic system.  The patient remains aware of the pain at the time, but is not bothered by it.  It really is wonderful stuff.

Midazolam has shown to be of no additional benefit when using ketamine as an analgesic.  There used to be (and sometimes still is in some places) concern about emergence phenomena, but midaz does not have any effect on this anyway.  The key is to make the environment as nice as possible for the patient, which may be tricky obviously, but I have not seen anyone have any particular adverse effects from ketamine.


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## MrBrown (Oct 26, 2010)

Brown asked the anaesthetist for ketamine but I dno what happened about that, the drugs they gave Brown made him remember not so well


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## Smash (Oct 27, 2010)

MrBrown said:


> Brown asked the anaesthetist for ketamine but I dno what happened about that, the drugs they gave Brown made him remember not so well



And unfortunately it appears that it also made him refer to himself in the third person all the time.  Tragic what happens when medicine goes wrong!


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## MrBrown (Oct 27, 2010)

Smash said:


> And unfortunately it appears that it also made him refer to himself in the third person all the time.  Tragic what happens when medicine goes wrong!



Technically it is the fourth person since Brown does not really exist and is the alter-ego of his creator 

Brown is a big proponent of RSI for both medical and trauma, provided it is used appropriately by sufficently knowledgable providers with a robust monitoring framework


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## swissmedic (Oct 29, 2010)

MrBrown said:


> Ketamine is not a traditional anaesthetic so to that end you are correct sir; it is an NMDA inhibitor whereas propofol for example inhibits GABA.
> 
> The result however is the same - the patient does not remember, which if Brown is treating them is a really good thing



We also do / use ketamine RSI for any status asthmaticus patients, it works great (keatmine is not only for analgetics it is works also very good as a bronchdilatation)
Matt


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## emtchick171 (Oct 29, 2010)

We carry diazepam...however it is ONLY used for seizure patients. You can call medical direction to request the administration of diazepam for sedation...but every time I've seen it requested for sedation it has been denied.

At this time our county is not allowed to do RSI..but it is a working-process and is on the verge of being allowed. Of course when we do get RSI, we will have to be able to administer something to make the PT unconscious.


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## swissmedic (Oct 29, 2010)

We still use versed i.v. or i.o. and temesta p.o. (it's lorazepam) for seizures, RSI and any anxiety patients to clam down...
Matt


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## Fox800 (Oct 29, 2010)

Our current guidelines (about to expire) do have a pain management/anxiety protocol with options for fentanyl, diazepam, and midazolam all off-line, at provider discretion. I am quite liberal with my benzos if I feel it's going to help the patient in situations that are extremely distressing (especially bad fractures).

Our new clinical guidelines have absolutely no provision for anxiety management. We don't even have a page for it. The medication formulary doesn't even have "anxiety" listed as an indication for diaz or midaz any more. I guess it'll be a consult with an ER physician, unfortunately.


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## MrBrown (Oct 29, 2010)

emtchick171 said:


> ...we will have to be able to administer something to make the PT unconscious.



1kg of big hammer peri-cranial prn


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## Emtpbill (Oct 29, 2010)

In Pennsylvania we carry versed for med. Assisted intubation, but protocols are clear there must be 2 ALS practitioners treating the patient.


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## MrBrown (Oct 29, 2010)

Oh dear, sedation assisted intubation is dangerous and was banned in this part of the world coz it made mortality go through the roof


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## Emtpbill (Nov 2, 2010)

MrBrown said:


> Oh dear, sedation assisted intubation is dangerous and was banned in this part of the world coz it made mortality go through the roof



   I hear you brown!!!   About 7 years ago we got versed to put people down to tube em,  about 3 years ago is when it was changed that 2 medics had to be treating. I'm sure stats had a play in the 2 medic thing.  The only time I give it now is for seizures if Ativan isn't working. Versed that is.


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## emtchick171 (Nov 2, 2010)

Emtpbill said:


> I hear you brown!!!   About 7 years ago we got versed to put people down to tube em,  about 3 years ago is when it was changed that 2 medics had to be treating. I'm sure stats had a play in the 2 medic thing.  The only time I give it now is for seizures if Ativan isn't working. Versed that is.



Wow...the 2 medic thing is an interesting fact. I know we don't do RSI just yet, but it is definitely being considered and will probably happen within the next couple/few months. 

It is interesting to know that y'all give Ativan and Versed for seizures, our first line drug is always Valium. Actually, that is the only drug we carry on the truck to help with seizures.


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## Boston.Tacmedic (Nov 2, 2010)

MrBrown said:


> We use ketamine in low (10-20mg bolus) doses for analgesia and big (1.5mg/kg) doses for anaesthesia.
> 
> Now interestingly here you cannot give ketamine to somebody who has been given midaz but you can give midaz for post-ketamine sedation management.
> 
> ...



I couldn't say it better myself , so I won't I agree 100%. Punishing the whole profession because of others poor training just holds us all back and needless endangers the PT. RSI works and works well.

My .02


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## Smash (Nov 3, 2010)

Emtpbill said:


> I hear you brown!!!   About 7 years ago we got versed to put people down to tube em,  about 3 years ago is when it was changed that 2 medics had to be treating. I'm sure stats had a play in the 2 medic thing.  The only time I give it now is for seizures if Ativan isn't working. Versed that is.



Whilst my preference is definitely for 2 medics to carry out a drug assisted intubation, I'm not sure that that is Mr Browns point. 

Sedation alone is not a good method for enabling intubation, especially in the types of patients that RSI is traditionally used for (eg head injuries with trismus). 

The idea of using sedation alone to enable intubation makes me feel queasy! Or worse, going nasal for a head injured patient...

I must say it's an interesting turn of phrase "to put people down". I put my dog down once...


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## MrBrown (Nov 3, 2010)

Drug assisted intubation (ie midaz'ing people to facilitate tubing them) has been banned most places Brown knows of .... any service that is half arsed coming to the party is just wrong


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## usalsfyre (Nov 3, 2010)

So while there is a definite use for medication only assisted intubation in the setting of predicted difficult airway, midazolam is *NOT* the agent of choice, as it has a very definite effect on respiratory drive, airway protective mechanisms and blood pressure. Etomidate and from what I understand ketamine are much better choices. 

Versed-only facilitated intubation is asking for trouble.


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## Emtpbill (Nov 3, 2010)

While I agree that most medics would love to have more medications to use to help intubate a patient, we can only use what is granted to us. If all that I am permitted to use is versed, then I will use it to the best of my abilities. The wheel of progress at times seems to fly, but other times gets beat out by a snail.


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## emtchick171 (Nov 3, 2010)

Emtpbill said:


> While I agree that most medics would love to have more medications to use to help intubate a patient, we can only use what is granted to us. If all that I am permitted to use is versed, then I will use it to the best of my abilities. The wheel of progress at times seems to fly, but other times gets beat out by a snail.



I couldn't have said it any better myself. That is part of our jobs...working with what we have & improvising to get the job done...no matter how good/bad it seems to be going.


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## MrBrown (Nov 3, 2010)

emtchick171 said:


> That is part of our jobs...working with what we have & improvising to get the job done...no matter how good/bad it seems to be going.



So working with what you have and/or improvising includes clinically dangerous undertakings which have the significant potential to cause secondary brain injury?

Perhaps the reaosn nobody has RSI is because nobody trusts you (not you specifically) with it.  With the kind of statements made on this forum by various people it is no suprise.  

Man this stuff just makes Brown's blood boil.


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## Emtpbill (Nov 3, 2010)

MrBrown said:


> So working with what you have and/or improvising includes clinically dangerous undertakings which have the significant potential to cause secondary brain injury?
> 
> Perhaps the reaosn nobody has RSI is because nobody trusts you (not you specifically) with it.  With the kind of statements made on this forum by various people it is no suprise.
> 
> Man this stuff just makes Brown's blood boil.



What I meant was that I can only use the skills I am proficient in, what I am given, and use my judgement on when to and when to not apply them. 
  just because another medic is not proficient has no bearing on the appropriateness of a certain modality being employed, correctly and competently, by me.


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## emtchick171 (Nov 3, 2010)

MrBrown said:


> So working with what you have and/or improvising includes clinically dangerous undertakings which have the significant potential to cause secondary brain injury?
> 
> Perhaps the reaosn nobody has RSI is because nobody trusts you (not you specifically) with it.  With the kind of statements made on this forum by various people it is no suprise.
> 
> Man this stuff just makes Brown's blood boil.



Maybe I should have been more specific with my post. Improvising is part of our jobs, we treat what we see we DO NOT diagnose. In everyday life we take chances (not just talking about on our jobs). Every decision we make has a consequence...whether it be good or bad. Sometimes, in certain situations you have to weigh out the good and the bad...and see which one is the best choice. 

- - I am not going to do ANYTHING on the back of my truck to intentionally harm my PT more than they already are...nor am I going to do anything that is contraindicated!


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## emtchick171 (Nov 3, 2010)

Emtpbill said:


> What I meant was that I can only use the skills I am proficient in, what I am given, and use my judgement on when to and when to not apply them.
> just because another medic is not proficient has no bearing on the appropriateness of a certain modality being employed, correctly and competently, by me.



I understood you, I believe you and I both confused Brown. Sorry for the confusion Brown, I should have been more clear.


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## MrBrown (Nov 3, 2010)

Emtpbill said:


> What I meant was that I can only use the skills I am proficient in, what I am given, and use my judgement on when to and when to not apply them.
> just because another medic is not proficient has no bearing on the appropriateness of a certain modality being employed, correctly and competently, by me.



Unfortunately it does because those who exhibit the most clinical risk (ie the least competent, educated, proficent whatever term you want to use) is who the system is set up for. 



emtchick171 said:


> Maybe I should have been more specific with my post. Improvising is part of our jobs, we treat what we see we DO NOT diagnose. In everyday life we take chances (not just talking about on our jobs). Every decision we make has a consequence...whether it be good or bad. Sometimes, in certain situations you have to weigh out the good and the bad...and see which one is the best choice.
> 
> - - I am not going to do ANYTHING on the back of my truck to intentionally harm my PT more than they already are...nor am I going to do anything that is contraindicated!



Good to hear, if you need help ring up Brown and him n Oz will come for a blast in the blue car or big red helicopter 

Unfortunately again, many a provider Brown has seen subscribe to the old ambo trick of "more is better" or somehow believe thier minimal education qualifies them to undertake risky clinical dexterities because "it helps"


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