# Rsi



## PFD2171 (Aug 22, 2011)

Looking for any agency out there who currently uses Versed as the induction agent for RSI. I recently began working for one who dose which seems odd in addition our ordered dosage is much less that it should be from what I have read for use in RSI.


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## sir.shocksalot (Aug 22, 2011)

We don't RSI where I work but I can say that I haven't seen Versed used by itself as an induction agent. What I have seen is patients get high doses (2-3 mcg/kg) of Fentanyl and high doses of Versed (0.2 mg/kg) together for sedation. Although 90% of the time I see Etomidate used.

This website seems to suggest the ideal dosage for Versed is 0.2 mg/kg:
http://www.uptodate.com/contents/se...gents-for-rapid-sequence-intubation-in-adults

Best bet is to chat with your medical director if you have questions and see what his/her thought process is.


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## mikie (Aug 22, 2011)

*Pilot Program in MD*





> (1)  Adult:
> Administer 0.05 mg/kg (2-5 mg) slow IVP over 1-2 minutes, while maintaining systolic BP greater than 90 mmHg. (NEW ’11)



this is the dose for Versed for the pilot RSI program in Maryland, used primarily by flight medics (troopers), but a few ground agencies have the  capabilities.


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## Cohn (Aug 22, 2011)

Flight crews in Arizona (AirEvac and LifeLine) use it for RSI


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## fast65 (Aug 22, 2011)

We use it along with succinylcholine and rocuronium for RSI, but it's not our main induction agent my any means. Our dose is 0.3 mg/kg


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## usalsfyre (Aug 22, 2011)

0.05mgs/kg?!? Let me guess, that's a standard morphine dose too...

Midazolam works as an induction agent. If it's not used with a paralytic (bad idea) it often requires considerable doses, and hypotension is a significant (and deadly) side effect. It's not my first choice as an induction agent but it certainly will do the job.


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## DESERTDOC (Aug 22, 2011)

We routinely used Midazolam as our primary induction agent, coupled with Fentanyl  as needed in the setting of burns or other trauma.  We had some latitude with our dosing .1MG/KG-.25MG/KG, I had good results at .25 per kilo.  While there are better medications out there, Midazolam will work.


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## Handsome Robb (Aug 22, 2011)

We don't do it but what I was taught was Midazolam 0.1-0.2mg/kg for the induction agent, a defasiculating dose of Vecuronium at 0.01mg/kg then Succinylcholine as the paralytic 1.5mg/kg.

Thats a standard RSI. We were taught to do it with other induction agents and non depolarizing paralytics as well.


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## fast65 (Aug 22, 2011)

I was taught using Etomidate (0.3 mg/kg) or midazolam (0.1 mg/kg), but where I'm at now, we have the option of using droperidol (0.1 mg/kg) as an induction agent as well.


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## usalsfyre (Aug 22, 2011)

There's a myriad of options avaiable. 

Most of your benzos, Ketamine, Etomidate, Droperidol, (formerly) thiopental, you can even do a decent job with a large enough fentanyl dose (preferably su/remifentinal though). All have their place and preferred indications.


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## mikie (Aug 22, 2011)

usalsfyre said:


> 0.05mgs/kg?!? Let me guess, that's a standard morphine dose too...



The PP allows for either Etomidate OR Midaz. for Inducation, Sux for paralysis, morphine (0.1mg/kg, which is new for 2011) and vecuronium for maintenance of paralysis.


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## usalsfyre (Aug 22, 2011)

mikie said:


> The PP allows for either Etomidate OR Midaz. for Inducation, Sux for paralysis, morphine (0.1mg/kg, which is new for 2011) and vecuronium for maintenance of paralysis.



That's a very low dose of midaz, and it's disturbing that the only "sedation" options are morphine and vec. Why do they not trust y'all up there?


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## mikie (Aug 22, 2011)

usalsfyre said:


> That's a very low dose of midaz, and it's disturbing that the only "sedation" options are morphine and vec. Why do they not trust y'all up there?



No disagreement here!  Compared to everyone else's protocols, it seems maryland uses half if not 1-2x less the dose, further more, to make things more wacky, the Midaz. dose for seizures is 0.1mg/kg


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## systemet (Aug 23, 2011)

Interesting dosing here.  When I was working, we used 0.1mg/kg midazolam with 3-5ug/kg fentanyl.  We withheld the midazolam if the patient was hypotensive.

They had us limit the single dose of midazolam to 5mg, out of concern for iatrogenic hypotension.  Which, actually made the dose only 0.1mg/kg for patients <= 5mg.  If the patient was hypotensive on presentation, we withheld the midazolam, and just gave fentanyl.  Current practice in that system for these patients is now to use ketamine.

I see people talking about 0.3mg/kg.  Is a 100kg patient really receiving a single dose of 30mg midazolam IV?  This seems like a lot, especially if there's any alcohol on board.

I don't know that I'd be too comfortable using morphine for maintenance of analgesia either, with the potential for hypotension.  But I can see that it would have the advantage of requiring less frequent dosing than bolus fentanyl.  What was the rationale for selecting morphine instead?


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## systemet (Aug 23, 2011)

^

Should read "<= 50kg".


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## Iceman26 (Aug 23, 2011)

Cohn said:


> Flight crews in Arizona (AirEvac and LifeLine) use it for RSI



Fire departments and EMS do as well. In Arizona it's Versed, Etomidate, and Succs. 

In some Chicago area medical systems they will only go with Versed and Etomidate and not go with the paralytic like Succs.


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## Shishkabob (Aug 23, 2011)

Iceman26 said:


> In some Chicago area medical systems they will only go with Versed and Etomidate and not go with the paralytic like Succs.



That's just stupid and dangerous.



We primarily have Fent, Etomidate and Roc as our line drugs, but have Versed and Ativan on the truck as well.


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## usalsfyre (Aug 23, 2011)

Linuss said:


> That's just stupid and dangerous.
> 
> 
> 
> We primarily have Fent, Etomidate and Roc as our line drugs, but have Versed and Ativan on the truck as well.



The last FD I worked for did the same thing. It's a very good way to end up with a hypotensive, hypoxic patient with trismus...


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## Shishkabob (Aug 23, 2011)

Trismus is my major fear with giving Etomidate.  I try to get the tube just doing Etomidate, but I do my due prudence and have Roc drawn up next to me (Had to do this to my last RSI when they developed trismus after amidate)


And a King...

And my crich kit...





Is it obvious RSI makes me scurred?


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## usalsfyre (Aug 23, 2011)

If it doesn't give a medic pause at least then that medic scares the caca out of me (and likely has never had an airway go bad).


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## mikie (Aug 23, 2011)

systemet said:


> What was the rationale for selecting morphine instead?



Morphine (except for P.O. Tylenol lol) is the only analgesic in the Maryland pharmacopeia.


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## Iceman26 (Aug 23, 2011)

usalsfyre said:


> The last FD I worked for did the same thing. It's a very good way to end up with a hypotensive, hypoxic patient with trismus...



Fentanyl is optional as a premedication along with Lido and Benzocaine, and per the words of the protocols even Etomidate is optional. 

"Versed 5mg IVP/IN

If not sedated sufficiently to intubate in 60 seconds: Etomidate 0.5 mg/kg IVP"

I remember when first looking these over being a bit surprised there was no paralytic. This is just one medical system of many in the metro area.


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## PFD2171 (Aug 23, 2011)

All the research I have done into Pharm texts, anesthesia and airway experts lists Versed as a drug that should not be used as an induction agent do to the fact that the dosing needed is so high and has so many negative side effects. Most suggest its use in the 2-5 mg range in the addition to Etomidate but not alone. I also found it interested that some agencies are still using Roc as a defasiculating agent as newer research has shown that it is not effective for that. Our goal is to provide the best care *allowed * by our protocols and remember we are not doctors just technicians.


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## Flight-LP (Aug 23, 2011)

PFD2171 said:


> All the research I have done into Pharm texts, anesthesia and airway experts lists Versed as a drug that should not be used as an induction agent do to the fact that the dosing needed is so high and has so many negative side effects. Most suggest its use in the 2-5 mg range in the addition to Etomidate but not alone. I also found it interested that some agencies are still using Roc as a defasiculating agent as newer research has shown that it is not effective for that. Our goal is to provide the best care *allowed * by our protocols and remember we are not doctors just technicians.



Versed is a wonderful tool and does have it's place, however I do agree there are other options that may be more beneficial (i.e. Etomidate, Ketamine, etc.)

I don't know of too many progressive agencies that even consider a defasic'ng agent as many have completely moved away from Sux and use Roc (or Vec) exclusively as their NMBA.

Yes the goal is to provide the best care, fortunately many of us are not limited by protocols and are able to operate in an autonomous fashion under clinical guidelines. Focusing on allowances and emphasizing a technician level does nothing for the promotion of professional development.


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## MrBrown (Aug 24, 2011)

Fentanyl, ketamine and suxamethonium/vecuronium here in NZ


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## Smash (Aug 24, 2011)

MrBrown said:


> Fentanyl, ketamine and suxamethonium/vecuronium here in NZ



And 'versed' depending on the situation.  But I love ketamine.  Very much.


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## systemet (Aug 24, 2011)

Iceman26 said:


> "Versed 5mg IVP/IN
> 
> If not sedated sufficiently to intubate in 60 seconds: Etomidate 0.5 mg/kg IVP"



60 seconds doesn't seem like a long enough time to wait for midazolam to take effect.  I think it's rare to have intubating conditions that quickly when using fentanyl + midazolam without a paralytic. 

Personal opinion (for what little it's worth): a large proportion of the difficulty seen when using opiates + benzos for a facilitated intubation is providers failing to wait long enough for the medications to take effect prior to attempting laryngoscopy.



> I remember when first looking these over being a bit surprised there was no paralytic. This is just one medical system of many in the metro area.



Unfortunately this seems to be fairly common in metropolitan regions.  There seems to be an assumption by many physicians that a crew within a city can just run to the ER and have their patient intubated by an ER fellow within 60 seconds of entering the ambulance bay. 10 minutes of critical hypoxia is devastating whether it happens in the field, or in during transport / the ER bay / triage / initial assessment by the EP.

There's obviously a deficiency in paramedic education and ongoing training when it comes to intubation in some (many?) systems. 

The opinion of many medical control groups seems to be that approaching airway control with benzo's + opiates is safer than doing RSI.  Perhaps because the fentanyl can be reversed quickly, or because the incidence of apnea is lower than when using NMBAs.  But I think sometimes (again, my very inexpert opinion), it just allows providers to make a bigger mess out of an already potentially difficult airway.


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## MrBrown (Aug 24, 2011)

Smash said:


> And 'versed' depending on the situation.  But I love ketamine.  Very much.



Damn it Smash you confuse the heck out of Brown, should I look for you on my next shift or not 

We have midazolam for neurogenic cause for coma with GCS less than or equal to ten, everybody else gets ketamine


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## Iceman26 (Aug 24, 2011)

systemet said:


> 60 seconds doesn't seem like a long enough time to wait for midazolam to take effect.  I think it's rare to have intubating conditions that quickly when using fentanyl + midazolam without a paralytic.
> 
> Personal opinion (for what little it's worth): a large proportion of the difficulty seen when using opiates + benzos for a facilitated intubation is providers failing to wait long enough for the medications to take effect prior to attempting laryngoscopy.
> 
> ...



I agree pretty much on all counts. There are a lot of systems here and for curiosity's sake I'm going to look at others to see what they do. There are some places here that are slow to come around to change and being progressive, and I suspect that's the case in many (not all) big city/metropolitan areas. Phoenix is not one of them, that I know.


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## omak42 (Aug 25, 2011)

PFD2171 said:


> Looking for any agency out there who currently uses Versed as the induction agent for RSI. I recently began working for one who dose which seems odd in addition our ordered dosage is much less that it should be from what I have read for use in RSI.



I work in WA and Versed is listed as an appropriate substitute for Etomidate.  Our initial dose is 2-5mg and afterwards .05-.1mg/kg to continue sedation.  We have some medics that use Versed exclusively because they dont want to do the math, but it is supposed to only be used if pt has an allergy to Etomidate.


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## Smash (Aug 25, 2011)

I have a fair bit of experience using versed (and fentanyl) for induction. Used appropriately it is a perfectly good drug most of the time. There are
times where there are better options (like ketamine). The key is to educate and empower (can you tell I've been watching Oprah?) the paramedics to use the most appropriate drug for the situation. 

Personally I think that the 2-5mg for induction, even with fentanyl, is grossly underdosing the patient and is inhumane.  If the powers that be are really worried about the negative cardiovascular effects they should consider better options like ketamine. 

I've said it before and will no doubt say it a million times again: Drug assisted intubation needs to be done properly or not at all.


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## usalsfyre (Aug 25, 2011)

Smash said:


> Drug assisted intubation needs to be done properly or not at all.


It's my turn to testify! Sing it loud Brother Smash!


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## triemal04 (Aug 26, 2011)

Smash said:


> I have a fair bit of experience using versed (and fentanyl) for induction. Used appropriately it is a perfectly good drug most of the time. There are
> times where there are better options (like ketamine). The key is to educate and empower (can you tell I've been watching Oprah?) the paramedics to use the most appropriate drug for the situation.
> 
> Personally I think that the 2-5mg for induction, even with fentanyl, is grossly underdosing the patient and is inhumane.  If the powers that be are really worried about the negative cardiovascular effects they should consider better options like ketamine.
> ...


If you are only using a benzo to facilitate intubation then I agree 2-5mg is nowhere near enough, but what about in conjunction with a paralytic?  Before we started carrying etomidate we'd use either versed or fentanyl (or a combo) along with sux/vec/roc; it took a little more thought to do it appropriately, but could be done well, especially as it was always followed up with repeat dose at fairly short interverals.


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## Smash (Aug 26, 2011)

triemal04 said:


> If you are only using a benzo to facilitate intubation then I agree 2-5mg is nowhere near enough, but what about in conjunction with a paralytic?  Before we started carrying etomidate we'd use either versed or fentanyl (or a combo) along with sux/vec/roc; it took a little more thought to do it appropriately, but could be done well, especially as it was always followed up with repeat dose at fairly short interverals.



I don't think that a benzo alone or with fentanyl should be used to facilitate intubation.  Unless you are doing a true "awake" intubation on a patient with ketamine or something, we need to make sure that airway reflexes are eliminated along with awareness to provide both the optimal intubating conditions and the optimal in humane patient care.

Even when using a NMBA 2-5mg as a blanket dose is suboptimal.  It might be ok for a colonoscopy, but it's not ok in your head injured, fractured, trismused patient.

So my recipe using versed is:  0.1mg/kg of versed (and this is a light dose) to eliminate awareness. I may reduce this if perfusion is tenuous, but really, that is what ketamine is for.  Fentanyl 5mcg/kg or thereabouts.  I know that pre-medication is a bit up in the air, but my rationale is that intubation is a painful procedure, so it seems reasonable to me to add some pain relief for a start.  It's also hopefully synergistic with the benzo and may help blunt the sympathetic surge associated with laryngoscopy.  

I'm then unfortunately required to use sux for passing the tube.  My preference would be for rocuronium, but this is not currently an option for me.

Once the tube placement is confirmed and secured, I get another BP straight away, and because I have used a light dose of sedation I will add some more versed and fentanyl immediately with the dose dependant on the BP.  It's then time for long term paralysis if I am going to use it at all.

Ongoing sedation and pain-relief is then achieved with an infusion of morphine (or fentanyl) and versed, at around 0.1mg/kg/hour +/- depending on perfusion, clinical situation and level of sedation.  Some situations call for heavy sedation, others are fine reasonably light on.  

Ongoing sedation and, most importantly, pain relief are vital, and I don't like the peaks and troughs associated with bolus dosing.  If propofol is used for ongoing sedation (which I don't necessarily think is optimal in the field, although in certain situations it has it's place) then it is important to remember to include some pain relief along with it, as props has no analgesic effect.


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## MrBrown (Aug 26, 2011)

It is more and more clear with each day that Smash is not human, he is some sort of Robocop type super ambo who has scanned billions of studies and textbooks into his mainframe, it would appear to include one or two on anaesthesia too.

All our RSI patients get fentanyl 1mcg/kg; those with neurogenic cause for coma who have a GCS =< 10 receive 0.05mg/kg midazolam, whereas everybody else gets 1.5mg/kg ketamie.

If you are over 60, heart rate is >100 and ..... something else (Brown can't be arsed signing into Moodle to get the Clinical Procedures) you get half dose of fentanyl and midaz (if ketamine is not used)


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## triemal04 (Sep 1, 2011)

Smash said:


> I Ongoing sedation and pain-relief is then achieved with an infusion of morphine (or fentanyl) and versed, at around 0.1mg/kg/hour +/- depending on perfusion, clinical situation and level of sedation.  Some situations call for heavy sedation, others are fine reasonably light on.


The rest I agree with, was curious about this though.  How well are you managing sedation with versed and morphine at 0.1mg/kg/hr?  Just based on my weight, that's only about 1.5mg of each every 10 minutes.  I rarely use MS (fentanyl=much better most of the time) but that just doesn't seem like enough, even in combination, to keep someone down.  Though you are using a larger induction dose than I am, so that helps I'm sure.


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## Smash (Sep 2, 2011)

triemal04 said:


> The rest I agree with, was curious about this though.  How well are you managing sedation with versed and morphine at 0.1mg/kg/hr?  Just based on my weight, that's only about 1.5mg of each every 10 minutes.  I rarely use MS (fentanyl=much better most of the time) but that just doesn't seem like enough, even in combination, to keep someone down.  Though you are using a larger induction dose than I am, so that helps I'm sure.



I will bump it up if need be, or tone it down, it depends on the situation, and whether I have long term paralysis on board as well, but I have never had any issues with under-sedation.  I watch carefully for any signs of under sedation, and I tend to err on the side of heavier sedation than lighter, especially given the amount of stimulus present in an ambulance as opposed to an ICU.  0.1mg/kg/hr offers a good starting point.


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## Melclin (Sep 4, 2011)

Has anyone heard Richard Dutton speak on intubating hypovolaemic trauma pts? 

He reckons that it basically doesn't matter which induction agent you use. You just can't use much of it. They're using thiopentol or propofol I think, traditionally agents you'd steer clear of in haemorrhagic shock. I guess the theory if it doesn't matter which one you use when it comes to circulatory collapse, you may as well have the positive effects on ICP, but I don't know and I'd be interested to find out.

Anyone have any light to shed on this or any thoughts?


SMASH: Are you using propofol to maintain sedation in ventilated intracranial bleeds with hypertension?


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## usafmedic45 (Sep 4, 2011)

> 0.05mgs/kg?!? Let me guess, that's a standard morphine dose too.



Well....remember the docs in Maryland don't trust the EMS providers so tend to right asinine orders like that.  I mean....who needs a secured airway when you're going by helicopter to Shock/Trauma, the world's best unaccredited "trauma center"?


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## MrBrown (Sep 4, 2011)

usafmedic45 said:


> Well....remember the docs in Maryland don't trust the EMS providers so tend to right asinine orders like that.  I mean....who needs a secured airway when you're going by helicopter to Shock/Trauma, the world's best unaccredited "trauma center"?



Hush you, the lure of Shock/Trauma is all it needs, any evidence to the contrary of its awesomness that is based in science is pure witch doctory Brown tells you, get the pitch fork and gasoline! 

/taking the piss


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