# Post intubation sedation



## StCEMT (Dec 20, 2016)

So came across a podcast (emcrit) that I will listen to after I get home from dinner with the family, but wanted to get wisdom/advice/suggestions/general bullshittery from you fine folks on this topic. The last two people tubed in my presence were just plain dead, so all I was pushing was epi, didn't really have to worry about sedation. Needless to say its a bit out of my bubble. I know what my protocols are for, but I still have other options in my box that I can probably try to call for under different circumstances if it seems prudent to do so. Curious as to what yalls thoughts are on the whole spectrum, from respiratory failure, post ROSC, hypovolemic trauma, etc. and just gonna let this roll where ever it leads.


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## VFlutter (Dec 20, 2016)

My go to is Ketamine for most situations and always with hypotensive patients. Also supplement with Fentanyl and Ativan. We have Versed but I tend to avoid it.


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## NomadicMedic (Dec 20, 2016)

...And we use versed. That's all I've got in my protocol. 

Although, if I'm taking a transfer, I can take Ativan from the pharm and use that if needed.


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## StCEMT (Dec 20, 2016)

Is Ativan a bit easier on the hypotensive folks Chase? Don't even have it and don't even think I ever gave it in the hospital.

I'm in the same boat as you DE. 2.5-5mg versed. I have Ketamine though, so I can at the very least give the doc a holler and ask.


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## VFlutter (Dec 20, 2016)

StCEMT said:


> Is Ativan a bit easier on the hypotensive folks Chase? Don't even have it and don't even think I ever gave it in the hospital.
> 
> I'm in the same boat as you DE. 2.5-5mg versed. I have Ketamine though, so I can at the very least give the doc a holler and ask.



Anecdotally I found Versed to frequently cause hypotension but most of my experience was sick cardiac patients. I do not think one benzo is clearly superior to the other in most situations. Pain control goes a long way and usually keeps most patients comfortable without needing much else. I am sure @Remi may be able to answer more

Interesting abstract. https://www.ncbi.nlm.nih.gov/pubmed/7943774


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## Carlos Danger (Dec 20, 2016)

Scott Weingart is all about using fentanyl as your primary agent for post-intubation sedation. Which is fine - fentanyl is a great drug and it certainly works well for this purpose - but I think the reasoning behind why he thinks fentanyl is a better drug than other options is flawed.

Advocates of a "fentanyl first" approach to post-intubation sedation always say something along the lines of "having a rigid piece of plastic shoved down your throat is very painful, and therefore these people need analgesia more than sedation". As evidence, they will point to the fact that when people who are intubated get fentanyl, their HR and BP drops and they appear more comfortable.

The problem with that argument is that the premise is untrue. First, being intubated _should not _be especially painful. It is uncomfortable. It is unnatural. It is anxiety inducing. It will cause a sympathetic response. But none of those things are the same as pain. If an ETT is painful, them something is wrong. It is too large, or poorly positioned, or it is taped improperly, or the cuff is overinflated. There should be no overriding need for potent analgesics. Second, the reason their HR drops when they get fentanyl is because fentanyl has pretty potent sympatholytic properties, not because they were experiencing severe pain before they got it. Lastly, the reason they look more comfortable after you give them fentanyl is because you just gave them additional sedation (fentanyl is a GABA agonist, too). I assure you that you can make a patient just as comfortable with an adequate dose of sedative alone.

Despite what we've all had drilled into our heads, "tachycardia does _not_ equal pain".

Now, there are good reasons to use fentanyl in the post-intubation setting. Primarily because it lets you cut way down on the dose of whatever other sedative you are using. Fentanyl is a "clean" drug, meaning that it wears off predictably and fairly quickly once you stop giving it, and has minimal lingering effects compared to other drugs. Propofol is clean too, as long as it isn't infused at high doses for a long period of time. Versed is a dirty drug. It's great in small doses for anxiolysis or brief, mild-moderate sedation but in large or continuous doses, it has some bad effects, especially in specific populations. Which is why it has fallen out of favor in the ICU world.

Versed is a fine drug to use after you've dropped a tube and you have a fairly short drive to the hospital and may need to repeat the dose once or twice. It works fine for that purpose in combination with an opioid. You just shouldn't use an infusion of it, or give many repeated doses, if you can help it. When I flew I used propofol and fentanyl or dilaudid. I think it is the best combination out there. Ketamine has its place too, but I don't think it is superior to propofol + fentanyl in the vast majority of cases.

I also think that the avoidance of NMB at almost all costs during transport is completely unnecessary.


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## Carlos Danger (Dec 20, 2016)

Chase said:


> Anecdotally I found Versed to frequently cause hypotension but most of my experience was sick cardiac patients. I do not think one benzo is clearly superior to the other in most situations. Pain control goes a long way and usually keeps most patients comfortable without needing much else. I am sure @Remi may be able to answer more
> 
> Interesting abstract. https://www.ncbi.nlm.nih.gov/pubmed/7943774



I don't know that it matters. All the benzos are remarkably hemodynamically stable in healthy patients. In fragile cardiac patients, all bets are off and it is hard to predict how they will react to these drugs, or which one will work better. I think the best approach is to use what you are most familiar with and give very small doses.


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## SpecialK (Dec 20, 2016)

Morphine and midazolam, or fentanyl and ketamine if the patient has shock in combination with rocuronium.

Given routinely post-RSI and post-intubation without RSI only if there is clinically significant movement.  

Withheld in patients who have a very poor prognosis if at all possible.


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## NomadicMedic (Dec 20, 2016)

Remi said:


> I don't know that it matters. All the benzos are remarkably hemodynamically stable in healthy patients. In fragile cardiac patients, all bets are off and it is hard to predict how they will react to these drugs, or which one will work better. I think the best approach is to use what you are most familiar with and give very small doses.



I think this is a key point. I'll admit, when I started tubing people, I was taught, and believed in, the "one size fits all" method of sedation. Every tube got a big slug of etomidate, a big dose of paralytic, fentanyl and more versed for post tube sedation. After seeing some bad stuff (precipitous drops in BP of fragile patients) I've learned that titrating to effect is a much better plan. If your protocol allows. 

However, despite what we read here from the more forward thinking medics, most EMS systems haven't caught up with EBM, and we're still bolus dosing sedation and we're stuck using Versed as the only sedation option.


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## VentMonkey (Dec 20, 2016)

I'm on board with @DEmedic's above post (shocking, I know). All we have is Fentanyl--->Versed for post RSI management. It works just fine and is always titrated to the patients tolerability of being intubated. We have all but moved away from Vec, and Roc post-RSI, though it's still in our nursing protocols.

Now, if we had Ketamine, I am more than willing to bet we would be using this more often than not. I know my CCP instructor was a big fan of Ketamine, and even supporting drips. I think push dose is fine for most scene flights especially with out flight times to our local ED's. Before my time at our CCT division we had Ketamine for a brief period, and everyone I have talked about it wishes we still had it, and/ or it comes back.

I don't know how well Propofol fits into the prehospital environment. I know "milk of amnesia" is a well like drug especially in neuro-ICU's what with "sedation vacations" and all, but most of the time in-flight I would imagine comfortable, tolerable, and relaxed are the way to properly manage one's airway post-RSI. 

The hospital can reassess and see what all longer-acting agents they want, if they want or need for them to remain intubated.


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## Carlos Danger (Dec 20, 2016)

VentMonkey said:


> I'm on board with @DEmedic's above post (shocking, I know). All we have is Fentanyl--->Versed for post RSI management. It works just fine and is always titrated to the patients tolerability of being intubated. We have all but moved away from Vec, and Roc post-RSI, though it's still in our nursing protocols.
> 
> Now, if we had Ketamine, I am more than willing to bet we would be using this more often than not. I know my CCP instructor was a big fan of Ketamine, and even supporting drips. I think push dose is fine for most scene flights especially with out flight times to our local ED's. Before my time at our CCT division we had Ketamine for a brief period, and everyone I have talked about it wishes we still had it, and/ or it comes back.
> 
> ...



Propofol works great in transport with an opioid or ketamine. I have always been a fan of using NMB, too. I think it is a shame that it's so frowned up these days.


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## VentMonkey (Dec 20, 2016)

Remi said:


> Propofol works great in transport with an opioid or ketamine. I have always been a fan of using NMB, too. I think it is a shame that it's so frowned up these days.


I don't know that's it's necessarily frowned up, to me it seems as though it is more along the lines (in my line of work anyhow) that they'll need to further assess, so let's focus our post-RSI efforts on comfort and/ or pain control so that the receiving ED/ EM's can further/ properly assess as they wish.


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## TXmed (Dec 20, 2016)

I beleive the shift to ketamine for sedation pre-hospital is that most providers to contain the knowledge of the people in this forum, so it is safer to let them push ketamine than it is versed/fent/propofol with lesser education.

I love propofol+ketamine with small amounts of fentanyl pushed just prior to strenous movements if needed.


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## StCEMT (Dec 20, 2016)

Remi: That's a good point. I do remember hearing the tachycardia being a potential sign of pain, but I see your point about the sympatholytic effects of fentanyl and properly sedating.

Ketamine might not be better than propofol+fentanyl, but propofol isn't an option for me so I gear my reading towards Ketamine as a backup. There are some instances our protocol says to use it over etomidate or we can consider it if we deem it more appropriate for patient condition. Still learning what some of those instances are, for example I believe an article I read stated etomidate was associated with a higher mortality rate in septic patients than Ketamine and considering my area, that is a very realistic possibility for me. Already had one of those patients, would have been tuned if the transport time wasn't <5 minutes.

For healthy patients, I wouldnt be worried about versed as much. As I said though, I seem to get a lot of not so healthy people some days. Having not given it enough in these cases, I would be a lot more cautious due to lack of exposure. Since I have no preference (yay for a clean slate?), would a small dose with preparation to support hemodynamics be your suggestion or is this where sedation with a gentler med like Ketamine comes into play?

I would have to get orders for Ketamine in this case, but trying to explore options my options for X situation.


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## Carlos Danger (Dec 20, 2016)

VentMonkey said:


> I don't know that's it's necessarily frowned up, to me it seems as though it is more along the lines (in my line of work anyhow) that they'll need to further assess, so let's focus our post-RSI efforts on comfort and/ or pain control so that the receiving ED/ EM's can further/ properly assess as they wish.


It is frowned upon by lots of people. Probably 10 years or so ago it started to be the "progressive" thing to do to avoid NMB. I've still never heard a good rationale for avoiding it, and it was my practice right up until the last transport I did. I always thought that NMB interfering with neuro assessment was just like prehospital opioid interfering with abdominal assessment. These people are all getting scanned anyway and if I give 10 of vec at the beginning of a 30 minute transport, it will be wearing off by the time we get to the receiving, unload, get down to the trauma bay, etc. And if they really need to, it's not like it can't be reversed.


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## VentMonkey (Dec 20, 2016)

Remi said:


> It is frowned upon by lots of people. Probably 10 years or so ago it started to be the "progressive" thing to do to avoid NMB. I've still never heard a good rationale for avoiding it, and it was my practice right up until the last transport I did. I always thought that NMB interfering with neuro assessment was just like prehospital opioid interfering with abdominal assessment. These people are all getting scanned anyway and if I give 10 of vec at the beginning of a 30 minute transport, it will be wearing off by the time we get to the receiving, unload, get down to the trauma bay, etc. And if they really need to, it's not like it can't be reversed.


Trust me when I say, our CFN/ CBS has had many the same arguments with some of our receiving staff.


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## MonkeyArrow (Dec 20, 2016)

Interesting that ketamine is first line for so many of you for post-ROSC sedation. For a purely respiratory issue, I see ketamine as a great option for post incubation sedation. However, I have always been taught that ketamine is a sympathomimetic, which would cause increases in myocardial oxygen demand and has excessive inotropic effects, which is bad for the "frail" heart, which for the sake of argument I am assuming most post-ROSC patients have. Also, ketamine has reported incidences of rebound hypertension, which can be rather interesting. Anecdotally, I have seen it given as induction/sedation in a hypotensive patient, who after induction, actually experienced a confirmed stretch of hypertension, so much so that we had to put away the levophed and start a cardene drip.


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## Carlos Danger (Dec 20, 2016)

StCEMT said:


> For healthy patients, I wouldnt be worried about versed as much. As I said though, I seem to get a lot of not so healthy people some days. Having not given it enough in these cases, I would be a lot more cautious due to lack of exposure. Since I have no preference (yay for a clean slate?), would a small dose with preparation to support hemodynamics be your suggestion or is this where sedation with a gentler med like Ketamine comes into play?
> 
> I would have to get orders for Ketamine in this case, but trying to explore options my options for X situation.



If someone is really hemodynamically unstable, then a small dose of ketamine is probably your safest bet. And then redose a little at a time as needed.

Versed is a good drug too, though. There aren't too many people who are so unstable that you need to worry about giving them any depressant at all. You'll know them when you see them.


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## NomadicMedic (Dec 20, 2016)

I've only transported patients sedated with propofol a handful of times, but it seems as though it probably wasn't the best choice of sedation for the rough riding environment of the ambulance. I used to ground transport patinets from a small hospital to Seattle pretty often and the one doc really liked propofol. Those  patients regularly seemed to be much more agitated than a patient sedated with Versed or Ativan while en route. Perhaps I was dosing too lightly? 

What are the thoughts of using things like ear plugs and extra padding for those patients when transporting in an Ambulance? I know the flight crews routinely use ear plugs for patients in the helicopter.


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## E tank (Dec 20, 2016)

Sedation and amnesia being related but not the same things, remembering that being critically ill/injured is a powerful amnestic. I'm sure there are those outliers that "remember everything, but patients on deaths door don't need much to not rememer.


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## MonkeyArrow (Dec 20, 2016)

DEmedic said:


> What are the thoughts of using things like ear plugs and extra padding for those patients when transporting in an Ambulance? I know the flight crews routinely use ear plugs for patients in the helicopter.


It is something that is gaining traction more in the ICU world, and something that at least to me makes sense to do on an ambulance. In the past couple of years, more critical care papers have come out stating the importance of ICU environment, and the effects of natural light, noise control, and day/night cycles on agitation/sedation requirements. As ICUs start to implement more of these maneuvers, I would think they make sense for the CCT crowd also. I haven't heard of any EMS outfits having a protocol for this yet, though.


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## Carlos Danger (Dec 20, 2016)

DEmedic said:


> I've only transported patients sedated with propofol a handful of times, but it seems as though it probably wasn't the best choice of sedation for the rough riding environment of the ambulance. I used to ground transport patinets from a small hospital to Seattle pretty often and the one doc really liked propofol. Those  patients regularly seemed to be much more agitated than a patient sedated with Versed or Ativan while en route. Perhaps I was dosing too lightly?
> 
> What are the thoughts of using things like ear plugs and extra padding for those patients when transporting in an Ambulance? I know the flight crews routinely use ear plugs for patients in the helicopter.



Dosing is part of it, I think we tend to be a little light on propofol in transport, but I would agree that by itself it just isn't great for the high-stimulus transport environment. Just adding some opioid makes a world of difference, though.


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## StCEMT (Dec 20, 2016)

Remi said:


> If someone is really hemodynamically unstable, then a small dose of ketamine is probably your safest bet. And then redose a little at a time as needed.
> 
> Versed is a good drug too, though. There aren't too many people who are so unstable that you need to worry about giving them any depressant at all. You'll know them when you see them.



Good to know. There any talk in your section of the world about those septic patients and how they are sedated (yay or nay etomidate) or is that one of those still being researched things?


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## Carlos Danger (Dec 20, 2016)

StCEMT said:


> Good to know. There any talk in your section of the world about those septic patients and how they are sedated (yay or nay etomidate) or is that one of those still being researched things?



I haven't heard anything new about etomidate. We know that it causes some adrenal suppression. Some studies indicate that it isn't clinically significant, others show increases in mortality with it. Overall I think most would agree that it is probably safest to just avoid it in septic or critically ill patients.

Since ketamine has regained popularity people are using it more. If I'm intubating someone hemodynamically tenuous I use a small dose of ketamine and a much smaller than normal dose of propofol, and I always have ephedrine and phenylephrine at hand. 

In the field where most intubations are trauma patients and most are generally healthy, I don't see any problem at all with etomidate. It's a good drug for the emergent RSI.


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## VentMonkey (Dec 20, 2016)

DEmedic said:


> I've only transported patients sedated with propofol a handful of times, but it seems as though it probably wasn't the best choice of sedation for the rough riding environment of the ambulance. I used to ground transport patinets from a small hospital to Seattle pretty often and the one doc really liked propofol. Those  patients regularly seemed to be much more agitated than a patient sedated with Versed or Ativan while en route. Perhaps I was dosing too lightly?
> 
> What are the thoughts of using things like ear plugs and extra padding for those patients when transporting in an Ambulance? I know the flight crews routinely use ear plugs for patients in the helicopter.


Yeah, it's a gentler sedative. I doubt it had anything to do with dosing. It really does seem great for weaning trials and things of that nature, but for transport? I still don't know that I am completely sold on it in the prehospital environment.

And yes, if you have them, earplugs, eye covers etc. all seem reasonably considerate regardless of mode of transport, more so with patients at risk for spikes in ICP.


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## VentMonkey (Dec 20, 2016)

Remi said:


> In the field where most intubations are trauma patients and most are generally healthy, I don't see any problem at all with etomidate. It's a good drug for the emergent RSI.


@Remi can you elaborate for the group why? I know I am interested in your thoughts and reasoning behind them.

Etomidate is currently our only RSI sedative/ hypnotic, so I have a natural vested interest.


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## Carlos Danger (Dec 20, 2016)

VentMonkey said:


> @Remi can you elaborate for the group why? I know I am interested in your thoughts and reasoning behind them.
> 
> Etomidate is currently our only RSI sedative/ hypnotic, so I have a natural vested interest.



I think it's just a good, reliable, safe drug. You get a dense, predictable anesthesia. It can drop the BP but it's pretty stable. Doesn't cause a lot of tachycardia. Favorable cerebrodynamics. Easy to use.


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## TXmed (Dec 21, 2016)

I do agree with @Remi, with the popularity of ketamine some people have begun to frown on etomidate but i do not believe it is earned. I personally use ketamine for the majority of my RSI's because it is very versatile with its dosages. For instance I will give asthmatics 2mg/kg, shock patients 0.5-1mg/kg, and can also do a DSI type procedure for oxygenation. But still like etomidate from time to time.


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## StCEMT (Dec 21, 2016)

TXmed said:


> I do agree with @Remi, with the popularity of ketamine some people have begun to frown on etomidate but i do not believe it is earned. I personally use ketamine for the majority of my RSI's because it is very versatile with its dosages. For instance I will give asthmatics 2mg/kg, shock patients 0.5-1mg/kg, and can also do a DSI type procedure for oxygenation. But still like etomidate from time to time.


How do you like DSI? I've listened to the gist about it, just not something (as far as I am aware) done anywhere around me nor have I seen it done in hospital.


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## VFlutter (Dec 21, 2016)

StCEMT said:


> How do you like DSI? I've listened to the gist about it, just not something (as far as I am aware) done anywhere around me nor have I seen it done in hospital.



DSI can be very useful. For example the hypoxic patient who is anxious or delirious and not tolerating a NRB or NIPPV. Are you going to just RSI this patient with sats in the 80s?  Keep them sitting up, place a NC at 15lpm, then push some ketamine and wait until they relax enough to place a NRB or assist ventilations for a minute then proceed with your paralytics and intubation. Usually the sats will improve as opposed to attempting a crash intubation on an inadequately oxygenated patient possibly resulting in a hypoxic arrest. 

This is still a quick procedure and you are not spending multiple minutes messing around after sedating. In my opinion it is kind of a grey area when RSI turns into DSI. The reason most places frown upon DSI is the increased risk of aspiration however many times saturations will improve considerably with just a NRB once the patient is sedate avoiding assisted ventilation. 

Also, take into account your sedative. Etomidate wears off pretty quick.


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## StCEMT (Dec 21, 2016)

Chase said:


> DSI can be very useful. For example the hypoxic patient who is anxious or delirious and not tolerating a NRB or NIPPV. Are you going to just RSI this patient with sats in the 80s?  Keep them sitting up, place a NC at 15lpm, then push some ketamine and wait until they relax enough to place a NRB or assist ventilations for a minute then proceed with your paralytics and intubation. Usually the sats will improve as opposed to attempting a crash intubation on an inadequately oxygenated patient possibly resulting in a hypoxic arrest.
> 
> This is still a quick procedure and you are not spending multiple minutes messing around after sedating. In my opinion it is kind of a grey area when RSI turns into DSI. The reason most places frown upon DSI is the increased risk of aspiration however many times saturations will improve considerably with just a NRB once the patient is sedate avoiding assisted ventilation.
> 
> Also, take into account your sedative. Etomidate wears off pretty quick.


Could doing so potentially put off an intubation (adequately) long enough to get to an ED?


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## VFlutter (Dec 21, 2016)

StCEMT said:


> Could doing so potentially put off an intubation (adequately) long enough to get to an ED?



I suppose it potentially could but that would not be my intention in doing the above. I have made the decision that the patient needs to be RSI'd due to whatever clinical condition or expected course and when I push the Ketamine my intention is paralyze and intubate that patient. However you would slightly delay the administration of the paralytic to hopefully better preoxygenate the patient and give yourself the most safe apneic time possible. If the patients sats improved from 80 to 100 then that is great but they are still getting intubated not left sedated on a NRB until you get to the ED.


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## StCEMT (Dec 21, 2016)

Chase said:


> I suppose it potentially could but that would not be my intention in doing the above. I have made the decision that the patient needs to be RSI'd due to whatever clinical condition or expected course and when I push the Ketamine my intention is paralyze and intubate that patient. However you would slightly delay the administration of the paralytic to hopefully better preoxygenate the patient and give yourself the most safe apneic time possible. If the patients sats improved from 80 to 100 then that is great but they are still getting intubated not left sedated on a NRB until you get to the ED.


Ok. Gonna go do a little brushing up on this one.


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## Carlos Danger (Dec 21, 2016)

Chase said:


> If the patients sats improved from 80 to 100 then that is great but they are still getting intubated not left sedated on a NRB until you get to the ED.



If sat improves that dramatically and they are breathing well, why then do they need to be intubated?


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## VFlutter (Dec 21, 2016)

Remi said:


> If sat improves that dramatically and they are breathing well, why then do they need to be intubated?



Good point and it may be a viable option to forgo intubation in certain situations however I would be hesitant to fly them.


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## Underoath87 (Dec 21, 2016)

How much ketamine is needed for DSI? My protocols only allow ketamine for RSI (2mg/kg IBW), but if the patient's sats were to improve "before I can finish pushing all the ketamine"...


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## Carlos Danger (Dec 22, 2016)

I guess I'm just not sold on the whole "DSI" thing. In his original podcast on the technique, Dr. Weingart gave the example of the patient who was delirious from hypoxemia and wouldn't cooperate with oxygenation efforts, making it impossible to place CPAP or a NRB. Give some ketamine and he relaxes, you place CPAP, now his Sp02 is in the upper 90's and you can more safely intubate.

My questions have always been these: If we fix their delirium with sedation and their hypoxemia with CPAP, why are we proceeding with intubation - especially in the field? Is this technique really safer or more effective than proceeding with a normal induction and simply mask-ventilating if necessary?

If all someone needs is some supplemental oxygen or CPAP, then do that for them. And if doing so requires a little anxiolysis, fine. But if someone is critically ill and hypoxemic and needs to be intubated regardless, then messing around with ketamine and CPAP probably isn't the best idea. Prop-->sux-->tube, mask if you need to. Keep it simple.

And there are some patients who you know might need to be intubated, but you also think CPAP might fix them up, too. So you try CPAP. And again, if you need to give them a little ketamine or whatever, fine. If it works, awesome - you avoided an intubation. If it doesn't work, no problem - tube them. We've always done this, and we never called it DSI.

I think conceptualizing DSI vs RSI as separate procedures just makes things complicated. It's all just airway management.


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## TXmed (Dec 22, 2016)

If i am committing to a RSI/DSI procedure i am fully committing. With asthmatic/COPD patients their sats can improve but you still have to address the hypercarbia, respiratory muscle fatigue, and bronchospasm that will possibly come back when their ketamine level drops. I also do this for combative head injury patients and combative drug OD patients with no immediate fix. One thing i do like about DSI is it helps people around me settle down, so many times people believe RSI is a rapid procedure and they forgo the small details "just to get the tube". I will generally do an apniec CPAP with NC+BVM with PEEP valve at 10 and not ever squeeze the bag. This also lets me place NPA's, more adequate suctioning, and assign duties to the people/team around me.

@Remi  I agree to an extent about conceptualizing DSI vs RSI, but I do believe it gets peoples narrow mindedness on RSI and chance to grow. A big pet peeve of mine is paramedics/doctors choosing to do "classic RSI" on everyone no matter the MOI/NOI, instead of changing the medication, dosage, technique of things to best suit the patient.


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## Handsome Robb (Dec 22, 2016)

We exclusively do DSI now, no RSIs. Our MD looked at our peri-intubation arrest/hypoxia rates and our morbidity and we were killing people by RSIing them. We generally start with 2mg/kg of ketamine but can go up from there, we don't carry etomidate. 

I've done a handful and like the process, it slows down a hectic, high stress situation. We are required to use and turn in a paper check list. 

DSI combined with the king vision we've had 100% first pass success for the vast majority of the last year with a few months in the 90s. 


Sent from my iPhone using Tapatalk


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## RocKetamine (Dec 22, 2016)

I mean DSI is basically just procedural sedation + pre-oxygenation with CPAP being an option not a requirement to provide pre-oxygenation. Weingart has repeatedly said he also likes it because of the chance of avoiding intubation all together. 

I don't think that it's appropriate for every patient, probably not even for most patients but it does seem to be beneficial for some. I'm sure we call all (hopefully) agree that having a patients saturation drop into the 60-70s during RSI because you weren't able to provide adequate pre-oxygenation isn't the best thing to happen. 

Different people/services/areas of the country have different definition of what RSI consists of, though the correct definition is endotracheal intubation after the administration of a sedative and neuromuscular blocking agent in rapid succession. It makes sense to me to separate RSI from DSI as the drugs are not given in rapidly, but rather in a delayed fashion after adequate pre-oxygenation/denitrogenation is achieved. 

Placing a NPA is just airway management, maybe we shouldn't separate that out from RSI either.


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## SpecialK (Dec 22, 2016)

Personally I think the distinction is reasonable.

Our airway management approach has changed fundamentally over the past 20 years or so.  In the olden days, people who needed more oxygenation than supplemental oxygen could provide automatically meant they needed to be intubated, and if they had a level of consciousness too great to allow them to be intubated easily then they just got given midazolam until basically they were obtunded enough to be intubated.  

Since then we have evolved significantly including carrying nasal airways, LMAs, PEEP, having RSI, formally adding DSI and rocuronium only RSI, and at some point in the future CPAP and mechanical ventilation (they cannot be added at the moment because of the cost).

And if I can send somebody off to oblivion with a bit of ketamine (and a mg or two of midazolam maybe) and oxygenate them no I wouldn't intubate them unless hospital was a very long way away or they needed a physically secure airway.


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## VentMonkey (Dec 22, 2016)

SpecialK said:


> Since then we have evolved significantly including...rocuronium only RSI


How on earth does this work, and/ or constitute evolving? Is this only in a "crash airway" scenario?

FWIW, I agree with your post overall, and you guys are light years ahead of my service.


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## SpecialK (Dec 23, 2016)

VentMonkey said:


> How on earth does this work, and/ or constitute evolving? Is this only in a "crash airway" scenario?



It's always been possible whether with rocuronium, or the older long-acting neuromuscular blocker which was vecuronium, but up until now it's been a bit "off the books" or, how to say, not formally written into the CPGs.

There are many contraindications to suxamethonium so there may be patients who could benefit from RSI but whom cannot be administered suxamethonium.  Rocuronium only RSI is an alternative for these patients because well, they are going to benefit from the procedure, and an alternative is available to suxamethonium.

Many hospital personnel are now only performing RSI with rocuronium.


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## Handsome Robb (Dec 23, 2016)

I'm assuming your implying substituting roc for sux in addition to the sedation/analgesia? 

We only use roc, no sux anymore. 


Sent from my iPhone using Tapatalk


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## SpecialK (Dec 23, 2016)

Handsome Robb said:


> I'm assuming your implying substituting roc for sux in addition to the sedation/analgesia?



Still.give the patient a general anaesthetic yes.  The neuromuscular blocker is just different.


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## TXmed (Dec 23, 2016)

http://emcrit.org/podcasts/post-intubation-sedation/


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## StCEMT (Dec 23, 2016)

TXmed said:


> http://emcrit.org/podcasts/post-intubation-sedation/


I had just opened this when I started this post. Buuut I wanted to see where the topic would lead here. The opposing view points and varied experiences that resulted are nice to see for someone in my position. Got exactly what I wanted.


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## TXmed (Dec 23, 2016)

Im not exactly a fan of adding a pressor just for the purpose of higher sedation with propofol. I prefer to add a ketamine drip/fentanyl drip to the propofol (i like to mix &match rather one med). But that is preference and there are patients where its somewhat appropriet *grits teeth*


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## Tigger (Dec 27, 2016)

SpecialK said:


> Since then we have evolved significantly including carrying nasal airways, LMAs, PEEP, having RSI, formally adding DSI and rocuronium only RSI, and at some point in the future CPAP and mechanical ventilation (they cannot be added at the moment because of the cost).


Disposable CPAP units are inexpensive and effective. Ours (attached) are like 50 USD per unit. I work at a place with the SureVent as well, it is not a ventilator but is much better than a BVM and inexpensive. 

Incidentally our Ketamine protocol was not clearly written so it seemed appropriate to use 2mg/kg for both induction and continued sedation. It seemed to work great as sedation (n=a few) however the state determined that is not an allowed use of Ketamine so back to fentanyl and versed for us.


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## Carlos Danger (Dec 27, 2016)

TXmed said:


> Im not exactly a fan of adding a pressor just for the purpose of higher sedation with propofol. I prefer to add a ketamine drip/fentanyl drip to the propofol (i like to mix &match rather one med). But that is preference and there are patients where its somewhat appropriet *grits teeth*



I almost never use ketamine alone. I use it as part of my non-narcotic general anesthetic technique, and I also use it during tricky sedation cases as a propofol-sparing agent, when it is important to maintain airway reflexes. Very generally speaking, I can just about cut my propofol dose in half with 25mg of ketamine front loaded.


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## SpecialK (Dec 28, 2016)

Tigger said:


> Disposable CPAP units are inexpensive and effective. Ours (attached) are like 50 USD per unit. I work at a place with the SureVent as well, it is not a ventilator but is much better than a BVM and inexpensive.



Thanks, mate.  Your CPAP looks interesting, I agree USD50 doesn't sound like much but if we look at stocking one medium and one large to each ambulance and not even counting response cars the initial cost of is USD50,000 approximately (excluding any bulk discount) plus whatever ongoing cost to replace expendables used however I imagine that wouldn't be very much.

There is a firm commitment from the ambulance service to introduce some form of CPAP when it can be afforded.  

Like I said before, bloody fire service sits on its bum and does nothing and is flush with insurance levy money yet ambos who are 4x as busy have to beg and grovel for every cent of the health budget because it comes from taxes!


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## Tigger (Dec 28, 2016)

SpecialK said:


> Thanks, mate.  Your CPAP looks interesting, I agree USD50 doesn't sound like much but if we look at stocking one medium and one large to each ambulance and not even counting response cars the initial cost of is USD50,000 approximately (excluding any bulk discount) plus whatever ongoing cost to replace expendables used however I imagine that wouldn't be very much.
> 
> There is a firm commitment from the ambulance service to introduce some form of CPAP when it can be afforded.
> 
> Like I said before, bloody fire service sits on its bum and does nothing and is flush with insurance levy money yet ambos who are 4x as busy have to beg and grovel for every cent of the health budget because it comes from taxes!


Well, at a certain point it needs to happen. Lots of large systems have rolled them out quickly in the last ten years, they really do make a difference especially if you aren't able to intubate patients.


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## NomadicMedic (Dec 28, 2016)

Fixed that for ya...

Well, at a certain point it needs to happen. Lots of large systems have rolled them out quickly in the last ten years, they really do make a difference especially *if you'd rather not intubate patients that can be better served with less invasive means. *


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## VentMonkey (Dec 28, 2016)

@SpecialK is it just the cost and/ or budget that's creating a delay in such a practical and inexpensive device? Is your medical director on board with it? Is it commonly used before going to intubation with respiratory patients in-hospital?

As advanced as the rest of the world is in regards to prehospital medicine, I find it remarkable your service has yet to add it to your scope.


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## Tigger (Dec 28, 2016)

DEmedic said:


> Fixed that for ya...
> 
> Well, at a certain point it needs to happen. Lots of large systems have rolled them out quickly in the last ten years, they really do make a difference especially *if you'd rather not intubate patients that can be better served with less invasive means. *


I am told that prior to CPAP's implementation that many/most CPAPed patients would just be intubated.


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## SpecialK (Dec 29, 2016)

VentMonkey said:


> @SpecialK is it just the cost and/ or budget that's creating a delay in such a practical and inexpensive device? Is your medical director on board with it? Is it commonly used before going to intubation with respiratory patients in-hospital?
> 
> As advanced as the rest of the world is in regards to prehospital medicine, I find it remarkable your service has yet to add it to your scope.



Yes, it is the cost.  



DEmedic said:


> Well, at a certain point it needs to happen. Lots of large systems have rolled them out quickly in the last ten years, they really do make a difference especially if you'd rather not intubate patients that can be better served with less invasive means.



Define "large"? We have approximately 500 ambulances and another 100 or so other response-capable vehicles so every one of them would need to get it not to mention the ongoing cost plus the cost of the oxygen (although I don't imagine it being a significant user of additional oxygen considering if we use a bag and mask with PEEP it's at 15 lpm aready).

The government gives zero funding for anything beyond the basic operating costs of the ambulance service which in reality probably means salaries and fuel.  Capital, vehicles, and equipment are financed through donations and sponsorships.  You simply have to look in the media to see how uninterested the government seem to be about it.  A "review" has been promised for almost a year but nothing has been achieved so far and I doubt anything meaningful will come in the near future anyway.


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## VFlutter (Dec 29, 2016)

SpecialK said:


> plus the cost of the oxygen (although I don't imagine it being a significant user of additional oxygen considering if we use a bag and mask with PEEP it's at 15 lpm aready).



CPAP uses significantly more oxygen than a BVM @ 15 lpm. Depending on the mask leak it could easily pull 25+lpm.


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## SpecialK (Dec 29, 2016)

Chase said:


> CPAP uses significantly more oxygen than a BVM @ 15 lpm. Depending on the mask leak it could easily pull 25+lpm.



Well then it's even less likely! The ambulance has one portable C and one bulk D oxygen.

Now that I remember, I know somebody who works down country a bit and they sometimes do interhospital transfers with CPAP; the hospital has a spare oxygen cylinder in ED for them to take because they aren't allowed to use the ambulance oxygen.


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## VFlutter (Dec 29, 2016)

SpecialK said:


> Well then it's even less likely! The ambulance has one portable C and one bulk D oxygen.
> 
> Now that I remember, I know somebody who works down country a bit and they sometimes do interhospital transfers with CPAP; the hospital has a spare oxygen cylinder in ED for them to take because they aren't allowed to use the ambulance oxygen.



Based on my calculations a jumbo D tank would last 26mins assuming 25L of flow. So that portable C isn't going to get you far.

There are plenty of stories of people underestimating their oxygen consumption and running out on transfers.


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## Carlos Danger (Dec 30, 2016)

You can cut WAY down on oxygen flow requirements by just using a ventilator that has an internal blender. The LTV1200 does, and I assume most newer vents do as well.


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## nater (Jan 1, 2017)

We use the Revel vents and have the LTV1200 as a backup unit. They consume less oxygen than the disposable CPAP masks, but some patients still drain a portable tank quick.  I doubt a service that is unwilling to invest in disposable CPAP masks will outfit units with ventilators.


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## Eden (Jan 14, 2017)

Ketamine/midazolam/morphine or fentanyl (usually with ketamine). Depends on the patient.
TBI's,CHF will get versed probably, Asthma/COPD/Hypotensive will get ketamine. Some will get both.


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