# Ketamine



## Missourimedic38 (May 4, 2020)

Protocol has can give ketamine in a drip 100mg in 100cc bag of normal saline. My service only carries 1000cc bags.


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## Missourimedic38 (May 4, 2020)

Missourimedic38 said:


> Protocol has can give ketamine in a drip 100mg in 100cc bag of normal saline. My service only carries 1000cc bags. Anyone give this med as drip


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## DesertMedic66 (May 5, 2020)

Tell your service you either need 100mg bags or need a different option for medication admin such as IVP.

My flight service gives it IVP and my ground service gives it IVPB in a 50mL bag.


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## Peak (May 5, 2020)

How does your service give fluids to peds? Do you stock buretrols?


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## akflightmedic (May 5, 2020)

Is this a scenario? A complaint? A request for knowledge? A comparison study?


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## Missourimedic38 (May 5, 2020)

akflightmedic said:


> Is this a scenario? A complaint? A request for knowledge? A comparison study?


Knowledge


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## VFlutter (May 5, 2020)

What is your dosing protocol and indications? Assuming this is low dose for pain management.

Tell who ever orders your supplies that you need 100ml bags. If not getting anywhere tell your supervisor or medical director you don't have the required equipment you need.


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## Tigger (May 5, 2020)

Missourimedic38 said:


> Protocol has can give ketamine in a drip 100mg in 100cc bag of normal saline. My service only carries 1000cc bags.


What are you giving 100mg of Ketamine for? Over what time?


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## Missourimedic38 (May 5, 2020)

Tigger said:


> What are you giving 100mg of Ketamine for? Over what time?


Pain control. In place of fentanyl or morphine


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## DesertMedic66 (May 5, 2020)

Missourimedic38 said:


> Pain control. In place of fentanyl or morphine


Just a straight 100mg to all patients? Usually ketamine for pain management is very low dose, like in the 0.1-0.3mg/kg range. 100mg is getting more into the dissociated stage.


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## Missourimedic38 (May 6, 2020)

Can be given as drip 100mg ketamine mixed with 100cc Normal Saline.


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## Seirende (May 6, 2020)

Missourimedic38 said:


> Can be given as drip 100mg ketamine mixed with 100cc Normal Saline.



Are you titrating to effect?


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## Missourimedic38 (May 6, 2020)

Seirende said:


> Are you titrating to effect?


Yes


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## Missourimedic38 (May 6, 2020)

I dont know any medic that will actually calculate drip without a pump


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## Tigger (May 6, 2020)

That seems like a very large single dose for analgesia. Let me ask again, over how long is this to be given?


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## akflightmedic (May 6, 2020)

Copy and paste that protocol....I just wanna see how that guideline is worded.


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## silver (May 6, 2020)

DesertMedic66 said:


> Just a straight 100mg to all patients? Usually ketamine for pain management is very low dose, like in the 0.1-0.3mg/kg range. 100mg is getting more into the dissociated stage.



100mg/100ml is one of the standard dilutions for analgesic infusions though.


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## GMCmedic (May 6, 2020)

This is an unnecessarily difficult and innacurate way to administer ketamine for pain absent pumps.


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## PotatoMedic (May 6, 2020)

Call me lazy but I like my 0.25 mg/kg ivp ketamine dose.  Much simpler than a pump setup


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## NomadicMedic (May 6, 2020)

We’re doing extremely low doses of Ketamine in a100ml bag. Like 0.2mg/kg. So a big 250 pound guy only gets like 35mg.

100mg seems like a lot for pain management.


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## Missourimedic38 (May 6, 2020)

the drug i learned in medic school was known as a drug of abuse. Supposbly can cause emergence phenomenon


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## Peak (May 6, 2020)

We typically give 0.1 to 0.2 mg/kg over 10 minutes for non-dissociative dosing. It is important to that both of timing and dosing effect psychogenic effects and therefore secondary gain.


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## Missourimedic38 (May 6, 2020)

Peak said:


> We typically give 0.1 to 0.2 mg/kg over 10 minutes for non-dissociative dosing. It is important to that both of timing and dosing effect psychogenic effects and therefore secondary gain.


Peak where you a medic?


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## Peak (May 6, 2020)

Missourimedic38 said:


> Peak where you a medic?



Yep. We didn’t have ketamine at that time though.


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## Missourimedic38 (May 6, 2020)

Peak said:


> Yep. We didn’t have ketamine at that time though.


Peak, you like ER nurse life better than medic? Or like the pay better?


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## Peak (May 6, 2020)

Missourimedic38 said:


> Peak, you like ER nurse life better than medic? Or like the pay better?



I like the respect I get as a graduate prepared healthcare professional.


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## akflightmedic (May 6, 2020)

Maine's Ketamine protocol for Pain mgmt.

i. Ketamine 0.2 mg/kg IV to a MAX dose of 25 mg 1. Repeat every 15 minutes as needed for pain to a cumulative MA)( dose of 1 mg/kg 
ii. Ketamine 0.5 mg/kg IN to a MAX dose of 25 mg 1. Repeat 0.25 mg/kg IN in 15 minutes as needed for pain x 1 

For agitation/delirium

Ketamine 4 mg/kg IM. Ketamine may not be used in patients greater than 65 year s old


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## Carlos Danger (May 6, 2020)

NomadicMedic said:


> We’re doing extremely low doses of Ketamine in a100ml bag. Like 0.2mg/kg. So a big 250 pound guy only gets like 35mg.


Wouldn’t that be 50mg? Not really that small of a dose.


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## Missourimedic38 (May 6, 2020)

Peak said:


> We typically give 0.1 to 0.2 mg/kg over 10 minutes for non-dissociative dosing. It is important to that both of timing and dosing effect psychogenic effects and therefore secondary gain.


Question is how did you do RN school working full time?


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## akflightmedic (May 6, 2020)

Tomorrow is my final...then NCLEX.

I worked 2 sometimes 3 jobs during school.

We had lecture for a few hours a day, twice a week (M&W freshman year, Tues/Thurs senior year). And then we had 12 hour clinical one day a week, every week for entire two years, only exception was our mental health rotation which was 2 six hour days on Thurs and Fri for 6 weeks.

It was very easy to fit work in and around this schedule.


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## Missourimedic38 (May 6, 2020)

akflightmedic said:


> Tomorrow is my final...then NCLEX.
> 
> I worked 2 sometimes 3 jobs during school.
> 
> ...


Ah. Im on a 48/96. 2 days on 4 off Ff/medic schedule.


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## akflightmedic (May 6, 2020)

Get to shift trading...

Also, attendance for lectures in my program was not mandatory. Only clinicals were. So I did miss many lectures throughout the 2 years, however I networked with classmates and found several who recorded every single lecture and they did not mind emailing to me after class.


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## Missourimedic38 (May 6, 2020)

akflightmedic said:


> Get to shift trading...
> 
> Also, attendance for lectures in my program was not mandatory. Only clinicals were. So I did miss many lectures throughout the 2 years, however I networked with classmates and found several who recorded every single lecture and they did not mind emailing to me after class.


I got to finish my pre reqs. My view on nursing school is I want the knowledge to make me a even better paramedic.


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## akflightmedic (May 6, 2020)

Majority of pre-reqs can be done online these days...and with 48 hours (assuming low call volume with that schedule), you have plenty of time to study and complete them. And nursing school is not in any way going to make you a better paramedic.


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## Missourimedic38 (May 6, 2020)

akflightmedic said:


> Majority of pre-reqs can be done online these days...and with 48 hours (assuming low call volume with that schedule), you have plenty of time to study and complete them. And nursing school is not in any way going to make you a better paramedic.


So more medical knowledge, being sharper on disease processes, starting IVs constantly in clinicals-wont make you better paramedic?


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## akflightmedic (May 6, 2020)

Many nurse programs do NOT even do IV training. I did THREE IVs during my clinicals. I would hope if you are a paramedic, you already have solid knowledge base. As an experienced paramedic having just completed nursing school, there was no additional medical knowledge. If you take AnP I and II, Micro and a Pharm course (which is part of your pre-reqs for most programs) you will become a far better provider. And quite frankly, this should be the required education to become a paramedic. Sharper on disease processes...again if you have solid core in those pre-reqs, you are already there.

Additionally, the mindsets and training/education philisophy differences between Paramedicine and Nursing are significantly different.


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## DesertMedic66 (May 6, 2020)

Carlos Danger said:


> Wouldn’t that be 50mg? Not really that small of a dose.


250 pound guy. So around 110kg. That would be a 22mg dose.


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## NomadicMedic (May 6, 2020)

Carlos Danger said:


> Wouldn’t that be 50mg? Not really that small of a dose.


Sorry, bad math. 23kg.
250lbs is 113kg. 
113 x 0.2=22.6.


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## Missourimedic38 (May 6, 2020)

akflightmedic said:


> Many nurse programs do NOT even do IV training. I did THREE IVs during my clinicals. I would hope if you are a paramedic, you already have solid knowledge base. As an experienced paramedic having just completed nursing school, there was no additional medical knowledge. If you take AnP I and II, Micro and a Pharm course (which is part of your pre-reqs for most programs) you will become a far better provider. And quite frankly, this should be the required education to become a paramedic. Sharper on disease processes...again if you have solid core in those pre-reqs, you are already there.
> 
> Additionally, the mindsets and training/education philisophy differences between Paramedicine and Nursing are significantly different.


Ivs are easy. Its just some people are harder sticks-paramedics put too much emphasis on lines, anyone can put em in. More medical knowledge and actually working in hospital in ER, just will make you better no doubt. Your seeing an actual diagnosis and just learning more.


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## Carlos Danger (May 6, 2020)

NomadicMedic said:


> Sorry, bad math. 23kg.
> 250lbs is 113kg.
> 113 x 0.2=22.6.


Yeah, med math isn’t my strong suit.


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## Missourimedic38 (May 6, 2020)

Carlos Danger said:


> Yeah, med math isn’t my strong suit.


Med math is for students and dorks


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## akflightmedic (May 6, 2020)

Missourimedic38 said:


> Med math is for students and dorks



Says the person who wants to become a nurse to be a better paramedic...LOL


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## Missourimedic38 (May 6, 2020)

akflightmedic said:


> Says the person who wants to become a nurse to be a better paramedic...LOL


Humor


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## akflightmedic (May 6, 2020)

Exactly.


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## NomadicMedic (May 6, 2020)

That's why I like preloads. 

What's the dose? 
One. 

Exactly. (Hand me a tan box, then a purple box)


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## DesertMedic66 (May 6, 2020)

NomadicMedic said:


> That's why I like preloads.
> 
> What's the dose?
> One.
> ...


We just changed to epi 0.5mg for cardiac arrests. I’m sure it won’t be too long before we start doing weight based.


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## Missourimedic38 (May 6, 2020)

DesertMedic66 said:


> We just changed to epi 0.5mg for cardiac arrests. I’m sure it won’t be too long before we start doing weight based.


Everyone wants to reinvent wheel. KISS-Keep it simple stupid


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## medichopeful (May 6, 2020)

Tigger said:


> That seems like a very large single dose for analgesia. Let me ask again, over how long is this to be given?



I mean to be fair, 100mg would be effective for pain control 🤷‍♂️


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## medichopeful (May 6, 2020)

Missourimedic38 said:


> Everyone wants to reinvent wheel. KISS-Keep it simple stupid



Epi in cardiac arrest is definitely something that needs to be reinvented in a different way.


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## Missourimedic38 (May 6, 2020)

medichopeful said:


> Epi in cardiac arrest is definitely something that needs to be reinvented in a different way.


1mg 1:10000 prefilled. Cant beat it


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## Missourimedic38 (May 6, 2020)

Missourimedic38 said:


> 1mg 1:10000 prefilled. Cant beat it


They are dead; epi 1:10000 has worked for years


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## GMCmedic (May 6, 2020)

DesertMedic66 said:


> We just changed to epi 0.5mg for cardiac arrests. I’m sure it won’t be too long before we start doing weight based.


And then IBW


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## DesertMedic66 (May 6, 2020)

Missourimedic38 said:


> Everyone wants to reinvent wheel. KISS-Keep it simple stupid


In some aspects sure, KISS works. In others KISS doesn’t.


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## GMCmedic (May 6, 2020)

Missourimedic38 said:


> They are dead; epi 1:10000 has worked for years


But has it?


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## DesertMedic66 (May 6, 2020)

Missourimedic38 said:


> They are dead; epi 1:10000 has worked for years


So you want to keep things the same because “it’s worked for years”? What about backboards? They worked for years?


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## Missourimedic38 (May 6, 2020)

DesertMedic66 said:


> So you want to keep things the same because “it’s worked for years”? What about backboards? They worked for years?


Backboards and epi are no comparison. Backboards were used in fear of ambulance chasing lawyers. Who wants a weight based medicine for a code?


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## Carlos Danger (May 6, 2020)

Missourimedic38 said:


> They are dead; epi 1:10000 has worked for years


Define "worked".


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## Missourimedic38 (May 6, 2020)

Carlos Danger said:


> Define "worked".


Well CPR and Epi 1:10000. You know a drug that works better?


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## Missourimedic38 (May 6, 2020)

Missourimedic38 said:


> Well CPR and Epi 1:10000. You know a drug that works better?


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## DesertMedic66 (May 6, 2020)

Missourimedic38 said:


> Backboards and epi are no comparison. Backboards were used in fear of ambulance chasing lawyers. Who wants a weight based medicine for a code?


If it shows to have a much better outcome on neurological status of code patient and thus their ability to walk out of a hospital then I am all for it.

Back in medic school I was scared to death of weight based medications. Now that I am in the critical care field I am much more comfortable with it and an advocate for it.

An epi preload is one of the easiest medications to give a weight based dose. You want 0.5mg? Just give 5mL. You want 0.2mg? Just give 2mL.

A wise man once told me in EMT school to KISS. Then when I got into paramedic school and critical thinking classes that same man said KISS is something we tell you to avoid you from thinking critically.


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## Missourimedic38 (May 6, 2020)

DesertMedic66 said:


> If it shows to have a much better outcome on neurological status of code patient and thus their ability to walk out of a hospital then I am all for it.
> 
> Back in medic school I was scared to death of weight based medications. Now that I am in the critical care field I am much more comfortable with it and an advocate for it.
> 
> ...


Not disagreeing with you on that school of thought. AHA sets guidelines on ACLS we are just wee paramedics.


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## DesertMedic66 (May 6, 2020)

Missourimedic38 said:


> Not disagreeing with you on that school of thought. AHA sets guidelines on ACLS we are just wee paramedics.


Both my ground agency and flight agency have gone completely away from AHA.


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## Missourimedic38 (May 6, 2020)

Missourimedic38 said:


> Not disagreeing with you on that school of thought. AHA sets guidelines on ACLS we are just wee paramedics.


Ive been a licensed paramedic 13.5 years. You?


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## Peak (May 6, 2020)

Missourimedic38 said:


> Question is how did you do RN school working full time?



By switching shifts and basically working, having lecture, or clinical six days a week.



Missourimedic38 said:


> I got to finish my pre reqs. My view on nursing school is I want the knowledge to make me a even better paramedic.



Nursing school didn’t make me a better medic. There is a lot of value to more training in anatomy, chemistry, and so on as well as the varied clinical exposure but much of that can be had without nursing school. 

I would think about the stereotype of the flight nurse versus the medic. Nursing encourages you to overthink prehospital care and slows you down. Even in the ED you are planning on how much you can get done at once, every question you could need to ask, and every focused exam you need to perform so that you are going back to that room a minimum number of times.

Nursing school is also about teaching a basic foundation level across nursing, and very few programs place an emphasis on critical care. Even with medic experience there is a very good chance that you will not have the opportunity to start in the ED or ICU, especially without relocating.

I would not expect nursing school to build skills in any way. EMS is all about skills, because in the field you don’t necessarily have other clinicians to fall back on. Even in medicine Docs often have surgery, anesthesia, ENT, and so on intubate, place lines, chest tubes, et cetera.

While I would say that I’m pretty skill heavy compared to the vast majority of nurses, it came out of being an ED charge more than from bedside practice. If I can line a patient, reduce dislocations, place an NJ, or whatever else and it gets the patient out of my ED instead of waiting for the Doc to have time, IR to have a slot, PICC to come down et cetera it opens up my bed and improves my department flow.


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## Carlos Danger (May 6, 2020)

Missourimedic38 said:


> Well CPR and Epi 1:10000. You know a drug that works better?


I don’t know a drug that works better, but that doesn’t mean epi does. The only reason it remains the standard is because it’s the standard, not because of efficacy.


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## E tank (May 6, 2020)

Prolly just makes bolus dosing


Missourimedic38 said:


> Well CPR and Epi 1:10000. You know a drug that works better?



Works better when?


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## Tigger (May 6, 2020)

Missourimedic38 said:


> Ive been a licensed paramedic 13.5 years. You?


Experience trumps knowledge and evidence every time.
If a paramedic practiced medicine like medicine was 13.5 years ago...
Also, perhaps condense your replies into a single statement? It’s very difficult to follow what you are asking.


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## VFlutter (May 6, 2020)

The short-sighted goal of AHA has been ROSC without care of downstream effects or outcomes. Getting a pulse back checked the clinical save box, who care if they died 3 days later in the ICU.

Vasopressin is probably a better choice followed by reduced or single dose Epi. Less ROSC but better neurological outcomes. Or for viable patients crash onto mechanical support.



DesertMedic66 said:


> ... flight agency have gone completely away from AHA.



Not that I disagree but that was cost savings measure more than a clinical decision.


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## E tank (May 6, 2020)

VFlutter said:


> *Vasopressin is probably a better choice followed by reduced or single dose Epi.* Less ROSC but better neurological outcomes. Or for viable patients crash onto mechanical support.
> Not that I disagree but that was cost savings measure more than a clinical decision.



🍭...give that dude a lolipop.....But...I think the decision to take vasopressin away was more of a 'dumbing down' measure than a cost saving one.....which is at least one reason why I haven't been ACLS certified in over 25 years.


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## MonkeyArrow (May 6, 2020)

VFlutter said:


> Vasopressin is probably a better choice followed by reduced or single dose Epi.


I was actually reviewing the literature the other day. I’m not sure there is good evidence for this. There’s not good evidence for much of anything, especially in humans.


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## DesertMedic66 (May 6, 2020)

E tank said:


> 🍭...give that dude a lolipop.....But...I think the decision to take vasopressin away was more of a 'dumbing down' measure than a cost saving one.....which is at least one reason why I haven't been ACLS certified in over 25 years.


The cost saving statement was in reference to my flight company going away from AHA. We were able to get a better deal utilizing the ARC for training and the ability of being able to test out on BLS CPR and ARC ACLS at our own base without having to attend a skills session.

I’m also sure there was an agreement for us to go with ARC since they are going to be supplying us with blood products.


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## medichopeful (May 6, 2020)

Missourimedic38 said:


> 1mg 1:10000 prefilled. Cant beat it



For ease of access and simplicity, you're right.  You can't beat a preloaded syringe.

For favorable patient outcomes, though, epi (in the way we have been giving it) has been shown time and time again to be harmful to patient's neuro outcomes.



Missourimedic38 said:


> They are dead; epi 1:10000 has worked for years



epi 1mg q3-5 min has been great at getting pulses back, but the evidence shows that in the long run these patient have severe neurological deficits, or they never make it out of the hospital alive.  If you achieve ROSC and the patient still dies later on, they are still dead.  If you achieve ROSC and the patient has a severe neurological deficit, it is still a bad outcome.

Just because something has been done for years, does not mean that it is beneficial, and it may in fact be harmful (such as epi in this case).  Just because the AHA says something, does not make it best practice.


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## Missourimedic38 (May 6, 2020)

Tigger said:


> Experience trumps knowledge and evidence every time.
> If a paramedic practiced medicine like medicine was 13.5 years ago...
> Also, perhaps condense your replies into a single statement? It’s very difficult to follow what you are asking.


I got ADD. Sorry


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## Missourimedic38 (May 6, 2020)

medichopeful said:


> For ease of access and simplicity, you're right.  You can't beat a preloaded syringe.
> 
> For favorable patient outcomes, though, epi (in the way we have been giving it) has been shown time and time again to be harmful to patient's neuro outcomes.
> 
> ...


Well we will see whats next.


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## Bullets (May 7, 2020)

Whats happening in this thread?


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## akflightmedic (May 7, 2020)

In the voice of Sean Connery, "Schoopidditee"


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## AusPara (May 7, 2020)

DesertMedic66 said:


> We just changed to epi 0.5mg for cardiac arrests. I’m sure it won’t be too long before we start doing weight based.



0.5 for cardiac arrests is an interesting one. Where did that come/what is the rationale?


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## Missourimedic38 (May 7, 2020)

akflightmedic said:


> In the voice of Sean Connery, "Schoopidditee"


I feel fingers pointed at me. Lol


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## GMCmedic (May 7, 2020)

AusPara said:


> 0.5 for cardiac arrests is an interesting one. Where did that come/what is the rationale?


I think the rationale is that weve been dosing based on a study in dogs from the 1960's if you google, but if you dig deeper the first documented study was 1906. Nobody knows what the optimal dose is and how often to give it, or when in the scenario to give it. Nobody will ever know those answers until someone goes away from the norm. 

There are a few systems that have move to 0.5 q3-5 minutes, and i expect several more will move in different directions. 

I actually expect AHA to go this route too.


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## mgr22 (May 7, 2020)

AusPara said:


> 0.5 for cardiac arrests is an interesting one. Where did that come/what is the rationale?



Too bad the PARAMEDIC2 study mentioned in this article didn't include 0.5 mg of epi as a choice:









						Grand Rounds: Hearts at the Expense of Brains
					






					www.emsworld.com


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## DesertMedic66 (May 7, 2020)

AusPara said:


> 0.5 for cardiac arrests is an interesting one. Where did that come/what is the rationale?


That is a good question. Unfortunately my ground agency does not provide us with any of the studies or really the reasoning why they are changing things. In some cases we use 1mg of epi, in others we use 0.5mg. For example our V-Fib/V-Tach protocol only includes a single dose of 1mg of epi during the entire arrest. If we witness the patient go into V-Fib/V-Tach we do 3 stacked shocks.


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## AusPara (May 7, 2020)

GMCmedic said:


> I think the rationale is that weve been dosing based on a study in dogs from the 1960's if you google, but if you dig deeper the first documented study was 1906. Nobody knows what the optimal dose is and how often to give it, or when in the scenario to give it. Nobody will ever know those answers until someone goes away from the norm.
> 
> There are a few systems that have move to 0.5 q3-5 minutes, and i expect several more will move in different directions.
> 
> I actually expect AHA to go this route too.



Thanks for your reply. 

As mgr22 noted, I was under the impression there wasn’t much to the idea in terms of evidence. 

I agree nobody really knows, but I’m surprised people are deviating from the peak body recommendations in the absence of compelling evidence to contrary. Must be passionate medical director there somewhere I would reckon. Interesting stuff.


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## Alan L Serve (May 17, 2020)

Subdissociative ketamine

0.1-0.3 mg/kg IV


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## Akulahawk (May 18, 2020)

I'm a fan of ketamine for pain control too. 0.1-0.3 mg/kg IV works pretty well for most. It doesn't last that long (one down side), but if you accidentally give too much, you won't shut down the respiratory drive. So, it's reasonably safe. 

For epi, I've heard of some places going to what's basically an EtCO2-driven dosing system. You give 0.5 or 1mg IV, and watch the EtCO2. If it _and_ the compressions are effective, you should see an increase in EtCO2. You don't give it again unless/until you see the EtCO2 drop off. Vasopressin is good stuff too but I haven't seen it used in the field and I haven't seen it used often in the in-hospital codes I've been a part of.


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## silver (May 18, 2020)

Akulahawk said:


> I'm a fan of ketamine for pain control too. 0.1-0.3 mg/kg IV works pretty well for most. It doesn't last that long (one down side)



and there we come back to the 100mg/100ml.

Can give 0.1-0.3mg/kg IV bolus followed by continuous infusion 0.1-0.3mg/kg/hr or 2-5mcg/kg/min.


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