# "Outside the norm" paramedic drugs



## NomadicMedic (May 20, 2012)

I'm curious if any ground medics are carrying drugs outside of the normal load out. For example, most of use have haldol, a benzo or two and benadryl for sedation. Anyone carrying Ziprasidone?

Antiemetics are usually Zofran and Phenergan. Anyone carry anything like Anzemet? 

It seems like the standard ALS pain meds are Fentanyl, Morphine and Toradol. What do you have in your box? Butorphanol?

My guess if it's anyone, it'll be someone from Texas.


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## akflightmedic (May 20, 2012)

n7lxi said:


> I'm curious if any ground medics are carrying drugs outside of the normal load out. For example, most of use have haldol, a benzo or two and benadryl for sedation. Anyone carrying Ziprasidone?



Ok, you got me. Why are you carrying Geodon? Are you encountering schizos in acute violent outbursts often enough to require this? Are there off label uses you are carrying this for?

Do the risks outweigh the benefits? What if they are on oral geodon and you give some more IM...bad juju there.

What benefit is there to administering geodon over other agents?



n7lxi said:


> Antiemetics are usually Zofran and Phenergan. Anyone carry anything like Anzemet?



This one I was not familiar with but from what I read it is given about an hour before chemo treatments or two hours prior to surgery.

So why and what is the benefit of this drug on an ambulance?



n7lxi said:


> It seems like the standard ALS pain meds are Fentanyl, Morphine and Toradol. What do you have in your box? Butorphanol?



This one I know under the name Stadol.

Widely used in veterinarian medicine...
Highly abused in the nasal spray form
More effective in women and used during labor or in conjunction with some surgical anesthesia.

Again, same question...what is the benefit over the other meds and why carry this when it is limited in its actions?


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## NomadicMedic (May 20, 2012)

I'm not currently carrying any of these, but know of services that do have the examples that I mentioned. 

My last ALS service carried Anzemet instead of Zofran. Benefit? I don't believe there was any, aside from the fact that it was what the med control doc wanted.

Another service I know of did carry Geodon, it was on med control orders only, and they did run in an area where there were many unstable psych patients who had been placed in group type homes following the closure of a state run mental facility. I don't know if they still carry it. 

 I'm curious if anyone is currently running with these (or other) meds.


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## STXmedic (May 20, 2012)

Olanzapine for behavioral/psychs


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## NomadicMedic (May 20, 2012)

PoeticInjustice said:


> Olanzapine for behavioral/psychs



Is the Zyprexa first line for these patients? What's the criteria for giving it?


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## STXmedic (May 20, 2012)

It can be. It reads, as standing orders, consider diazepam OR Midazolam OR Olanzapine. I still usually just go versed first line.


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## Anjel (May 20, 2012)

I wish we had zyprexa zidas(spelling?) . Works amazing sublingual. But I dont see being able to put it in someones mouth who is uncooperative.


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## Sasha (May 20, 2012)

Anjel1030 said:


> I wish we had zyprexa zidas(spelling?) . Works amazing sublingual. But I dont see being able to put it in someones mouth who is uncooperative.



Sit on them and plug their nose.

Works great for 3 year olds.

The only "outside the norm" drugs we have are on our critical care trucks, which I'm not allowed to play on.


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## Tigger (May 20, 2012)

I've read some a bit about ketamine, anyone carrying that on their rig, no one is in my areas.


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## STXmedic (May 20, 2012)

Ketamine here. Well, not on the rigs yet. It just got in to our supply.


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## Doczilla (May 20, 2012)

Ketamine is extremely underutilized.


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## usalsfyre (May 20, 2012)

I won't list CCT drugs because they really don't count.

Last service I was at had nitro infusions, famotidine and norepi. There's a service just west of here that supposedly carries hydromorphone.


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## Bosco836 (May 20, 2012)

n7lxi said:


> Antiemetics are usually Zofran and Phenergan. Anyone carry anything like Anzemet?



We use Gravol (dimenhydronate) IM or IV here as our (only) antiemetic drug.


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## Veneficus (May 20, 2012)

akflightmedic said:


> This one I was not familiar with but from what I read it is given about an hour before chemo treatments or two hours prior to surgery.



They are both anti-emetics, on the ambulance, stopping vomiting or relieving nausea is a good thing in my mind. 

I like phenergan (promethazine) more than zofran because of the side effect profile. (which includes "mild sedation")

Use it secondary to narc administration, for motion sickness, or for a "sick" person.

Most people now like zofran because of "less" side effects, but I liken it to nyquil vs. dayquil. When you want to feel better and rest, especially if you are going to be chilling in the ER for a few hours, it is best to be a bit more relaxed.

It is also a first generation H1 blocker. So you do not need it an diphenhydramine seperately. 

Really it is not a good idea if you have to drive, work, etc, though. 

I keep phenergan in the house.

As for the rest, I would replace morphine with meperidine. 

Outside the USit is routinely used as a medication to reduce labor pain by peripheral IV instead of needing regional anesthesia. (it does not reduce smooth muscle contraction like morphine)

Good stuff too.


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## we talking bout practice (May 20, 2012)

We also use Gravol, north of the border.


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## Tigger (May 20, 2012)

Veneficus said:


> They are both anti-emetics, on the ambulance, stopping vomiting or relieving nausea is a good thing in my mind.
> 
> I like phenergan (promethazine) more than zofran because of the side effect profile. (which includes "mild sedation")
> 
> ...



Was not aware of the "moderate sedation" qualities of phenergan. It's our only anti-emetic at the sports medicine job and has worked very well the one or two times the doc has given it in the last couple of years. Well enough that the player could play in a game an hour later, so I guess the sedation properties cannot be too significant?


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## STXmedic (May 20, 2012)

Tigger said:


> Was not aware of the "moderate sedation" qualities of phenergan. It's our only anti-emetic at the sports medicine job and has worked very well the one or two times the doc has given it in the last couple of years. Well enough that the player could play in a game an hour later, so I guess the sedation properties cannot be too significant?



I frequently have patients PTFO after IV Phenergan. Definitely has some sedative properties.


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## NomadicMedic (May 20, 2012)

Tigger said:


> Was not aware of the "moderate sedation" qualities of phenergan. It's our only anti-emetic at the sports medicine job and has worked very well the one or two times the doc has given it in the last couple of years. Well enough that the player could play in a game an hour later, so I guess the sedation properties cannot be too significant?



Don't know how much the doc gave, but every time I gave 12.5mg of Phenergan... everyone was loopy.


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## NomadicMedic (May 20, 2012)

How about beta blockers? 

Some other "non standards"; My service currently carries 60mg of PO Prednisone, PO (liquid) Benadryl, 50mg of Labetelol and PO (liquid) Maalox.


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## RocketMedic (May 20, 2012)

usalsfyre said:


> I won't list CCT drugs because they really don't count.
> 
> Last service I was at had nitro infusions, famotidine and norepi. There's a service just west of here that supposedly carries hydromorphone.



Champion and Careflite, I reckon?

They carry nubain (not that exciting) on EPFD in lieu of morphine. We've got solu-medrol, terbutaline, vecuronium, mag and inotropium at my current service- a bit out of the box for the area. We also have bretyllium in our supply and protocols, but not on the trucks.

One service here doesn't even carry narcs or benzos on their MICU trucks.


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## NomadicMedic (May 20, 2012)

I didn't think Bretyllium was made anymore? Like the Bretyllium factory laid off all the oompa loompas... Or the Bretyllium mine collapsed ... Or something like that.


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## medicsb (May 20, 2012)

When I left my old job a year and a half ago, we were still carrying flumazenil.  Some desk jockey swore it was required by the state, but interestingly, the state regs didn't mention it.  We also still had thiamine, verapamil, terbutaline, metoprolol, and labetalol.  When I started, we had bumex, decadron, and alternate opiate antagonist (i forget which), but only because there had been a shortage of lasix, solu-medrol, and narcan at some point.

I think there may still be some MICUs in NJ carrying insulin for the treatment of hyperkalemia.


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## Jon (May 21, 2012)

medicsb said:


> When I left my old job a year and a half ago, we were still carrying flumazenil.  Some desk jockey swore it was required by the state, but interestingly, the state regs didn't mention it.  We also still had thiamine, verapamil, terbutaline, metoprolol, and labetalol.  When I started, we had bumex, decadron, and alternate opiate antagonist (i forget which), but only because there had been a shortage of lasix, solu-medrol, and narcan at some point.
> 
> I think there may still be some MICUs in NJ carrying insulin for the treatment of hyperkalemia.


I don't think half that stuff is on the PA list at all!

One of my jobs is going to decadron, because our doc likes it better in some cases, and it means we don't have to worry about a solu-medrol shortage down the road.


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## Jon (May 21, 2012)

Jon said:


> I don't think half that stuff is on the PA list at all!
> 
> One of my jobs is going to decadron, because our doc likes it better in some cases, and it means we don't have to worry about a solu-medrol shortage down the road.


In my neck of the woods, some services are starting to carry PO/SL Zofran. Primary reason for stocking it was for Tactical/Remote medicine (EMS strike teams and SWAT medics), but now the region is OK with it going on the trucks for "regular" patients, especially with folks having a hard time getting ahold of Zofran.

As for Narcs-  Versed/Ativan, Morphine/Fentanyl - Some or all of the above, depending on the shortage of the month. Nothing really cool here. Toridol would be cool.


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## medicsb (May 21, 2012)

Jon said:


> I don't think half that stuff is on the PA list at all!
> 
> One of my jobs is going to decadron, because our doc likes it better in some cases, and it means we don't have to worry about a solu-medrol shortage down the road.



Yeah, NJ is weird like that.  Limited standing orders (actually they've become more liberal since i left), but docs might order a ton of interventions depending where you worked.  Anyhow, most of those drugs never got used.  Terbutaline was occaisionally given to a bad asthmatic or COPD patient (did hear of a doc ordering it on a patient in preterm labor) and metoprolol would be given to STEMIs before the big study out of China.  Now and then thiamine was given to altered mental status patients with a known EtOH abuse history.  Only gave labetelol once, but I know that some other projects used it more often.


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## stallion (May 21, 2012)

Interesting to see what everybody uses....and what some of us lack. Here's a few that we have that may be out of the norm

Prochlorperazine (Stemetil) in addition to odansetron as anti emetics

I've think there are a few services out there that carry AB's...we have ceftriaxone. We primiarly use it for meningococcal disease, however, we are also able to start end goal directed therapy (used in addition with fluids and dexamethasone) for sepsis.

We also have IV beta 2 agonists (along with nebulized). 

Very jealous of the services who carry oral/liquid anti-histamines...would love to have PO Zyrtec (cetirizine)


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## Veneficus (May 21, 2012)

Tigger said:


> Was not aware of the "moderate sedation" qualities of phenergan. It's our only anti-emetic at the sports medicine job and has worked very well the one or two times the doc has given it in the last couple of years. Well enough that the player could play in a game an hour later, so I guess the sedation properties cannot be too significant?



It is dose dependant.

at 6-50mg (usually in ems used at 12.5 or 25mg) it can be significantly depressing.


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## Remeber343 (May 21, 2012)

We have a significant elderly population where i am, we do 6.25/12.5/25mg, of course it is dependent on the severity of the patient. Also want to be a bit careful when giving it with narcs, they work well together, It can cause quite the sedation.


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## Handsome Robb (May 21, 2012)

n7lxi said:


> How about beta blockers?



We don't carry it but I know an agency near me carries atenolol. 

The last time I saw it was for SBP > 220 with symptoms of HTN, I can't remember what/if there was a diastolic pressure listed as well.

We carry a pretty standard list where I work.


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## Handsome Robb (May 21, 2012)

NVRob said:


> We don't carry it but I know an agency near me carries atenolol.
> 
> The last time I saw it was for SBP > 220 with symptoms of HTN, I can't remember what/if there was a diastolic pressure listed as well.
> 
> We carry a pretty standard list where I work.



I lied, labetolol not atenolol.


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## Doczilla (May 21, 2012)

I also think beta blockers are underused in Ems. Not really for hypertensive crisis, but theyre great in AMI. Think about it, what if your chest pain has a total occlusion, (safe bet in any STEMI) that reflex tachycardia from the nitro might just kill them. 

Choosing dexemethasone over methylprednisolone is strange, because in the context of airway burns , asthma , COPD, anaphalaxys, and other acute stuff, solu medrol works faster.


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## WestMetroMedic (May 21, 2012)

It is my understanding that there is no statistical decrease in morbidity and mortality with beta blocker administration in the setting of acute myocardial infarction.  I think there are also better things that you can do for these patients such as judicious admin of nitro via gtt at an aggressive rate. I've carried lopressor at my previous service and have it a couple of times and haven't seem any real improvements in my patients or declines and the service pulled it from the trucks shortly after I left.

Other random ones I have carried are Cardizem (not a fan)
Levophed
Labatelol
Proparicaine
Xopenex (saleswoman must have been hot enough to convince our medical director to carry this ridiculous waste of money)

My current service is very utilitarian but we do have Ketamine for profound agitation and next month, we are going to start using it as a pain adjunct.  It is an amazing medication for mental health crisis patients.


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## Veneficus (May 21, 2012)

NVRob said:


> I lied, labetolol not atenolol.



labetolol is a great drug, but I think esmolol would be better. 

It can be easily titrated and similar to propofol, when you turn off the drip the effects stop very rapidly. I have never seen it used outside of the ICU though.

I have used labetolol in the EMS setting and while it works very well, I would be concerned about mixing it with other agents like morphine or versed in patients who may require them as well.


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## Doczilla (May 21, 2012)

I'll have to look it up, but beta blockers have a big edge over nitro in total occlusions (stemi) . And again, poor decisions with nitro and total occlusions can be deadly. Some of the more cardioselective ones don't really hurt RV infarcts, too. 

I've used propofol extensively on both sides. Big fan. I like ketamine better for general purpose though


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## medicsb (May 21, 2012)

Doczilla said:


> I'll have to look it up, but beta blockers have a big edge over nitro in total occlusions (stemi) . And again, poor decisions with nitro and total occlusions can be deadly. Some of the more cardioselective ones don't really hurt RV infarcts, too.
> 
> I've used propofol extensively on both sides. Big fan. I like ketamine better for general purpose though



Look up the results of COMMIT.  The use of early IV beta-blockers in MI has been greatly narrowed because of this study.  Their routine administration has largely been abandoned in many practices.


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## mycrofft (May 21, 2012)

Silly question, but if the drug is within protocols I wouldn't think of it as outside the norm. If it was outside the protocols, what is it doing on a vehicle?


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## Veneficus (May 21, 2012)

mycrofft said:


> Silly question, but if the drug is within protocols I wouldn't think of it as outside the norm. If it was outside the protocols, what is it doing on a vehicle?



I think it is in reference to some services being more liberal or advanced than others in what they deem appropriate for prehospital administration.


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## NomadicMedic (May 21, 2012)

Many of these drugs are outside of the "standard" load out that the majority of paramedic level services carry. If you read the first post, you'll note that I was curious about exceptions from the standard drugs.


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## mycrofft (May 21, 2012)

Who sets the standards?
If it is up to each agency's medical controller, they can stock almost anything then, right?


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## Akulahawk (May 21, 2012)

mycrofft said:


> Who sets the standards?
> If it is up to each agency's medical controller, they can stock almost anything then, right?


I would say that the drugs that can be stocked _could_ be anything that is approved by the Local EMS agency and approved by the State EMSA. In California's case, all the drugs listed in this thread could be stocked, if it's approved... but with some of them... good luck getting it approved by anyone (that matters).:blink:


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## jwk (May 21, 2012)

WestMetroMedic said:


> My current service is very utilitarian but we do have *Ketamine for profound agitation* and next month, we are going to start using it as a pain adjunct.  It is an amazing medication for *mental health crisis patients*.



I'm curious if this is common use in EMS.  Knowing the emergence delirium associated with it's use and the fact that it's a phencyclidine derivative (think PCP) it doesn't seem like a great drug for this indication.


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## mikie (May 21, 2012)

*Just curious, no MJ here...*

Does anyone carry Propofol?  Or is that only carried if initiated by a doc (an infusion)?


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## NomadicMedic (May 21, 2012)

mikie said:


> Does anyone carry Propofol?  Or is that only carried if initiated by a doc (an infusion)?



A few of my friends in Washington carry propofol for RSI.


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## usalsfyre (May 21, 2012)

mikie said:


> Does anyone carry Propofol?  Or is that only carried if initiated by a doc (an infusion)?



Protocols were approved by our OMD last week, waiting on the state now. CCT only drug though. Propofol's got some "quirks" regarding its effect on the myocardium though...


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## WestMetroMedic (May 21, 2012)

jwk said:


> I'm curious if this is common use in EMS.  Knowing the emergence delirium associated with it's use and the fact that it's a phencyclidine derivative (think PCP) it doesn't seem like a great drug for this indication.



Is standard in the Minneapolis area.  One of our associate medical directors, John Ho, does a lot of speaking on excited delirium and also works with Taser on medical stuff.  in addition to being a medical director for my agencyand a neighboring ALS fire department, he works one weekend a month as a sheriff deputy.  His research, which, like a typical rube, I cannot cite, is showing that of your available options, Ketamine is the best since it doesn't contribute to the manifestation of malignant hyperthermia and has such a rapid onset compared to the benzos and hypnotics we have traditionally used.  There really aren't many decent options to begin with for these patients since the pathophysiology of this process isn't fully known.


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## medicsb (May 21, 2012)

I'm curious how frequently these "outside the norm" drugs are utilized.  Especially drugs like labetalol, propofol, ceftriaxone, or maalox.  I imagine they're being used almost never.  Am I wrong in this assumption?


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## jwk (May 21, 2012)

n7lxi said:


> A few of my friends in Washington carry propofol for RSI.



Propofol is an anesthesia drug, and there is huge debate about whether anyone besides anesthesia personnel should administer it via IV bolus.  RN's in many states are prohibited by their state licensing boards from giving propofol boluses - it's only allowable by infusion with ventilated patients.  

IMHO, and I use propofol daily, it's absolutely foolish to try and use this drug in pre-hospital care.  It's not reversible - once it's in, it's in.  There are numerous side effects, and in the patient population most of you would want to use it in, propofol would not be the drug of choice anyway given it's cardiovascular side effects. There are far better choices. 

Lastly - the package insert for propofol states that it is for use by anesthesia personnel only, and that is the way both the FDA and manufacturers want to keep it.  If you box someone using propofol in the field, there will be a line of plaintiff's lawyers waiting to talk to the family and someone will be writing checks with lots of zeroes.


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## triemal04 (May 21, 2012)

jwk said:


> I'm curious if this is common use in EMS.  Knowing the emergence delirium associated with it's use and the fact that it's a phencyclidine derivative (think PCP) it doesn't seem like a great drug for this indication.


I've never used or carried ketamine but there's been a small amount of talk about looking to use it for sedation due to drug shortages.

I've heard/read that a low to moderate dose of a benzo given at the same time will help blunt the emergence phenomena.  Any truth to that?

The other part to that is, in your experience, how often are you seeing that when it's given for a relatively short period of time; say a max of 45 minutes?


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## jwk (May 21, 2012)

WestMetroMedic said:


> Is standard in the Minneapolis area.  One of our associate medical directors, John Ho, does a lot of speaking on excited delirium and also works with Taser on medical stuff.  in addition to being a medical director for my agencyand a neighboring ALS fire department, he works one weekend a month as a sheriff deputy.  His research, which, like a typical rube, I cannot cite, is showing that of your available options, Ketamine is the best since it doesn't contribute to the manifestation of malignant hyperthermia and has such a rapid onset compared to the benzos and hypnotics we have traditionally used.  There really aren't many decent options to begin with for these patients since the pathophysiology of this process isn't fully known.



Hmmm - I'm constantly amazed at how willing people are to risk their careers with off-label use of medications.  The use of ketamine is psychiatric crises is not well studied, most reports are purely anecdotal, and the ones I've read come nowhere close to justifying it's use for this indication.  It is not a widely recognized or accepted use for the drug.  Sure it works (as do a lot of other drugs) but there are tons of side effects and considerations that come along with it, and using it on top of a bunch of other anti-psychotic potions (as in several of the published articles) is just baseless.  "We tried everything else and this is the only thing that worked" is hardly justification for routine use.


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## jwk (May 21, 2012)

triemal04 said:


> I've never used or carried ketamine but there's been a small amount of talk about looking to use it for sedation due to drug shortages.
> 
> I've heard/read that a low to moderate dose of a benzo given at the same time will help blunt the emergence phenomena.  Any truth to that?
> 
> The other part to that is, in your experience, how often are you seeing that when it's given for a relatively short period of time; say a max of 45 minutes?



I always give midazolam when I'm giving ketamine.  The post-procedure delirium is not that common (it's more common in kids) but it can be extremely impressive when it does happen.

Most of the procedures I give ketamine for are short - I give an initial bolus and maybe a smaller bolus 20 minutes later if the procedure is still going.  But it's never ever my sole agent - propofol/ketamine is more typical with a little midaz along the way.  I personally don't use it by infusion although I know a lot of people that do, especially mixed with propofol, which is referred to as "ketafol".


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## Doczilla (May 21, 2012)

As long as you have a benzo, ketamine is fine. And the ICP stigma was pretty much debunked.


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## medicsb (May 21, 2012)

jwk said:


> Hmmm - I'm constantly amazed at how willing people are to risk their careers with off-label use of medications.



I imagine it has to do with not many physicians (or medics, or nurses) losing their careers over off-label use of meds, but I don't doubt that a number of docs have been sued and lost.  

Anyhow, I think you made some pretty good points regarding prehospital propofol and ketamine for psych/agitated delerium.


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## triemal04 (May 22, 2012)

medicsb said:


> I'm curious how frequently these "outside the norm" drugs are utilized.  Especially drugs like labetalol, propofol, ceftriaxone, or maalox.  I imagine they're being used almost never.  Am I wrong in this assumption?


I know of a few places that carry various beta-blockers.  They're used more for rapid afib than anything, or occasional for _very_ refractory vf.  If the numbers were really crunched, my guess is that they could be removed and there wouldn't be a problem.


medicsb said:


> Look up the results of COMMIT.  The use of early IV beta-blockers in MI has been greatly narrowed because of this study.  *Their routine administration has largely been abandoned in many practices.*


As it should be.  That's the real point that that study should enforce.  Indiscrimenently giving every patient with an MI a beta-blocker and then continueing that treatement post-repurfusion just doesn't sound like a good idea to begin with.  But that doesn't change the fact that there are some patients who will respond to, and should be given beta-blockers during an MI.  Like everything, it just means that a little more thinking needs to be done before pushing a med.


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## NomadicMedic (May 22, 2012)

One of the most informative threads I've read in a while.

Thanks to all participating!


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## Melclin (May 22, 2012)

medicsb said:


> I'm curious how frequently these "outside the norm" drugs are utilized.  Especially drugs like labetalol, propofol, ceftriaxone, or maalox.  I imagine they're being used almost never.  Am I wrong in this assumption?



We carry ceftriaxone. Predominantly for meningoccal meningitis. I don't know that its ever been given accurately for this, if it has I suspect you could count the number of times on one hand. We can also give it for severe sepsis "on consult" (which means speaking with an experienced intensive care paramedic in the control rooms regarding the appropriateness of its use in cases where transport exceeds 1 hour. If they don't wanna take responsibility for that, we can theoretically speak with the hospital that we plan on transporting too, but I've never done this, its very rare, and I don't really know how it works.). I've never given it but called for it once and was denied on the basis that the person on the line didn't feel the person was sick enough for prehospital empiric abx. I've had quite a few other pts who would have qualified had the tranport time been longer.

I've been interested for a while in expanding sepsis management to include lactate measurement and drawing of cultures to remove the main barrier to prehospital abx. We bang on (and spend lots of money) all the time about fluid resuscitating hypotensive trauma pts of whom we see very few (lets leave aside the fact that we're probably not doing them any favours by giving them 3L of cold fluid that neither carries oxygen nor clots), while rarely focusing on sick sepsis pts of whom we see many and in whom the benefits of early abx have been well established. I hope that the few services I've heard of in the US doing lactates publish in peer reviewed journals so we can add to the evidence (hopefully in favour) behind prehospital sepsis management.


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## stallion (May 22, 2012)

I've had a little experience with the use of cef...given it twice in the past year, both times for severe sepsis. As Melclin pointed out, there's lots good (and maybe ongoing) research on the topic. Obviously there's no sense in giving anti-biotics out to everyone meeting SIRS criteria, especially when you're only 10minutes from hospital, however when considering extended transports times with severely septic patient, it definitely has its place.


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## NomadicMedic (May 22, 2012)

We're currently performing POC lactate testing, with a lactate of >4.0 mmol/L along with clinical signs/suspicion of sepsis for entrance into the sepsis protocol. 

Core temperature greater than 38°C  or less than 36°C
Heart rate greater than 90 bpm
Respiratory rate >20
Hypotension

We're not doing ABx, but infusing a liter of NS, with a second liter if hypotension continues, followed by dopamine and a "sepsis alert" to the ED.


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## rwik123 (May 22, 2012)

jwk said:


> Propofol is an anesthesia drug, and there is huge debate about whether anyone besides anesthesia personnel should administer it via IV bolus.  RN's in many states are prohibited by their state licensing boards from giving propofol boluses - it's only allowable by infusion with ventilated patients.
> 
> IMHO, and I use propofol daily, it's absolutely foolish to try and use this drug in pre-hospital care.  It's not reversible - once it's in, it's in.  There are numerous side effects, and in the patient population most of you would want to use it in, propofol would not be the drug of choice anyway given it's cardiovascular side effects. There are far better choices.
> 
> Lastly - the package insert for propofol states that it is for use by anesthesia personnel only, and that is the way both the FDA and manufacturers want to keep it.  If you box someone using propofol in the field, there will be a line of plaintiff's lawyers waiting to talk to the family and someone will be writing checks with lots of zeroes.



Isn't it just as dangerous as other meds such as paralytics that agencies that RSI have on the truck? It's not reversible but so aren't a whole lot of other drugs... Yet it's a relatively short acting drug that can be titrated to effect. 

I'm by no means knowledgable on it, just wanna hear others experience with it.


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## Doczilla (May 22, 2012)

Succinylcholine has 13 contraindications; only a handful of which apply to the prehospital setting. Malignant hyperthermia for example , which does not manifest until they are in the hospital for a while. Others, like burns and crush injuries are only pertinent if the injury is >24 hours old, and even then only causes a serum potassium increase of about .5. Unless it was 7.9 when you give it to them, not really a big deal. Im sure the clenched jaw, and seizures that make succynlcholine so valuable in head injuries make it worth it. 

Remember, etomidate wears off in less than 10 mins. Not providing maintenence sedation is barbaric. Propofol is pretty stable, and even cardioprotective with strong antiemetic and anticonvulsive properties that make is very desirable. It dosent take a genius to use it.


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## Melclin (May 22, 2012)

n7lxi said:


> We're currently performing POC lactate testing, with a lactate of >4.0 mmol/L along with clinical signs/suspicion of sepsis for entrance into the sepsis protocol.
> 
> Core temperature greater than 38°C  or less than 36°C
> Heart rate greater than 90 bpm
> ...



We have identical criteria for sepsis, minus the lactate measurement. 

Treatment at what you would call the ALS level, involves saline up 60mls/kg, with adrenaline infusion +/- push doses in whatever combination is required. With notification. 

So all in all, quite similar. Do you know if your protocol is being studied for publication? In what way does lactate affect inclusion in the sepsis protocol?


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## mycrofft (May 22, 2012)

1. Is the malignant hyperthermia from these meds the same as the one which has geographic clusters in some parts of the country and world? (Might affect where you use those drugs sometimes; a couple of those clutters in Nebraska were pretty rural).
2. IV ABX in the field...what about potential for anaphylaxis, are you equipped and ready to cope with the reaction to the reaction to an IV bolus? 

Odd how on the one hand we are striving to make antibiotics use more tailored to the proven presence and type of infection on one hand (using technology we developed to detect and react to chem/biological agents), and yet striving to take and start them sooner in the field without such? Not necessarily bad, but sort of ironic.


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## medicsb (May 22, 2012)

Doczilla said:


> Succinylcholine has 13 contraindications; only a handful of which apply to the prehospital setting. Malignant hyperthermia for example , which does not manifest until they are in the hospital for a while.



The onset of malignant hyperthermia is pretty swift and needs to be identified ASAP and cooling measures initiated immediately, and if dantrolene is available it needs to be given ASAP.  Fortunately it is quite rare, but as mycroft noted, the genetic mutation predisposing one to it is prevalent in certain geographical regions, and I've heard of paramedics in at least one of those regions using only rocuronium for paralyis).  

Also whether or not propofol requires a genius to administer it, I don't see why it would be used in the prehospital setting except for novelty.


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## NomadicMedic (May 22, 2012)

I don't believe our lactate/sepsis measurements are being used for any publication. We advise of a "sepsis alert" simply to make the hospital aware of that patient that may need immediate antibiotics and/or fluid resuscitation. And again, a patient must have a lactate of 4.0 mmol/L to meet the "sepsis alert" criteria.


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## Doczilla (May 22, 2012)

Results vary. Onset can be delayed as much as a few hours, and the role of succynlcholine in MH has not been clearly defined. My point is, the armchair quarterbacks that play a role in determining what we do in the field do not consider the availability of a detailed history if RSI becomes neccesary. If their condition warrants a pharmalogical control of their airway, chances are we're pretty tied up.

Most exclusionary criteria, using this as an example, are taken straight from the hospital. 

Sure, there are many reasonable alternatives to propofol in continuous sedation. I don't advocate one agent over another. However, im skeptical of the stigma surrounding propofol. If you're trained in RSI, you should seek proficiency in every agent you could potentially use. 

A little knowledge is a dangerous thing. 



medicsb said:


> The onset of malignant hyperthermia is pretty swift and needs to be identified ASAP and cooling measures initiated immediately, and if dantrolene is available it needs to be given ASAP.  Fortunately it is quite rare, but as mycroft noted, the genetic mutation predisposing one to it is prevalent in certain geographical regions, and I've heard of paramedics in at least one of those regions using only rocuronium for paralyis).
> 
> Also whether or not propofol requires a genius to administer it, I don't see why it would be used in the prehospital setting except for novelty.


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## Christopher (May 22, 2012)

medicsb said:


> ...and I've heard of paramedics in at least one of those regions using only rocuronium for paralysis...



NC just added it to our RSI formulary so I hope we drop succ as soon as the new protocols get Ok'd.


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## jwk (May 22, 2012)

Doczilla said:


> Results vary. Onset can be delayed as much as a few hours, and the role of succynlcholine in MH has not been clearly defined. My point is, the armchair quarterbacks that play a role in determining what we do in the field do not consider the availability of a detailed history if RSI becomes neccesary. If their condition warrants a pharmalogical control of their airway, chances are we're pretty tied up.
> 
> Most exclusionary criteria, using this as an example, are taken straight from the hospital.
> 
> ...



I'm not sure where you're getting your information on malignant hyperthermia and succinylcholine, but you're way off.

MH is a rare but extremely high mortality syndrome that is caused my two things - halogenated anesthetic agents and succinylcholine.  The link between MH and sux has most certainly been clearly defined and a HX of MH is an absolute contraindication to the use of sux in any situation.

As far as propofol, there is a big difference between giving it by infusion to a ventilated patient for long transports (not unusual at all) and giving it for RSI or intiation of sedation by paramedics (a questionable practice at best and not supported by any controlled studies that I'm aware of.)


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## NomadicMedic (May 22, 2012)

Here's a paramedic service protocol that uses it. (available freely on the Internet)

Grays Harbor Emergency Medical Services Patient Care Procedure Protocol
RAPID SEQUENCE INTUBATION


DOSE

0 - 10 minutes

Preparation

0 - 5 minutes

Preoxygenation to an O2 Sat of >90%

0 - 3 minutes
Pretreatment: ~Lidocaine for reactive
airways or  ICP ~Atropine for children < 8 years old

Adult: 1.0mg/kg IV
PEDS: 0.02mg/kg IV

Zero minutes
Paralysis with induction: Pre-medication:
~Propofol OR
~Versed
Paralysis:
~Succinylcholine

Adult: 1.0-2.5mg/kg IV
PEDS: 2.5-3.5mg/kg IV
Adult: : 1-4mg IV to max 0.1mg/kg
PEDS: 0.1mg/kg (up to 5.0mg)
Adult: 1.0 - 1.5mg/kg IV
PEDS: 1.0-2.0mg/kg IV
Zero plus 25 seconds

Protection - Sellick's Maneuver
Zero plus 45 seconds

Placement- intubate, check placement

After confirmed placement
For sedation:
~ Propofol OR
~Versed OR ~Valium
If Versed or Valium used, also use Fentanyl 50mcg.
For continued paralysis: ~Vecuronium OR
~ Pancuronium

Adult: 1.0-2.5mg/kg IV
PEDS: 2.5-3.5mg/kg IV
Adult: 1-4mg IV to max 0.1mg/kg
PEDS: 0.1mg/kg ( 5.0mg max)
Adult: 5-10mg slow IV
PEDS: 0.1-0.3mg/kg IV
Adult: 0.1mg/kg IV
PEDS: >9 y/o 0.1mg/kg IV
Adult: 0.06-0.1mg/kg IV
PEDS: 0.04-0.1 mg/kg IV


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## Smash (May 22, 2012)

jwk said:


> As far as propofol, there is a big difference between giving it by infusion to a ventilated patient for long transports (not unusual at all) and giving it for RSI or intiation of sedation by paramedics (a questionable practice at best and not supported by any controlled studies that I'm aware of.)



Questionable: why?  How much of EMS is supported by controlled studies?  For that matter, how much of medicine in general is supported by controlled studies?

Our medics who work a combination of HEMS and ground response (chase cars) use propofol for RSI on a regular basis with good success and very few complications.
The options we have are fentanyl+midazolam, or ketamine, or fentanyl+propofol.  Neuromuscular blockers include suxamethonium, rocuronium, pancuronium and vecuronium.
Ongoing sedation is then with morphine+midazolam or propofol+morphine (fentanyl can obviously be substituted for the morphine)


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## Doczilla (May 22, 2012)

Jwk, no one said anything about using propofol as an induction agent. And feel free to cite some studies.


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## medicsb (May 22, 2012)

Smash said:


> Questionable: why?  How much of EMS is supported by controlled studies?  For that matter, how much of medicine in general is supported by controlled studies?
> 
> Our medics who work a combination of HEMS and ground response (chase cars) use propofol for RSI on a regular basis with good success and very few complications.
> The options we have are fentanyl+midazolam, or ketamine, or fentanyl+propofol.  Neuromuscular blockers include suxamethonium, rocuronium, pancuronium and vecuronium.
> Ongoing sedation is then with morphine+midazolam or propofol+morphine (fentanyl can obviously be substituted for the morphine)



I imagine your ICPs are for more experienced and educated/trained than the average medic in the US, which is where I imagine JWK's experience with medics is centered.

The idea of RSI or propofol, etc. gets scary when medics in places like Grays Harbor County are allowed to use such drugs.  New medics there are only required to get 4 tubes per year over their first 3 years, and then only 2 per year there after.  Considering that the majority of ETI candidates would be cardiac arrests, I bet the average medic would be lucky do one RSI in a year, especially considering the number of medics that seem to be in that particular system.


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## Doczilla (May 22, 2012)

Alright, I'm not posting from my phone anymore. :angry:

I'm not trying to quibble on every contraindication of succynlcholine. My point is, there's times where you have absolutely no way of determining if somoene meet every little bit of criteria for a drug to be class I. 

If MH triggers based on a 1:5000 reaction among people with the genetic trait, then certianly it would be horrible. Core temps of 110 are not pleasent. But if you have a head injury with a clenched jaw that is actively seizing, I guarantee succynlcholine users won't be asking "Does anyone know if he has Myasthenia gravis, malignant hyperthermia, narrow angle glacouma, [list goes on...]?" 

What are you going to do, wait till you're satisfied to push the drug? But even if you do, there will always be someone to read you a list of exclusionary criteria and slap you on the pee-pee, regardless if the guy is alive because of that drug or not.


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## Smash (May 23, 2012)

medicsb said:


> I imagine your ICPs are for more experienced and educated/trained than the average medic in the US, which is where I imagine JWK's experience with medics is centered.
> 
> The idea of RSI or propofol, etc. gets scary when medics in places like Grays Harbor County are allowed to use such drugs.  New medics there are only required to get 4 tubes per year over their first 3 years, and then only 2 per year there after.  Considering that the majority of ETI candidates would be cardiac arrests, I bet the average medic would be lucky do one RSI in a year, especially considering the number of medics that seem to be in that particular system.



Yes, you probably have a point there.  However there are certainly individuals and services that run rings around me and mine in the US, so I don't know that blanket statements regarding propofol are that relevant.  Unless one can cite some specific studies or specific reasons why propofol is a bad drug.

On a sort of side note, my reading of all the literature so far on prehospital intubation doesn't support the idea that intubation is bad and should be done away with.  It merely supports the idea that intubation done badly is bad (and should probably be done away with in certain areas or certain circumstances if the will to ensure adequate initial and ongoing education is not there)

Doczilla, I agree with what you are saying with regards to suxs.  Most people who get it are not in a position to tell you their history, most probably wouldn't know it anyway, and honestly, if it's a choice between the smashed head blowing bubbles of blood and vomit and the glaucoma, I'm going to deal with the head and airway issues anyway.  
However, that is one of the reasons why I think rocuronium is a far better drug for RSI.  Sux works great most of the time, but when it doesn't, it really doesn't.


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## Doczilla (May 23, 2012)

Agreed. I use vecuronium more anyway, onset time is comperable, maybe another min tops.


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## jwk (May 23, 2012)

Smash said:


> Doczilla, I agree with what you are saying with regards to suxs.  Most people who get it are not in a position to tell you their history, most probably wouldn't know it anyway, and honestly, if it's a choice between the smashed head blowing bubbles of blood and vomit and the glaucoma, I'm going to deal with the head and airway issues anyway.
> However, that is one of the reasons why I think rocuronium is a far better drug for RSI.  Sux works great most of the time, but when it doesn't, it really doesn't.



I'm not arguing against the use of sux pre-hospital.  I was simply pointing out that Doczilla's statement about the connection between sux and MH is unclear, which was incorrect.  I'm much more comfortable with pre-hospital use of sux than I am propofol, and my concern with propofol is because of it's poor hemodynamic profile and my assumption that most patients who might need RSI probably don't need propofol to complicate matters.

And to your point - I'm not sure why you think roc is a better drug for RSI than sux.  Roc works fine, but it is never as fast as sux, and sometimes if you need relaxation quickly, roc just isn't fast enough.  You can up the dose of roc as much as you want, but it is never going to be as fast as sux, which is why there is so much ongoing research into faster non-depolarizing NMB's.  Sux is still the gold standard for true RSI.  And I'm curious - when have you had sux not work?


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## Doczilla (May 23, 2012)

Great point. Getting pimped by an anesthesia doc is a treat. 

I guess I'm partial to vec (same class as roc as we all know) because I've had to sit on dudes for a while. When I do use sux, ill follow up with an "anesthesia bag" for continuous sedation consisting of ketamine, versed, and vec running at a weight-dependent rate. 

While its true that propofol might cause a B/P dip initially, I haven't seen it much. Then again, I've only used it a few dozen times for these purposes (I'm not counting fracture reductions or dental extractions). I'm sure as an anesthesiologist you've used it more--- but don't you think that the anticonvulsant, antiemetic, and cardioprotective effects are desirable in trauma? (Head injuries especially). 

Sure, you won't see someone seizing when you successfully RSI someone without an EEG; but a seizing brain is still in danger due to the cellular mechanisms that take place and enhance/accellerate the injury process. I think its relatively safer compared to using high-dose quinidines and barbituates, with a much lower cardiovascular side effect profile. 

Plus, serial maintenance doses of etomidate or versed can be difficult to time if you haven't been fully trained in I.V anesthesia, and haven't been granted permission to hang drips of ketamine, versed, or fentanyl. Correct me if I'm wrong please.


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## medicsb (May 23, 2012)

Smash said:


> On a sort of side note, my reading of all the literature so far on prehospital intubation doesn't support the idea that intubation is bad and should be done away with.  It merely supports the idea that intubation done badly is bad (and should probably be done away with in certain areas or certain circumstances if the will to ensure adequate initial and ongoing education is not there)



I agree.  Though I'd add "suffiecient hands on experience".  Initial and ongoing education will only go so far if you are only seeing real patients very rarely (though you would get good at managing the difficult to intubate sim-man).


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## Aidey (May 23, 2012)

jwk said:


> And I'm curious - when have you had sux not work?



My agency has had at least 3 incidents as of March where sux didn't work. I haven't heard if there have been any more since then. In all 3 cases adequate doses were given through patent IV lines. I'm not sure that they ever figured out what happened.


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## Veneficus (May 23, 2012)

jwk said:


> I'm not arguing against the use of sux pre-hospital.  I was simply pointing out that Doczilla's statement about the connection between sux and MH is unclear, which was incorrect.  I'm much more comfortable with pre-hospital use of sux than I am propofol, and my concern with propofol is because of it's poor hemodynamic profile and my assumption that most patients who might need RSI probably don't need propofol to complicate matters.



Interestingly enough, all of the anesthesiologists I met in Britian use propofol almost exclusively on trauma patients.

Not suggesting it is right or wrong, just food for thought.


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## jwk (May 23, 2012)

Aidey said:


> My agency has had at least 3 incidents as of March where sux didn't work. I haven't heard if there have been any more since then. In all 3 cases adequate doses were given through patent IV lines. I'm not sure that they ever figured out what happened.



If you're satisfied the IV's were patent then really the only explanation for that would be a bad lot of sux.  Probably too late now, but you could see if the lot numbers on the bottles were the same.  We occasionally get a batch of drugs where the effect isn't nearly what you expect it to be.  This has happened on numerous occasions with rocuronium.  Whether related to the manufacturer (several different generic brands) and their quality controls, or it being out in a room temp or higher environment for too many weeks, I don't know.

If the problem is they just don't relax, it's probably bad drug.  If the problem is something like a trismus, where they really lock up their jaws, that's different, and that is occasionally seen along with MH.

BTW - to the poster who mentioned geographic pockets of MH - this most certainly happens, and it's good to know if you're in one of those areas.  It tends to occur in (how can I say this delicately) a more homogeneous population than might normally be found in an urban area.


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## jwk (May 23, 2012)

Veneficus said:


> Interestingly enough, all of the anesthesiologists I met in Britian use propofol almost exclusively on trauma patients.
> 
> Not suggesting it is right or wrong, just food for thought.



I'm actually a ketamine fan for trauma, unless there's concern about head injuries.  I do use propofol for some trauma and for sick patients, but greatly decrease the dose.  You'd be surprised how little it sometimes takes to produce unconsciousness (if you're patient).  Most of our elective cardioversions are done with propofol, and I rarely give more than 40mg even for bigger patients.


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## Aidey (May 23, 2012)

jwk said:


> If you're satisfied the IV's were patent then really the only explanation for that would be a bad lot of sux.  Probably too late now, but you could see if the lot numbers on the bottles were the same.  We occasionally get a batch of drugs where the effect isn't nearly what you expect it to be.  This has happened on numerous occasions with rocuronium.  Whether related to the manufacturer (several different generic brands) and their quality controls, or it being out in a room temp or higher environment for too many weeks, I don't know.
> 
> If the problem is they just don't relax, it's probably bad drug.  If the problem is something like a trismus, where they really lock up their jaws, that's different, and that is occasionally seen along with MH.



I don't know any more about it than what I posted. It was investigated above my head. The only reason I know about it is because I used sux during that time and they wanted to know if it worked or not. I wanted to know why they wanted to know.


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## WestMetroMedic (May 23, 2012)

If we want to keep a medication assisted intubation process like RSI and legitimize its presence in EMS to our hospital counterparts, then perhaps we should start pumping put some good research and not the crap that San Diego has pumped out...

My understanding of Propofol, which is limited to education received and some brief interfacility trips to out HBO chamber, is that it is not the best medicine for the non ICU or surgical setting as the hubbub that exists outside of those environments causes a lower response to the dose being administered and requires a higher dose and in a med that is BP effecting like Propofol, perhaps this isn't the best idea, especially when there are perfectly acceptable options already in wide acceptance. 

But I suppose, we as EMS providers think we are the best practicioners in the field, so we should be able to do whatever we feel like.


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## usalsfyre (May 23, 2012)

It's all in how you treat the patient on Propofol. Loud noises, lights and low doses due to crappy volume status are the enemy.

Using it for induction is a different kettle of fish though.


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## Smash (May 24, 2012)

jwk said:


> I'm not arguing against the use of sux pre-hospital.  I was simply pointing out that Doczilla's statement about the connection between sux and MH is unclear, which was incorrect.  I'm much more comfortable with pre-hospital use of sux than I am propofol, and my concern with propofol is because of it's poor hemodynamic profile and my assumption that most patients who might need RSI probably don't need propofol to complicate matters.



Most, but not all.  We typically use propofol for people with a normal GCS who are not hemodynamically compromised but who require a secure airway - for example, airway burns.  If the patient is hemodynamically compromised we opt for ketamine, otherwise our standard drugs are midazolam and fentanyl.  There's no one size fits all regimen.



> And to your point - I'm not sure why you think roc is a better drug for RSI than sux.  Roc works fine, but it is never as fast as sux, and sometimes if you need relaxation quickly, roc just isn't fast enough.  You can up the dose of roc as much as you want, but it is never going to be as fast as sux, which is why there is so much ongoing research into faster non-depolarizing NMB's.  Sux is still the gold standard for true RSI.  And I'm curious - when have you had sux not work?



At 1.2mg/kg of roc compared with 1.5mg/kg of sux there is no appreciable difference in intubating conditions between the two.  If the roc is underdosed (0.6 - 1.0mg/kg) then yes, there is a delay.  Although I have had sux not work on a couple of occasions, my point was more to the fact that there are a large number of contraindications to sux and a large number of adverse effects as well, none of which are seen with roc.
Roc gives the same intubating conditions in the same time, increases safe apnea time, has no side effects and has no contraindications (discounting allergy of course) - what's not to like?


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## MHAUS (May 25, 2012)

*Malignant Hyperthermia Association of US*

Did you know about the MH Hotline 1-800-644-9737
See mhaus dot org for more information.


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## MHAUS (May 25, 2012)

The MH Hotline is 1-800-644-9737
More at mhaus dot org


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## jwk (May 25, 2012)

Smash said:


> At 1.2mg/kg of roc compared with 1.5mg/kg of sux there is no appreciable difference in intubating conditions between the two.  If the roc is underdosed (0.6 - 1.0mg/kg) then yes, there is a delay.  Although I have had sux not work on a couple of occasions, my point was more to the fact that there are a large number of contraindications to sux and a large number of adverse effects as well, none of which are seen with roc.
> Roc gives the same intubating conditions in the same time, increases safe apnea time, has no side effects and has no contraindications (discounting allergy of course) - what's not to like?



If roc was THE drug for RSI, we wouldn't use sux at all because of the potential complications that go along with it.  There's a reason it hasn't gone away, and that is speed of onset.  There IS a difference.  

In the average 70kg patient, your dose of roc is 84mg.  I've never given that much in my life.  You can increase the dose of roc as much as you want, but it's not going to speed up your onset time appreciably.  Even your definition of underdosing would be high for us, but then we're using it for different purposes.  

The other big drawback of roc, and will be until sugammadex is widely available in the US, is that once it's in, you can't reverse it immediately, so if you can't intubate your patient and can't ventilate them, you're screwed.  That's why sux is still the drug of choice for potential difficult intubations as well (my definition of difficult  ).  If you can't intubate and can't ventilate, your patient will be breathing again in a couple minutes.


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## Smash (May 25, 2012)

jwk said:


> If roc was THE drug for RSI, we wouldn't use sux at all because of the potential complications that go along with it.  There's a reason it hasn't gone away, and that is speed of onset.  There IS a difference.



Except that difference is not statistically significant and arguably not clinically significant either.

Pantawala, AE et al (2011) Comparison of succinylcholine and rocuronium for first-attempt intubation success in the emergency department.  Acad Emerg Med.

Perry JJ et al (2008) Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database of Systematic Reviews

Mallon, W. et al. (2009)  Rocuronium vs. succinylcholine in the emergency department: A critical appraisal J Emerg Med.





> The other big drawback of roc, and will be until sugammadex is widely available in the US, is that once it's in, you can't reverse it immediately, so if you can't intubate your patient and can't ventilate them, you're screwed.  That's why sux is still the drug of choice for potential difficult intubations as well (my definition of difficult  ).  If you can't intubate and can't ventilate, your patient will be breathing again in a couple minutes.



That is the same rationale that the above two reviews use to come to the conclusion that sux is the superior drug despite the lack of difference in intubating conditions.

However there are a couple of problems with that philosophy.  

First of all, it isn't true.  Critical desaturation will occur prior to sux wearing off even in healthy patients.  In unhealthy patients (i.e. the ones we are intubating, not the ones in the OR for an elective procedure) that is even more so the case.  Sux will actually hasten desaturation, presumably through increased O2 consumption due to fasciculations.  Rocuronium on the other hand prolongs the period of safe apnoea you have, allowing more time for intubation attempts or alternative airways to be used.

Tang, L. et al (2011) Desaturation following rapid sequence induction using succinylcholine vs. rocuronium in overweight patients. Acta Anaesthesiol Scand.

Heier, T et al (2001) Hemoglobin desaturation after succinylcholine-induced apnea: a study of the recovery of spontaneous ventilation in healthy volunteers.  Anesthesiology.

Benumof JL et al (1997) Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology

Naquib, M et al (2005) Succinylcholine dosage and apnea-induced hemoglobin desaturation in patients.  Anesthesiology

Taha, SK et al (2010) Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction.  Anaesthesia

The other major issue I have with that approach for in-field RSI is:  If you are about to RSI a patient, and your back up plan if you can't intubate is to just let them breath up on their own, why are you trying to RSI them in the first place?


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## WestMetroMedic (May 27, 2012)

I'm not sure what everyone else has for an RSI protocol, but when I worked at a service that did RSI, we had a backup device like the CombiTube (I haven't RSI d in over 5 years).  A BLS airway is a good airway but an RSI provides you definitive control if you are successful, it also streamlines your processes.  If you can't get three tube because they look slightly less jowely than Larry king, you will still have top roll old school but at least you tried.  

Moral of the story is- everyone should have a backup device if you want RSI.


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## jwk (May 27, 2012)

Smash said:


> Except that difference is not statistically significant and arguably not clinically significant either.
> 
> Pantawala, AE et al (2011) Comparison of succinylcholine and rocuronium for first-attempt intubation success in the emergency department.  Acad Emerg Med.
> 
> ...



I don't review EMS literature for anesthesia.  The literature you quote may be fine for ED and EMS but we have different definitions for RSI in the OR.  You'll have to take my word for it - I'd have the tube in with sux while you were still watching the clock with roc.     Unless there is an absolute contraindication for sux, for a true RSI, we will always use suc over roc because there is a difference - it may not be apparent to those who only intubate occasionally, but to those of us who do it multiple times every day for years, and who define airway management and RSI, there is.




Smash said:


> That is the same rationale that the above two reviews use to come to the conclusion that sux is the superior drug despite the lack of difference in intubating conditions.
> 
> However there are a couple of problems with that philosophy.
> 
> ...



Again, we have different definitions for RSI.  I never said the SaO2 wouldn't drop with sux and no ventilation - it most certainly will.  However, if you can't intubate/ventilate, and you've given roc, your option is to cut the neck.  Not necessarily so with sux.  One of the paths down the ASA Difficult Airway Algorithm is "awaken the patient".  Can't be done with roc - it can be done with sux (although you may be puckering along the way).  We use sux as opposed to roc for bariatric patients as well and for the same reason.  Can't intubate?  Wake 'em up.


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## usalsfyre (May 27, 2012)

jwk said:


> Again, we have different definitions for RSI.  I never said the SaO2 wouldn't drop with sux and no ventilation - it most certainly will.  However, if you can't intubate/ventilate, and you've given roc, your option is to cut the neck.  Not necessarily so with sux.  One of the paths down the ASA Difficult Airway Algorithm is "awaken the patient".  Can't be done with roc - it can be done with sux (although you may be puckering along the way).  We use sux as opposed to roc for bariatric patients as well and for the same reason.  Can't intubate?  Wake 'em up.


Like you say, different setting. ASA algorithms assume better options not often available in the EMS setting. Like Smash says, if "wake'em up" is a viable option in our world I would seriously question your candidate selection. If we get can't get the tube you need to placing some form of alternative airway, even if that involves a scalpel.


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## TatuICU (May 28, 2012)

n7lxi said:


> We're currently performing POC lactate testing, with a lactate of >4.0 mmol/L along with clinical signs/suspicion of sepsis for entrance into the sepsis protocol.
> 
> Core temperature greater than 38°C  or less than 36°C
> Heart rate greater than 90 bpm
> ...



Why dopamine if I may ask? Is it solely because of the central line issue with levo?


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## TatuICU (May 28, 2012)

Melclin said:


> We have identical criteria for sepsis, minus the lactate measurement.
> 
> Treatment at what you would call the ALS level, involves saline up 60mls/kg, with adrenaline infusion +/- push doses in whatever combination is required. With notification.
> 
> So all in all, quite similar. Do you know if your protocol is being studied for publication? In what way does lactate affect inclusion in the sepsis protocol?



Because getting a lactate measurement allows you to initiate sepsis treatment much sooner.  A lot of these patients who are very sick, don't look very sick at first.  By the time you start seeing symptoms that would alert you to possible septic shock (hypotension, etc), you've lost time and the patient's morbidity increases dramatically.  A lactate above 4 is associated with a very high death rate. With a level above 4 you know the inflammatory cascade has started wreaking havoc on your patient because it is of course produced by anaerobic metabolism and maybe our best lab marker for tissue hypoperfusion.


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## NomadicMedic (May 28, 2012)

TatuICU said:


> Why dopamine if I may ask? Is it solely because of the central line issue with levo?



Because Dopamine is the only pressor we carry.


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## TatuICU (May 28, 2012)

n7lxi said:


> Because Dopamine is the only pressor we carry.



gotcha


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## Melclin (May 28, 2012)

TatuICU said:


> Because getting a lactate measurement allows you to initiate sepsis treatment much sooner.  A lot of these patients who are very sick, don't look very sick at first.  By the time you start seeing symptoms that would alert you to possible septic shock (hypotension, etc), you've lost time and the patient's morbidity increases dramatically.  A lactate above 4 is associated with a very high death rate. With a level above 4 you know the inflammatory cascade has started wreaking havoc on your patient because it is of course produced by anaerobic metabolism and maybe our best lab marker for tissue hypoperfusion.



Well yeah. I understand _why_ they're doing lactates. 

But my question was how it fits into the _sepsis protocol_ eg do they have to have a certain ammount of SIRS criteria + lactate or is it an either/or thing, do they _have_ to have an elevated lactate to be included etc. 4 is quite high. Does it have to be above 4 to go down that pathway?

My point being that people meeting those criteria would be getting fluid anyway +/- a pressor depending on their numbers, so I'm interested in how lactate fits into the picture in this particular trial.


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## Smash (May 28, 2012)

jwk said:


> I don't review EMS literature for anesthesia.  The literature you quote may be fine for ED and EMS but we have different definitions for RSI in the OR.



I appreciate that, however this is an EMS website discussing EMS issues, I would have thought it somewhat apposite to look at EMS literature.  Which, incidentally,  these studies aren't, they are all in ER or OR settings.  I understand that you may have different definitions for RSI in the OR; but again we are discussing EMS issues.



> You'll have to take my word for it - I'd have the tube in with sux while you were still watching the clock with roc.



I'm sorry, I mean no disrespect, but rather than take the word of a pseudonym on a website I will take my own experience combined with what published data I can find.  I appreciate that there is much I can learn from yourself and from others on this site, but that learning must be filtered through my own experience and knowledge and modified by the system in which I work.



> Unless there is an absolute contraindication for sux, for a true RSI, we will always use suc over roc because there is a difference - it may not be apparent to those who only intubate occasionally, but to those of us who do it multiple times every day for years, and who define airway management and RSI, there is.



And therein lies a great deal of the problem as I see it.  We are typically dealing with the complete unknown and won't know if there is a contraindication to sux.  I don't have a history to consult and I can't talk to the patient before the procedure: I'm flying by the seat of my pants.  

Do they have hyper-K?  I can hazard a guess from the situation and the ECG, but I don't know.  Malignant hyperthermia?  No idea.  Duschene muscular dystrophy?  Maybe someone is around who can let me know, maybe not.  Sux apnea?  Could have used roc after all!

Every time we use sux in the EMS setting we are playing the odds.  The odds might be long, but eventually they are bound to catch up.  I might not intubate multiple times a day, only multiple times a month, but those odds still play on my mind.  With roc I don't have those worries and I know that I have a bit longer to get that airway secure before things go south.



> Again, we have different definitions for RSI.  I never said the SaO2 wouldn't drop with sux and no ventilation - it most certainly will.  However, if you can't intubate/ventilate, and you've given roc, your option is to cut the neck.  Not necessarily so with sux.  One of the paths down the ASA Difficult Airway Algorithm is "awaken the patient".  Can't be done with roc - it can be done with sux (although you may be puckering along the way).  We use sux as opposed to roc for bariatric patients as well and for the same reason.  Can't intubate?  Wake 'em up.



And again, different scenario from what I am doing (and why I am doing it) in the field.


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## ditchdoc125 (Jun 25, 2012)

In Alberta, we have dimenhydrinate, metoclopramide and ondansetron for antiemetics, the use of each drug is based on the suspected underlying cause of the n/v. There's the odd cowboy out there that will use haldol SQ, but we don't talk about that.....

The use of Ketamine is standard when your hypotensive patient requires RSI and maintenance of sedation. We also have it available for pain refractory to fentanyl/morphine or profound hypotension with on-line consult.

Some other not so "norm" drugs we have are tenecteplase, tetracaine, ketorolac and transexamic acid (this one is new, it is an antifibrinolytic used in the setting of traumatic hemorrhage) .


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## Smash (Jun 25, 2012)

Are you studying TXA or just going ahead with it on the basis of CRASH2 and MANERS?  What are your criteria for administration?


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## Handsome Robb (Jul 7, 2012)

Word on the street is we will be getting Ketamine on standing orders in the near future for first line sedation and pain management along with what we already have (fentanyl, morphine and versed). Also I heard talk and read in our clinical meeting minutes about beta blockers (either labetolol and/or metoprolol) for hypertensive crisis, CVA and AMI along with calcium channel blockers for new onset AF with RVR and with associated hypotension. 

We have a CQI meeting coming up in the near future and I will report back when I hear the official word.


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## medicsb (Jul 7, 2012)

> ...I heard talk and read in our clinical meeting minutes about beta blockers (either labetolol and/or metoprolol) for hypertensive crisis, CVA and AMI along with calcium channel blockers for new onset AF with RVR and with associated hypotension.




If the criteria for a CCB is actually "AF with RVR AND associated hypotension", then I'd be really worried about your medical director.  Why would you give a medication that consistently reduces BP to a patient that is already hypothensive?

The beta blockers will collect a lot of dust or be over used.


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## Handsome Robb (Jul 8, 2012)

medicsb said:


> If the criteria for a CCB is actually "AF with RVR AND associated hypotension", then I'd be really worried about your medical director.  Why would you give a medication that consistently reduces BP to a patient that is already hypothensive?
> 
> The beta blockers will collect a lot of dust or be over used.



Maybe I'm missing something but CCB in AF with RVR is a widely accepted treatment, no? Control the rate, increase ventricular filling thus increase CO, pressure comes up...like I said I've been wrong before and I may have misread the notes. 

You could argue associated hypotension would make it symptomatic and thus equal Edison medicine but if their mentation is intact I'd rather use medications first. I'm still not sold on the idea of treating AF with RVR in the prehospital field, especially with the short transport times in my system unless they are circling the drain.


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## medicsb (Jul 8, 2012)

NVRob said:


> Maybe I'm missing something but CCB in AF with RVR is a widely accepted treatment, no? Control the rate, increase ventricular filling thus increase CO, pressure comes up...like I said I've been wrong before and I may have misread the notes.
> 
> You could argue associated hypotension would make it symptomatic and thus equal Edison medicine but if their mentation is intact I'd rather use medications first. I'm still not sold on the idea of treating AF with RVR in the prehospital field, especially with the short transport times in my system unless they are circling the drain.



It is a widely accepted treatment, but is typically not given to hypotensive patients.   Actually, hypotension is a contraindication for diltiazem or verapamil.  If you get a chance to use it, you'll see that it often doesn't "normalize" the rate until a few doses have been given, and then it is often followed with an infusion (not typically done prehospital).  Anyhow, similar to beta-blockers, CCBs are negative inotropes, thus any gain in EDV could be moot if the ESV is also increased.  Additionally, both CCBs have vasodilatory properties that also add to a drop in BP.  

IF you recall COxSVR(or TPR) = MAP, CO = SV x HR, and SV=EDV-ESV.  

The CCBs will do the following: 
[(incr.LVEDV - incr.LVESV) x decr.HR] x decr.SVR = decr. MAP

If the patient is hypotensive or borderline, it may be worth giving a fluid bolus to improve the BP or to decrease the degree of change in BP.  Some might advocate CaCl as a pretreatment, but I believe the evidence in support of this is nonconclusive.


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## NomadicMedic (Jul 8, 2012)

medicsb said:


> ... If you get a chance to use it, you'll see that it often doesn't "normalize" the rate until a few doses have been given, and then it is often followed with an infusion (not typically done prehospital)...



Is this just anecdotal? My experience has been the opposite. 20mg of Cardizem has slowed just about every case of Afib with RVR I've treated. Admittedly I've given the drug only about 10 times...


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## STXmedic (Jul 8, 2012)

Second n7's. Anecdotal as well, but I've never had a single dose not normalize the rate.

Rob, I guess as with any arrhythmia causing significant hypotension, the truly unstable get some form of electricity. Here, if we want to give cardizem with a SBP <120, we have to call or use Amio instead. And they want electricity for any SBP <90.


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## medicsb (Jul 8, 2012)

n7lxi said:


> Is this just anecdotal? My experience has been the opposite. 20mg of Cardizem has slowed just about every case of Afib with RVR I've treated. Admittedly I've given the drug only about 10 times...



Anecdotal, yes.  But, pretty much every dose I've given has decreased AV conduction (even when just 10mg - smaller dose due to borderline BP, which I forgot to mention before), usually by 20-40 beats per minute.  But when the original ventricular rate was 140-180, the result isn't a "normal" rate (say, <100), but usually its enough to relieve palpitation, dyspnea, and/or chest pain/discomfort.  Also, I'd say only about 1/4 of the patients got the full 20mg dose as we would use weight-based doses up to 20mg on the 1st dose.  Maybe had we used 20mg across the board, I would have seen more frequent rate "normalization".  
(FWIW, my "n=" isn't very big, somewhere around 20-25 over 5 years.  Not small, but not big.)


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## dahus7712 (Jul 30, 2012)

Geodon, dilaudid, flumazenil


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## NomadicMedic (Jul 31, 2012)

dahus7712 said:


> Geodon, dilaudid, flumazenil



Wow. I didn't think any services in Washington carried flumazenil. Where is that, and is it on standing order?


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## Handsome Robb (Jul 31, 2012)

medicsb said:


> It is a widely accepted treatment, but is typically not given to hypotensive patients.   Actually, hypotension is a contraindication for diltiazem or verapamil.  If you get a chance to use it, you'll see that it often doesn't "normalize" the rate until a few doses have been given, and then it is often followed with an infusion (not typically done prehospital).  Anyhow, similar to beta-blockers, CCBs are negative inotropes, thus any gain in EDV could be moot if the ESV is also increased.  Additionally, both CCBs have vasodilatory properties that also add to a drop in BP.
> 
> IF you recall COxSVR(or TPR) = MAP, CO = SV x HR, and SV=EDV-ESV.
> 
> ...



That makes a lot of sense, thank you for explaining it!

Per our CQI meeting we will be not carrying CCBs.

They did add Metoprolol for STEMIs with a SBP >140 and a HR >100 after NTG. As you said it seems like they will collect dust. The STEMIs I've seen, albeit not many, did not meet the criteria for it

Also we are phasing in vasopressin in arrests. Not as a replacement for dose one or two though you either use the usual 1 mg 1:10,000 epi q3-5 *or* Vasopressin 40 IU q20. It's one or the other not both.


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## Veneficus (Jul 31, 2012)

n7lxi said:


> Wow. I didn't think any services in Washington carried flumazenil. Where is that, and is it on standing order?



Nobody should be carrying flumazenil on an ambulance. 

Standing order or not.


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## NomadicMedic (Jul 31, 2012)

Veneficus said:


> Nobody should be carrying flumazenil on an ambulance.
> 
> Standing order or not.



Agreed... That's why I asked.


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## AWDennis (Jul 31, 2012)

Anti-emetics : Inapsine
                    Ondansetron

RSI Meds: Etomidate
              Succinylcholine
              Vecuronium
              Midazolam

Pain Meds: Fentanyl 
               Nitrous Oxide

Corticosteroids: Solu-Medrol

And there are currently two studies in the county, a "ALPS" study and a "HypoResus" study


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## dahus7712 (Jul 31, 2012)

I work form Lifeline Ambulance up in Omak. I'm just starting as a new medic and it's totally a cowboy system up here. Ya it's in our protocols for an unconscious. Narcan and romazacon to rule out.


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## usalsfyre (Aug 1, 2012)

AWDennis said:


> Anti-emetics : Inapsine
> Ondansetron
> 
> RSI Meds: Etomidate
> ...



With the exception of Inapsine I'd say all of these are pretty standard...


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## usalsfyre (Aug 1, 2012)

dahus7712 said:


> Narcan and romazacon to rule out.



:blink:

I'd be pretty well ignoring that protocol :unsure:...


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## Smash (Aug 1, 2012)

usalsfyre said:


> :blink:
> 
> I'd be pretty well ignoring that protocol :unsure:...



Protocol?  What protocol? I don't see no protocol here...

I wonder how many seriously bad days that protocol leads to, for patient and paramedic alike?!


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## Aidey (Aug 1, 2012)

Smash said:


> Protocol?  What protocol? I don't see no protocol here...
> 
> I wonder how many seriously bad days that protocol leads to, for patient and paramedic alike?!



This is not the protocol you are looking for...


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