# Repeat Dose for Anectine



## MedicPrincess (Jun 23, 2007)

What is the repeat dose for Anectine?  Is there a repeat dose?

Last shift we RSI'd a 14 yo.  While responding to the hospital, my medic repeated the Versed and the Anectine twice, for a total of 6mg Versed (lets try not to get into her initial dose being the wrong amount) and 120mg Anectine.

The ER Dr was pretty upset about the repeated doses of the Anectine.  I was to pi$$ed and my medic for so many other things, I didn't stand there and listen to what he was saying to her and I just tuned out her incessant talking in the truck on the way to meet with our shift CPT.

I checked our protocols and my ALS field guide and cannot find anything on giving repeat doses or not giving repeat doses.  

Thanks.....and only 6 more Mondays until I finish medic school!!


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## Guardian (Jun 23, 2007)

It seems your partner had the right succs dose but was light on the versed.  Then when your partner repeated doses, it brought the versed up to normal but was heavy on the succs.  This can have some bad side effects (bradycardia, asystole) which explains why the ED doctor was upset.  The repeat dose of succs wasn't necessary and contraindicated.


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## VinBin (Jun 23, 2007)

How much did the kid weigh?


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## Flight-LP (Jun 23, 2007)

Anectine dosing is usually 1-1.5mg/kg for adults and 1-2mg/kg for kids. It can be repeated. 120mg of Anectine isn't a problem, remember that Sux is short acting, keep 'em ventilated and prevent transient hypoxia and you'll be o.k. 

I have a different view on the Versed dosing. Personally I hate using Benzo's as a sedative agent for an RSI, Etomidate is a much better option. 6mg of Versed to sedate for induction is too much for an average 14 y/o, this will kill quicker than the Sux. Hang in there girl, you don't have that much longer. Besides, why has she not been fired yet???????


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## MedicPrincess (Jun 23, 2007)

Per the kids mom he weighed 90lbs.  The doses were broke down into three doses with each dose being 40mg Sux and 2mg Versed each time.

His vitals remained stable throughout.  BP 100's systolic, HR remained around 110-120,  O2 sat's above 96%.


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## Ridryder911 (Jun 23, 2007)

Ironically I am at a CCP course at this time and true the Sux dose is about right. Personally I like Etomidate, but FYI according to many literature it is not recommended on kids (<12) in which this scenario and possibly the body weight would had justified an adult dosage. 


We just debated a smiliar scenario on RSI lab. ... 

Be safe, 

R/r 911


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## Guardian (Jun 23, 2007)

help me to understand this, I must be missing something...

90lbs is about 40 kg, which is about normal for a 14y/o


If we are giving a liberal dose, we would give 2mg/kg of succinylcholine...

thats 40 times 2 which equals 80mg.  This kid was given a total of 120mg, that’s 40 extra mg's of succs which can kill!!!???

a side effect of too much succs is asystole.

was it a long transport?


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## MedicPrincess (Jun 23, 2007)

Ground transport was 10 miles = 14 minutes, at 1 a.m.  The kid should have been flown to the childrens hospital 2 counties over.  But under my name on my shirt is says "driver".... or EMT, somedays I wonder which, last shift, it definantly said "driver" or "equipment fetcher"....None of the Medics on scene agreed with this "driver" that we needed to launch a helo.

The hospital went ahead and flew him to the childrens hospital later in the morning.


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## VinBin (Jun 23, 2007)

EMTPrincess said:


> But under my name on my shirt is says "driver".... or EMT, somedays I wonder which, last shift, it definantly said "driver" or "equipment fetcher"....None of the Medics on scene agreed with this "driver" that we needed to launch a helo.


 

Sorry to hear that you were treated that way...

But now that we have discussed drug doses in this case so much, what was the call about?


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## Bongy (Jun 24, 2007)

Hello everybody...
At first,I have to say,that in Israel we never use Sux in prehospital..But my expirience at anestesiology says that dose was high(I mean a total one)...You(or your medic) can bring youself to situation that you will have AWAKE AND PARALYZED pt!! What was a reason for second dose? If patient starts to breath - let her,just assist,if he starts to move - give Benzo(or if BP doesn't allow that - Ketamine)...
What was a reason for RSI? 
At a bottom line... Rabdomyolysis in prehospital is a VERY bad thing...And hyperkalemia as result even worse..


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## Guardian (Jun 24, 2007)

Bongy said:


> Hello everybody...
> At first,I have to say,that in Israel we never use Sux in prehospital..But my expirience at anestesiology says that dose was high(I mean a total one)...You(or your medic) can bring youself to situation that you will have AWAKE AND PARALYZED pt!! What was a reason for second dose? If patient starts to breath - let her,just assist,if he starts to move - give Benzo(or if BP doesn't allow that - Ketamine)...
> What was a reason for RSI?
> At a bottom line... Rabdomyolysis in prehospital is a VERY bad thing...And hyperkalemia as result even worse..




yea, good point, I hadn't even thought of rhabdo or hyperk.  I guess this is why so many RSI protocols say to call for ped dose...it's really a situational thing.  I mean if you were forced to give more (the initial dose wasn't working and you had to stop a seizure for example) that’s one thing.  On the other hand, if you just kept loading on more just because you were giving it in combination with versed, that could have grave consequences.  So the question becomes, what was the reason behind RSI and why the repeated doses?  Like I said in my first post, I suspect the intial dose of versed wasn't enough and in trying to make up for it, she gave too much Succinylcholine.


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## MedicPrincess (Jun 24, 2007)

After a few hours of drinking, he was carried back to the condo his family was staying in.  He stumbled in, fell a few times, and began vomitting.  By the time we got there he had already aspirated (although impressive to hear, really crappy lung sounds).  He became unresponsive with continued vomitting.


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## Ridryder911 (Jun 24, 2007)

Sux is a great drug, when and used properly. In fact it is the most used  paralytic in the U.S. and prehospital arena. It acts fast and has a short duration (5-12 minutes) in fact in comparrision to to other paralytics one of the shortest duration. Where in comparison to Vercuronium (20-60 minutes), Rocuronium (30-60 minutes), Pancuronium (45-90 minutes). 

Sure, one needs to be concerned of Rhabdo and as well those with potential high potassium levels such as severe crushing injuries, post burns (>24hrs) and dialysis patients. However, the dose and the indication for the use of an paralytic for a one time administration, usually has little to no side effects. Then again, in the emergency setting one has to use some common sense in the use and administration of any medication. 

As long as there is a sedative used with sux, there is no "traumatic" event. I much rather successfully intubate the first time than to traumatize the hypopharynx area and increase the potential of laryngospasm and aspiration. 
Sometimes neuromuscular blocking agents is needed for paralysis even after induction is administered. There is nothing like knocking out the respiratory drive and LOC with induction agents, only to have your patient still mouth "clenched" down, or attempt to introduce the ETT and see laryngospasm. 

Yes, Sux has uncommon side effects such as defasculations, but really that is usually associated with erroneous administration and the worse is they will feel sore the next day. Something we don't want to perform, but I doubt that is the worse of their problems. Again, we are only using it to initially paralyze then a longer agent should be utilized for long term, and an increase of sedative agents.  

It would be great that all patients only responded to induction agents, but alas that is not always the case. 

Before bashing the medic, remember Sux is sometimes rapidly absorbed and metabolized in youth, and those with substance abuse such as meth/crank. It is not uncommon the dose has to be doubled on such cases. I personally have administered three times the dose on a crank head due to those effects. Induction agents was no avail (Versed, Etomidate, even Morphine Sulfate) had little to no effect at all, as well as the high dose of Sux. After discussing with ER anesthesiology, I was informed this was not unusual. So let's be a little diverse that it is not all is black and white. 

I do not really know the reason for RSI other than attempting to secure the airway in a decreased LOC with aspiration. Some of those with ETOH is hard to judge the amount of sedation. Too much or not enough. 

I am sure or would really hope that all programs has a TQI and they should be reviewed and monitored.

R/r 911


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## Bongy (Jun 24, 2007)

In addition to what Rid says,I would like to add,that specially in alcohol intoxication,I would prefer to avoid usage of Sux. Pt has acidosis,dehydrated, potassium level high... So..There is enough drugs for induction of anastesia..


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## Bongy (Jun 24, 2007)

In my experience,I NEVER saw pt that you can't sedate... All we have in Israel in prehospital is Benzo(Midazolam and Diazepam)and dissociative (Ketamine)... Always enough.. In case that presented,I would prefer Ketamin(also because his bronchodilative feature) in dosage of 3-5 mg/kg... It IS possible to intubate WITHOUT trauma,breathing pt.. Paralyzing drug are necessary for surgical procedure.. They are possible but not MANDATORY in RSI...My opinion..


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## Ridryder911 (Jun 24, 2007)

Apparently you do not have the meth & crank, and drug abusers, I see. As well most of my patients have a Mallampati class of III to IV. So anterior intubations are the norm and not unusual. I can administer and start at 5mg of Versed and nothing will occur due to the history of substance abuse. I have even given Etomodiate and other sedation measures without induction or sedation. I personally prefer to stay away from Ketamine due to the prolong duration. So yes, inductions can occur, but rarely have I seen results with the common dosages or until they became hemodynamically unstable. 

As well, sedation does not prevent laryngospasms and in many cases muscle relaxation enough to intubate. ICP can occur if the pain threshold crosses, or if the patient becomes combative. Thus the reason for paralytics, of course with adjunct sedation.

The potassium issue is valid, and one should be concerned with; but not really something emergency providers worried about. Potassium levels are usually within safe range on "normal" adults. Very rarely is a patient hyperkalemic without other symptomologies. As well, burns and crushing injuries; potassium shift is at least usually 12 -24 hours after the acute injury. Then again, just use another different paralytic such as Vecuronium. Unless they have a history of past medical issues such as Dialysis, post burns, malignant hyperthermia, and known glaucoma, they will receive Sux from me if need be.

Sux is one of the oldest and safest medications around if used properly, like any other med. It is rapid acting, and short duration. If used properly can be an adjunct to difficult airway management. 

R/r 911


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## Bongy (Jun 24, 2007)

Ridryder911 said:


> Apparently you do not have the meth & crank, and drug abusers, I see. As well most of my patients have a Mallampati class of III to IV. So anterior intubations are the norm and not unusual. I can administer and start at 5mg of Versed and nothing will occur due to the history of substance abuse. I have even given Etomodiate and other sedation measures without induction or sedation. I personally prefer to stay away from Ketamine due to the prolong duration. So yes, inductions can occur, but rarely have I seen results with the common dosages or until they became hemodynamically unstable.
> 
> As well, sedation does not prevent laryngospasms and in many cases muscle relaxation enough to intubate. ICP can occur if the pain threshold crosses, or if the patient becomes combative. Thus the reason for paralytics, of course with adjunct sedation.
> 
> ...


With all my respect(and I have a lot) to your drugs availiability,we just DON'T have it... No thinks like etomidate or Sux in prehospital in Israel. And you wrong...We have A LOT of drug obuse,but still,somehow,I never failed to induce sedation for intubation. In case of junky pt.just dosage ajustment is nessesary. About ketamine... I realy don't understand the reason of staying away.Drug is VERY safe(all you need is just to give some benzo in order to avoid halluciantion... All muscular relaxant are somehow disballance electrolytes and in prehospital pattern(where you have no lab)better not to play dangerous games - for the pt...


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## Guardian (Jun 25, 2007)

Bongy said:


> With all my respect(and I have a lot) to your drugs availiability,we just DON'T have it... No thinks like etomidate or Sux in prehospital in Israel. And you wrong...We have A LOT of drug obuse,but still,somehow,I never failed to induce sedation for intubation. In case of junky pt.just dosage ajustment is nessesary. About ketamine... I realy don't understand the reason of staying away.Drug is VERY safe(all you need is just to give some benzo in order to avoid halluciantion... All muscular relaxant are somehow disballance electrolytes and in prehospital pattern(where you have no lab)better not to play dangerous games - for the pt...






I think the American view, for the most part, is the consensus that if you're going to RSI, RSI fully and do it right the first time.  Ketamine is a great drug, but as Rid pointed out, it doesn't cause muscle relaxation like a true neuromuscular blocking drug does.  Thus, even though it works most of the time, there is a chance something could go wrong.  This coupled with it's slightly longer duration and effects on cardiac output, and you can see why it's not the preferred drug.

So, to do a job right the first time, most believe you must completely control the airway so that intubation can be performed in a controlled manner.  To do this, we completely sedate with etomidate and completely paralyze with Succinylcholine.  The safety record of both of these drugs are very good.

With our drugs, there hasn't been any real problems with hyperk, etc.  Although I could foresee such problems if we intentionally or accidentally give too much as in EMTPrincess's original post.  Remember, our drugs are short acting and once we have controlled the airway with ETI, we maintain the sedation with standard drugs like morphine or diazepam.  So, the initial drugs are only a one time thing.


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## Guardian (Jun 25, 2007)

Ridryder911 said:


> Before bashing the medic, remember Sux is sometimes rapidly absorbed and metabolized in youth, and those with substance abuse such as meth/crank. It is not uncommon the dose has to be doubled on such cases. I personally have administered three times the dose on a crank head due to those effects. Induction agents was no avail (Versed, Etomidate, even Morphine Sulfate) had little to no effect at all, as well as the high dose of Sux.




I'm having a hard time with this.  Meth effects dopamine transporters in the synaptic cleft, although I don't remember exactly how.

succinylcholine basically acts as acetylcholine and depolarizes.

So, how are these two connected, i.e. why is succinylcholine less effective on meth users?


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## Guardian (Jun 26, 2007)

Also, with peds you have to give more succinylcholine because of the increased extracellular water.  This makes perfect sense for young peds (esp. <5y/o) but the extracellular water is about the same as an adults by the age of 14.  So why would we ever have to give an increased dose to a 14y/o pt?


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## RescueShirts.com (Jul 11, 2007)

EMTPrincess said:


> What is the repeat dose for Anectine?  Is there a repeat dose?
> 
> Last shift we RSI'd a 14 yo.  While responding to the hospital, my medic repeated the Versed and the Anectine twice, for a total of 6mg Versed (lets try not to get into her initial dose being the wrong amount) and 120mg Anectine.
> 
> ...




In our service, Sux is only used for intubation (one dose).

We use Vecuronium for all intubated patients (i.e. after we intubate them, or transporting pre-intubated patients). 

Malignant hyperthermia is a risk with Sux... and that only goes up with repeated doses.

I guess if you work in a system with short transport times, there may not have been much need to include a long acting paralytic to your RSI protocols.

We actually use a low (defasciculating) dose of Vec along with Sux (during the initial intubation) in patients with severe burns, crush injuries, and severe head injuries.


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