Airway Management and Intubating without Drugs

SandpitMedic

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I hope AMC expands the PDP protocol to also be used as a bridge to infusion as opposed to strictly peri-intubation. The protocol is frequently being misused or liberally applied.

Also still frustrated not having pre-filled PDPs. Mixing PDPs kind of defeats the purpose and is not quick or accessible in an emergency. If you are having to mix a Vaso/Neo drip just to pull out the PDP then you mind as well just start an infusion.
In the article I posted they did say that mixing your own PDPs was a major cause of medication errors, of which there were many.

Again, these are retrospective studies not RCTs.
 

SandpitMedic

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VFlutter

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Personally I think that Epi is the ideal PDP however it does have the most potential for drug errors and I understand the reluctance to adopt it outside of the hospital.

I mix our Vasopressin 20units/20ml and Phenylephrine 10mg/100ml then pull out 20ml so either drug its 2 ml every 2 minutes. Hook up the 20ml syringe of PDPs and a 3ml syringe with a stopcock to the IV line. Treat it like Pediatric doses. Seems to be the safest, albeit not quickest, way of doing things without prefilled. Wish it wasn't so expensive and you could mix it up and keep it for 72hrs but oh well.
 

StCEMT

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If you are having to mix a Vaso/Neo drip just to pull out the PDP then you mind as well just start an infusion.
Probably why it's something I've never pushed here. If I had RSI capabilities then I would, but anyone I'd even consider it on will get an infusion. The set ups we have for pumps is pretty simple and I can have it primed and running in not much more time.
 

Remi

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Also still frustrated not having pre-filled PDPs. Mixing PDPs kind of defeats the purpose and is not quick or accessible in an emergency. If you are having to mix a Vaso/Neo drip just to pull out the PDP then you mind as well just start an infusion.
Having prefills is nice, but I wouldn’t say not having them defeats the purpose. It shouldn’t take long at all to mix up an infusion, but it should be quite a bit quicker to make a syringe and give a bolus. It literally takes seconds to make a syringe of 100mcg/ml of epi or neo, if you know exactly how much to draw up based on whatever concentration you carry.

Honestly, it shouldn’t even be needed that often during airway management. It’s much better to simply adjust your dose of induction agent and prevent a big drop in the first place than it is to chase the BP with pressors.
 

SandpitMedic

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Having prefills is nice, but I wouldn’t say not having them defeats the purpose. It shouldn’t take long at all to mix up an infusion, but it should be quite a bit quicker to make a syringe and give a bolus. It literally takes seconds to make a syringe of 100mcg/ml of epi or neo, if you know exactly how much to draw up based on whatever concentration you carry.

Honestly, it shouldn’t even be needed that often during airway management. It’s much better to simply adjust your dose of induction agent and prevent a big drop in the first place than it is to chase the BP with pressors.
I think the idea the AMC is going with is if they start out with hypotension prior to intubation and fluids aren’t doing it then move to PDP. Also, blood admin is preferred also if you have that capability. I wouldn’t interpret the guidelines to mean chasing BPs with PDP when they are going to be on a levo or other continuous infusion anyhow. It’s the bridge. But then again, there are some cowboys out there.

As for Epi vs phenyl, the phenylephrine is preferred due being a direct alpha agonist. You get all the vasoconstrictor effect and increased SVR with no inotropic or chronotropic effects to worry about.
 

VFlutter

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As for Epi vs phenyl, the phenylephrine is preferred due being a direct alpha agonist. You get all the vasoconstrictor effect and increased SVR with no inotropic or chronotropic effects to worry about.
I understand alpha only when the goal is to mitigate the potential hypotension caused by induction but is increased SVR without inotropy really preferred in a peri-arrest shocky patient?
 

Remi

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I understand alpha only when the goal is to mitigate the potential hypotension caused by induction but is increased SVR without inotropy really preferred in a peri-arrest shocky patient?
If the sole cause of the hypotension is vasodilation (i.e. propofol in a non-bleeding patient), then yes, neo or vaso tends to work really well.

In a sick patient though, vasodilation induced by induction agents is not usually the sole cause of peri-induction hypotension and inotropy can be helpful, so ephedrine or epi tends to work better. Patients who are already tachycardic see a much smaller increase in heart rate from these drugs than patients who are not tachy to begin with.

In a trauma patient, you may be better off accepting the transient hypotension, even if it is severe. Vasopressors are a poor substitute for circulating blood volume, and can increase bleeding.

If you are really concerned about inducing hypotension with your inductions drugs, the best strategy, as I mentioned earlier, is to simply reduce your dose of those drugs.
 

SandpitMedic

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We must remember that although we (folks on this forum reading this thread) see this a lot, each patient is different and will respond differently to different drugs. Do the best you can with your latest approved guidelines and you won’t be wrong. Medicine is ever-evolving. Despite the latest and greatest, everyone cannot be saved.

People like CRNAs and PAs and Docs get to pick and choose what they want. Flight and CCT medics/ RNs the same within bounds. But the average paramedic out there needs to follow their guidelines with confidence. (Hint: so do Docs and other providers).

Medics need to know the drugs, the physiology, and the anatomy. And they need to do do their best each and every time.
 
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