California Pediatric Intubation

[CALEMT]

I haven’t heard anything about that changing.

Not until April when the new revisions come out.

 

[VentMonkey]

I'm guessing pediatric supraglottics are not replacing the tubes...

I should clarify and expand a bit. The adjuncts required for FBAO removal will all remain in our airway itinerary. Our cut off for ETI by protocol definition is 14 years old, and yes, assuming we have a pediatric patient who can successfully “accept” an SGA, that is sufficient.

Specifically, I have only heard speculation of our county medical director pushing for pediatric friendly SGA’s such as LMA’s and i-gel’s. I will ask him directly next time I see him, I can’t imagine he is opposed. He’s fairly open-minded, approachable, and certainly EMS-friendly.

 

[DesertMedic66]

Not until April when the new revisions come out.

I still don’t think that is going to change. I don’t see the county holding out until then to remove or change that from the protocols.

In April they will probably announce the Ketamine trial study we are supposed to be entering, an update on the TXA trial, I wouldn’t be surprised if there was an update to the APOD policy, and the normal ImageTrends information, and probably an EVOC update.

 

[CALEMT]

I still don’t think that is going to change.

Same here, but at the same time you wonder. I am excited for the Ketamine trial study.

 

[Carlos Danger]

I'm guessing pediatric supraglottics are not replacing the tubes...

That would be shame. I can't think of any reason not to.

 

[RocketMedic]

What are y'all doing with ketamine?

 

[DesertMedic66]

What are y'all doing with ketamine?

Hasn’t been fully announced yet as to what the study is geared towards and/or who will be excluded (patient wise) from the trial study. All we have been told is “hey guys, we might/are supposed to start a trial study”. They do a horrible job at giving us a heads up and instead will have us sit in a meeting and say “hey guys, we now have Ketamine. We can only use it for these selected items. Here is a test that the majority of our medics can’t pass because they can’t process new information”.

 

[RocketMedic]

Ketamine for pain is awesome. Same for ED

 

[DesertMedic66]

Ketamine for pain is awesome. Same for ED

It could be used for both and I really hope so but I highly doubt it. We have morphine and Fentanyl for pain and Versed for ED, however we are having a lot of issues with that protocol as of right now.

 

[Tigger]

It could be used for both and I really hope so but I highly doubt it. We have morphine and Fentanyl for pain and Versed for ED, however we are having a lot of issues with that protocol as of right now.

Versed is not particularly suitable for true excited delirium.

 

[DesertMedic66]

Versed is not particularly suitable for true excited delirium.

It has actually worked pretty well in my experience. What makes it not suitable? The main issue we have is that our medics like to call everything ED even if the patient meets none of the classic signs of it. For that reason there is talk about removing it from our standing orders.

 

[E tank]

It has actually worked pretty well in my experience. What makes it not suitable? The main issue we have is that our medics like to call everything ED even if the patient meets none of the classic signs of it. For that reason there is talk about removing it from our standing orders.

There can be some disinhibition in the elderly with versed, which can make things a little worse. But with regard to ketamine...a very useful drug but there will be those folks that will experience the intense dysphoria. I'd hope that something like versed or even valium would be given with it.

It fell out of favor and actually earned a notorious reputation and early in my career, very few people would touch it. Once folks realized smaller doses with an anxiolytic with it were very effective, the reputation faded from institutional memory.

The last thing we'd want is to rekindle that bad reputation because it wasn't used with something else to dull the edge.

My opinion.

 

[Tigger]

It has actually worked pretty well in my experience. What makes it not suitable? The main issue we have is that our medics like to call everything ED even if the patient meets none of the classic signs of it. For that reason there is talk about removing it from our standing orders.

A true excited delirium patient needs a whole lot of Versed. Probably more Versed than I am comfortable giving without risking significant respiratory depression. Ketamine does that have that untoward side effect and also appears to last longer. For someone that's extremely agitated I will start with Versed, but ED with adrenergic agitation is something that needs to be dealt with now and a single dose of 5mg/kg of ketamine stops nearly everyone's reaction. Versed on the other hand seems to be a lot more patient specific and I don't want to wait around and see which dose of Versed is going to work. I get that it might work, but there are just better options with less of a side effect profile.

 

[DesertMedic66]

A true excited delirium patient needs a whole lot of Versed. Probably more Versed than I am comfortable giving without risking significant respiratory depression. Ketamine does that have that untoward side effect and also appears to last longer. For someone that's extremely agitated I will start with Versed, but ED with adrenergic agitation is something that needs to be dealt with now and a single dose of 5mg/kg of ketamine stops nearly everyone's reaction. Versed on the other hand seems to be a lot more patient specific and I don't want to wait around and see which dose of Versed is going to work. I get that it might work, but there are just better options with less of a side effect profile.

Unfortunately we are only able to use Versed. So it’s either Versed or nothing for our ED patients.

 

[Tigger]

Unfortunately we are only able to use Versed. So it’s either Versed or nothing for our ED patients.

That's too bad. It seems like it's hard to get the EMSAs (I think) to the right thing. Poor protocols don't excuse poor care and it's unfortunate that they handcuff providers so badly. Hopefully they will at least require pedi SGAs.

 

[DesertMedic66]

That's too bad. It seems like it's hard to get the EMSAs (I think) to the right thing. Poor protocols don't excuse poor care and it's unfortunate that they handcuff providers so badly. Hopefully they will at least require pedi SGAs.

We shall find out. In my county we have only been carrying King size 3,4,5 and we haven’t had Pedi intubation in well over 7 years. In the county next to us they carry King 2, 2.5, 3, 4, 5 and they just took pedi intubation out. The most odd thing is that both of these counties have the same exact county medical director...

 

[CALEMT]

The most odd thing is that both of these counties have the same exact county medical director...

Yet same but different protocols.

 

[Qulevrius]

Unfortunately we are only able to use Versed. So it’s either Versed or nothing for our ED patients.

It’s the same for us. Which is funny in a sad way, because per protocols it’s 0.1mg/kg with max at 5mg (adults get 5mg flat, unless less than 50kg), but we very commonly see ED or AD patients that are virtually unaffected by Versed.

 

[RocketMedic]

I really like ketamine for its ability to abort the fight quickly. Less chance of something going wrong.