Controlled Substances

[Tigger]

What do you carry in your narcotics safe?
How much of each?
What concentration?
What do you wish you had or what would you get rid of?
How are your guidelines? Do you feel you can adequately manage pain, seizures, agitation etc?
Standing orders, call-in, some of both?

Basically I enjoy talking about how different systems do things, would love to hear how you feel your agency's controlled substances stuff works. Feel no pressure to talk about any of these or in any order.

For me:

Both of my jobs use essentially the same guidelines. The only call in for use of controls is Ketamine admin exceeding 1mg/kg/hr. Fentanyl 100mcg bolus for adult patients, as many times as needed. We are permitted to mix a benzo with fentanyl using half the typical dosing of each. Can treat agitation with valium, versed, and/or droperidol no questions asked. EtCO2 is required for any use of controls, to include a single dose. I find this silly.

Recently we started carrying Dilaudid to have another option with current difficulties with getting Ketamine. I am not sure when I want to use this medication tbh. we can only five it once.

Drug box wise:

FD Job: 4 fentanyl 100mcg/2ml, 3 Versed 5mg/5ml, 2 Valium 10mg/2ml, 1 Ketamine 200mg/10ml. Engines carry half that with no Ketamine.
I would like to carry 5mg/1ml Versed, seems better for IM and IN use. I like having valium, I know its old skool but seems to work nicely for anxiety and skeletal muscle relaxation with fractures and the like.

AMR: 3 fentanyl 100mcg/2ml, 3 Versed 5mg/5ml, 1 Dilaudid 1mg/1ml, 1 Ketamine 500mg/5ml.
Currently we can only use Ketamine for RSI induction. Non-RSI medics do not carry it.

 

[DesertMedic66]

Flight: every base is different as far as how much meds are carried and there are also some areas that have specific state/county requirements. For my base: 1000mg Ketamine (50mg/mL), 700mcg Fentanyl (50mcg/mL), 30mg Versed (2.5mg/mL), and either 4 or 8mg of Ativan (can’t remember the concentration off the top of my head). Protocols are very aggressive with really only max single doses but no limit on repeats and all standing order. I’m actually pretty good with this set up.

Ground: 500mg ketamine (50mg/mL), 20mg Versed (2.5mg/mL), 400mcg Fentanyl (50mcg/mL). Protocols are very restrictive with max dosage on every medication and on-line control to go above which we frequently do because of our extended transport times. I wish we had Ativan, IV Tylenol, and Toradol. I also would like our max dosages to get changed on our medications.

 

[NomadicMedic]

Pennsylvania, ground ALS. 500mg ketamine, 20mg versed, 4mg ativan, 200mcg fentanyl and 20mg morphine.

pain management protocols here are woefully archaic.

 

[coolidge]

What do you carry in your narcotics safe?
How much of each?
What concentration?
What do you wish you had or what would you get rid of?
How are your guidelines? Do you feel you can adequately manage pain, seizures, agitation etc?
Standing orders, call-in, some of both?

Basically I enjoy talking about how different systems do things, would love to hear how you feel your agency's controlled substances stuff works. Feel no pressure to talk about any of these or in any order.

For me:

Both of my jobs use essentially the same guidelines. The only call in for use of controls is Ketamine admin exceeding 1mg/kg/hr. Fentanyl 100mcg bolus for adult patients, as many times as needed. We are permitted to mix a benzo with fentanyl using half the typical dosing of each. Can treat agitation with valium, versed, and/or droperidol no questions asked. EtCO2 is required for any use of controls, to include a single dose. I find this silly.

Recently we started carrying Dilaudid to have another option with current difficulties with getting Ketamine. I am not sure when I want to use this medication tbh. we can only five it once.

Drug box wise:

FD Job: 4 fentanyl 100mcg/2ml, 3 Versed 5mg/5ml, 2 Valium 10mg/2ml, 1 Ketamine 200mg/10ml. Engines carry half that with no Ketamine.
I would like to carry 5mg/1ml Versed, seems better for IM and IN use. I like having valium, I know its old skool but seems to work nicely for anxiety and skeletal muscle relaxation with fractures and the like.

AMR: 3 fentanyl 100mcg/2ml, 3 Versed 5mg/5ml, 1 Dilaudid 1mg/1ml, 1 Ketamine 500mg/5ml.
Currently we can only use Ketamine for RSI induction. Non-RSI medics do not carry it.

How do you reconcile with how much inventory you have on hand compared to how much you ordered, administered and wasted?

 

[Tigger]

Those with Ativan, do you refrigerate? I worked at a spot where we had it and kept it in the fridge unlocked which I didn't think was quite kosher but "it can't live in the safe or it ages out too fast."

Forgot we have Toradol, I use it a fair amount. AMR has IV Tylenol as well which apparently rarely gets used. I think the infusion is looked at as more of a hassle than a quick shot of Toradol.

Also forgot that I loathe our Ketamine concentration. It is very difficult to give IM or IN, which I find Ketamine effective for (0.5mg/kg). We had an "oopsie" with a paramedic who spent years talking about useless Ketamine was and then one day deciding the pain dose was 300mg IV and now we have to carry the lowest amount of Ketamine per vial that we can get our hands on.

 

[Tigger]

How do you reconcile with how much inventory you have on hand compared to how much you ordered, administered and wasted?

At my FD job we use PSTrax for all of this. It handles all tracking from when controls are received from the pharmacy to when the paramedics waste and then get restocked.

AMR uses a paper slip system which is much messier.

 

[DesertMedic66]

Those with Ativan, do you refrigerate? I worked at a spot where we had it and kept it in the fridge unlocked which I didn't think was quite kosher but "it can't live in the safe or it ages out too fast."

Forgot we have Toradol, I use it a fair amount. AMR has IV Tylenol as well which apparently rarely gets used. I think the infusion is looked at as more of a hassle than a quick shot of Toradol.

Also forgot that I loathe our Ketamine concentration. It is very difficult to give IM or IN, which I find Ketamine effective for (0.5mg/kg). We had an "oopsie" with a paramedic who spent years talking about useless Ketamine was and then one day deciding the pain dose was 300mg IV and now we have to carry the lowest amount of Ketamine per vial that we can get our hands on.

We keep our Ativan restock in a fridge along with Succ, Roc, and Dilt. The Ativan we keep on us is not temp controlled and expires 60 days after we pull it out of the fridge.

 

[Aprz]

@DesertMedic66 Do you mean 5 mg/ml Versed vials? Ativan concentration is usually 2 mg/ml.

 

[DesertMedic66]

@DesertMedic66 Do you mean 5 mg/ml Versed vials? Ativan concentration is usually 2 mg/ml.

Oh dang my bad. That would be correct 5mg/mL

 

[johnrsemt]

FT job: 400mcg Fentanyl, 40mg Morphine (which we are dropping soon), 10mg Versed, 500mg/10mL Ketamine. No Valium in the boxes, but we do have Valium Auto Injectors at 1 station.

PT Job: 300mcg Fentanyl, 30mg Morphine, 15mg Versed (which isn't 'locked' up), it is an A-EMT drug; and 10mg Haldol (Medic drug).
We don't have them locked up, they are in the jump bags, and they are number tagged closed. Then in a bigger jump bag, which is tagged shut.

 

[BobBarker]

Los Angeles Ground CCT:
Morphine - 36mg
Versed - 30mg
Never had to use either one and don't like them. Since we are IFT, the sending hospital provides whatever medication we need or want lol.

 

[Tigger]

Los Angeles Ground CCT:
Morphine - 36mg
Versed - 30mg
Never had to use either one and don't like them. Since we are IFT, the sending hospital provides whatever medication we need or want lol.

No fentanyl for IFT??

 

[BobBarker]

No fentanyl for IFT??

Nah. If a patient needs pain medicine we always ask the staff to pre-medicate the patient right before transport (assuming they haven't been recently enough) and/or we will ask they staff to provide medication to medicate during transport if it is anything other than morphine, which we carry.
In all honesty, we've only transported a handful of patients who needed pain meds enroute who were not on an infusion (i.e. intubated, PCA, etc.). Most are pre-medicated or understand they will get a dose at the arriving hospital not too long after.

 

[Tigger]

Just figured with taking intubated patients (maybe that’s not how it works where you are) that some some fast acting analgesia might be available.

 

[BobBarker]

Just figured with taking intubated patients (maybe that’s not how it works where you are) that some some fast acting analgesia might be available.

LA County is marked as the "First and Worst" EMS system, so it doesn't surprise me. You have to get EMS Board approval to carry anything beyond the drugs they allow and AED's aren't even required on a BLS ambulance. We take intubated patients daily, (knock on wood), nothing has happened yet where we need anything beyond what we were given.

 

[Aprz]

700 mcg Fentanyl (100 mcg/2 ml x7)
25 mg Midazolam (5 mg/5 ml x5) or 40 mg Midazolam (10 mg/2 ml x4)
1,000 mg Ketamine (500 mg/10 ml x2)
8 mg Ativan (2 mg/ml x4)

Our protocol for Fentanyl and Ketamine are both weight based.

Fentanyl 0.5-1 mcg/kg max single dose 100 mcg.

Ketamine pain 0.1-0.25 mg/kg, post intubation sedation 0.5-1 mg/kg, and RSI 1-2 mg/kg.

Midazolam adult sedation 2.5-5 mg, adult seizure 5 mg IV 10 mg IM, pediatric sedation 0.05-0.1 mg/kg, pediatric seizure 0.05-0.2 mg/kg.

Ativan adult sedation 1-2 mg, adult seizure 4 mg, pediatric sedation 0.05-0.1 mg/kg, pediatric seizure 0.1 mg/kg.

No requirement to call base to give drugs or give additional doses. Not strict with going outside of protocol range as well eg if the protocol says I can give a 90 kg patient 45-90 mcg Fentanyl, it is okay to give 100 mcg to keep the math simple. I like it a lot. Great protocols.

We used to carry 5 mg/ml Midazolam, but we switched to the 1 mg/ml when we ran out. Not great for IM, but most patients I see already have an IV. Where I worked, EMTs can do IVs.

We don't have a lot of restock for Ketamine. I know a lot of people running out. I've seen some 200 mg/20 ml vials.

Ativan restock is kept in the fridge. Once it is taken out of the fridge, it is only good for 60 days. We carry other refrigerated drugs like Succinylcholine, Rocuronium, and sometimes Diltiazem.