Giving medication down ET tube

[medic417]

Ativan replaced diazapam which is nice for seizures since it can be given IM. No more PR administration.

Valium can be given IM as well.

In my experience Ativan has failed to break seizures as well as Valium does. This is another case of it would be better if the service has more than one option.

 

[usafmedic45]

Valium can be given IM as well.

It CAN be, but it is not a recommended route especially in patients with low body mass or poor circulation and an IMMEDIATE need for the onset of medication action. The actual prescribing information for Valium (found here: http://www.rocheusa.com/products/valium/pi_iv.pdf) actually uses the phrase "by far preferred" to describe the preference for the IV route to the IM route. This is in part due to the slower absorption of diazepam from muscle versus the onset of effects from IV administration, the risks of injection site complications (due to what the medication is dissolved in), anecdotal reports of slightly increased rates of paradoxical reactions with use of IM administration vs IV, and poorer correlation between dose and effect in IM administration vs IV (in other words, difficulty in titrating the dose needed to control the seizures which could lead to excessive dosing of the patient or prolonging of the seizure activity through persistent underdosing). I would administer it rectally before I thought about giving it IM.

 

[usafmedic45]

In my experience Ativan has failed to break seizures as well as Valium does.

Please refer to the cartoon at the bottom left:

Then go read the 2002 article by Cock and Shapira in QJM on the subject (here: http://qjmed.oxfordjournals.org/cgi/reprint/95/4/225 ). I think you'll find something a little more substantial than too many EMS worker's favorite defense for their preferences of medications or procedures ("in my experience").

As the saying goes "Relying on your experience alone simply means you're going to keep making the same mistakes with an ever increasing level of confidence."

This is another case of it would be better if the service has more than one option.

Then it would be wise to carry something other than another benzodiazepine. However, most medical directors are going to be loathe to give their medics barbiturates, etc for good reason.

 

[Ridryder911]

Valium can be given IM as well.

In my experience Ativan has failed to break seizures as well as Valium does. This is another case of it would be better if the service has more than one option.

Valium does not "break seizures" it only relaxes the muscles so the seizure activity is not noticed; but still continues at a cerebral level.

R/r 911

 

[medic417]

Then it would be wise to carry something other than another benzodiazepine. However, most medical directors are going to be loathe to give their medics barbiturates, etc for good reason.

As with all meds not one size fits all. This is one reason procedures like RSI are being pulled from many services. Patient doesn't respond properly but no other med or dosage choices. Sometimes drugs of same family work better than others.

 

[medic417]

Valium does not "break seizures" it only relaxes the muscles so the seizure activity is not noticed; but still continues at a cerebral level.

R/r 911

My bad I went with the presumption that was understood. Thanks for the term correction so the newer Paramedic students will not be confused.

 

[usafmedic45]

Valium does not "break seizures" it only relaxes the muscles so the seizure activity is not noticed; but still continues at a cerebral level.

Which is why (along with the often marked serum level swings) it can not be used for long term control.

As with all meds not one size fits all.

You will not find a more staunch supporter of that bit of truth than myself.

Sometimes drugs of same family work better than others.

This is true but see my points below on the hazards of having backups.

This is one reason procedures like RSI are being pulled from many services.

Actually that's a gross oversimplification, but let's not sidetrack this thread by dissecting that issue just this second.

Patient doesn't respond properly but no other med or dosage choices.

How often does that actually happen in the field? When I did quality control from 1999 to 2001, seizure calls made up ~1% of our cases and intractable seizures made up less then 10% of those cases (in other words, about 0.0001%).

I am not arguing that having choices is a bad thing, I am arguing that the current crop of ALS providers are not a group I would be throwing phenytoin or pentobarbital and tell them "Here you go in case you need it". Simply put there is too little knowledge base among EMS personnel as a group (as often demonstrated in this and, to even greater degrees, other EMS forums) to warrant opening the floodgates to every backup medication we could need for a life-threatening emergency. Technically one could argue that seizures are- in an established epileptic without other complicating factors with high mortality of their own (intracranial bleed, infectious disease, drug overdose, etc)- not a frank life-threatening condition because of the low mortality associated with them.

Sudden unexpected death in epilepsy is an issue in a small subset of the population (1 out of 1,000 roughly, accounting for about 10% of deaths in patients with a diagnosis of one form or another of epilepsy) and death from absolutely intractable status epilepticus is similarly uncommon. This is not a reason why active seizing- especially that which does not respond to an initial dose of benzodiazepines- should not be considered to be an indication for transport without delay to the closest emergency department. The field is simply no place to play around by mixing multiple benzos in addition to whatever the patient may be taking for long term control of the underlying issues.

 

[medic417]

I am not arguing that having choices is a bad thing, I am arguing that the current crop of ALS providers are not a group I would be throwing phenytoin or pentobarbital and tell them "Here you go in case you need it". Simply put there is too little knowledge base among EMS personnel as a group (as often demonstrated in this and, to even greater degrees, other EMS forums) to warrant opening the floodgates to every backup medication we could need for a life-threatening emergency. Technically one could argue that seizures are- in an established epileptic without other complicating factors with high mortality of their own (intracranial bleed, infectious disease, drug overdose, etc)- not a frank life-threatening condition because of the low mortality associated with them.

Sudden unexpected death in epilepsy is an issue in a small subset of the population (1 out of 1,000 roughly, accounting for about 10% of deaths in patients with a diagnosis of one form or another of epilepsy) and death from absolutely intractable status epilepticus is similarly uncommon. This is not a reason why active seizing- especially that which does not respond to an initial dose of benzodiazepines- should not be considered to be an indication for transport without delay to the closest emergency department. The field is simply no place to play around by mixing multiple benzos in addition to whatever the patient may be taking for long term control of the underlying issues.

I see your point and agree to a point. My opinion is that if a medical director can not trust the Pre Hospital Medical Professional to be educated enough to do the job properly they should refuse to allow that person to operate under their license.

I also think based on very Rural EMS where we have long patient contact times. One service is over an 90 miles of bad roads to the nearest hospital. So you need options if first choice fails.

 

[usafmedic45]

One service is over an 90 miles of bad roads to the nearest hospital.

Two questions: Where the hell do you work? Also are you talking "90 miles to the nearest good hospital" or "90 miles to anything that can legally call itself a hospital"?

I see your point and agree to a point. My opinion is that if a medical director can not trust the Pre Hospital Medical Professional to be educated enough to do the job properly they should refuse to allow that person to operate under their license.

Likewise, but unfortunately many (most?) medical directors are about as involved in their services' medics as a mother in a Detroit project is with her children (in other words, only gets off their butt to issue beatings, whether deserved or not).

So you need options if first choice fails.

Agreed.

Then if you are that far out and have a progressive medical director who is actively involved, you might look into trying to get the protocol expanded. However, if it were me, I would prefer a benzo (lorazepam being my choice) and a barbiturate (pentobarbital in my case) for use in case of intractable seizures that do not respond to the benzo. To me, that makes more sense than switching from one to the other among the same class. However, I do not see as being any more practical than the option of also adding propofol as third line agent for seizures that do not yield to the first tow medications which was something I once discussed over dinner as an academic exercise with my medical director and one of his deputies.

 

[medic417]

Two questions: Where the hell do you work? Also are you talking "90 miles to the nearest good hospital" or "90 miles to anything that can legally call itself a hospital"?

Then if you are that far out and have a progressive medical director who is actively involved, you might look into trying to get the protocol expanded. QUOTE]

90 miles to a supposed level 4, nothing closer. Nearest level 1 is about 250 miles.

Director was very involved but is leaving this month to retire. Not sure about the new director as they are a city doctor.

 

[usafmedic45]

Two questions: Where the hell do you work? Also are you talking "90 miles to the nearest good hospital" or "90 miles to anything that can legally call itself a hospital"?

Then if you are that far out and have a progressive medical director who is actively involved, you might look into trying to get the protocol expanded. QUOTE]

90 miles to a supposed level 4, nothing closer. Nearest level 1 is about 250 miles.

Director was very involved but is leaving this month to retire. Not sure about the new director as they are a city doctor.

I wish you the best of luck with your new medical director and if I can be of any service in pulling together the scientific literature, etc to support any needed changes to protocols or to protect the current ones, feel free to PM me.

 

[medic417]

I wish you the best of luck with your new medical director and if I can be of any service in pulling together the scientific literature, etc to support any needed changes to protocols or to protect the current ones, feel free to PM me.

Thanks. If he is willing to listen I may take you up on that.

 

[MrBrown]

We still have the option of adrenaline going down the ET tube in an arrest but this is being discouraged as the evidence is not supporting it and we are moving towards IO access.

 

[Smash]

Valium does not "break seizures" it only relaxes the muscles so the seizure activity is not noticed; but still continues at a cerebral level.

R/r 911

Actually it does 'break' seizures. All benzodiazepines bind to ligands on GABA receptors that are known a BZD receptors (benzodiazepine receptors)

Through magical neurochemcial secret business this increases the effects of GABA in the brain. GABA is of course the major inhibitory neurotransmitter, so propagation of abberant signals in the brain (the seizure) is reduced and/or terminated, thus terminating the seizure (extemely truncated sleep deprived version for general consumption

Generalized seizure activity increase neuronal activity by over 250%, burning up fuel and oxygen and creating waste that is unable to be cleared quickly enough and eventually destroying brain cells.

If we gave something to just relax the muscles and allow unchecked neurological activity to continue we would be allowing the brain to continue frying. Pancuronium or vecuronium relax the muscles but allow seizure activity (as distinct from convulsive activity) to continue unabated, and of course there is no way that we would give either to a patient in status epilepticus because we can't monitor the seizure activity.

 

[paramedic007]

Its kinda complicated

I work as an educator with UCLA School of Medicine, and when I teach ACLS classes we have been (for the passed 4 years) de-emphasizing giving medications via the ETT here are the reasons why AHA recommended this:
Efficacy of the medication given via the ETT,
It has unpredictable as far the benefits to the patient when you give the drug this way,
there is no data that shows how effective or how quickly the medication would reach its target organ if it will at all.

Thus in the 2005 guidelines IV or IO are the most desireable routes because we know that giving medications IV or IO are predictable and rapid, you give a medication IO it is just as effective as IV and it becomes available in the bloodstream immediately upon insertion.

Remember back to paramedic training...aspiration is a bad thing...why would we want to aspirate someone on purpose??

 

[usafmedic45]

Remember back to paramedic training...aspiration is a bad thing...why would we want to aspirate someone on purpose??

You do understand WHY aspiration (in the sense of gastric contents) is bad and the difference between what epinephrine for example and a partially digested pepperoni pizza and a couple of glasses of beer right will do to the lungs? I've never seen nor heard any documented cases of aspiration pneumonitis from administration of any of the medications previously recommended for endotracheal administration. I do see what you are trying to get at, but please let's not confuse the less astute amongst us anymore than they already are.

 

[VentMedic]

I've never seen nor heard any documented cases of aspiration pneumonitis from administration of any of the medications previously recommended for endotracheal administration.

The jury is still out on that. We do have some studies on saline down the ETT which is why we now use sparingly if at all when suctioning. NICU has pretty much outlawed it in some hospitals. I do remember the day when we practically drowned the patient and then suctioned it out. Those days are gone except during bronchoscopies.

 

[Shishkabob]

NICU has pretty much outlawed it in some hospitals.

I'd like to think that 2ml in a 6l space is much different from 1ml in a 1l space, and as such would lead to more complications in the NICU as opposed to a normal ICU.

 

[VentMedic]

I'd like to think that 2ml in a 6l space is much different from 1ml in a 1l space, and as such would lead to more complications in the NICU as opposed to a normal ICU.

My remarks are also in reference to the adult ICU literature. We used to do an average of 2 to 5 ml per suction on an adult.

 

[Shishkabob]

Oh it wasn't meant in a combative nature at all. I struggled with how to phrase it >_<