Ideal Drug Box

[Melclin]

Indeed. I am enjoying this thread.

I agree with you about the panc, redcross.

On inspection of my copy of Robers and Heges Clinical procedures in Emergency medicine, "One consensus panel recommends pancuronium for maintaining paralysis, except in patients with cardiac disease or
hemodynamic instability.[115] The panel recommended vecuronium for the latter patient groups"

For what its worth (from a student), I'm going to go with Sux and Rocuronium on account of roc's increasing popularity in the ED as the initial paralytic in RSI, when sux is contraindicated (which gives us more options) and the possibility of adding suggamadex to the list down the line for reversing its action (if that's possible, you might do away with sux altogether). Also panc causes cardiovascular troubles - "Many patients experience an increase in heart rate, blood pressure, and cardiac output because of the vagolytic effect of the drug...[recommended for use] except in patients with cardiac disease or hemodynamic instability" , which you might think would be a significant portion of our patients.

Fentanyl and midaz for analgesia and sedation here. I was at a conference on trauma last year where RSI came up. An intensivist was concerned with the use of midazolam in the pre-hospital environment for Stephen Barnard's RSI trial in head injured pts for fear of hypotension. Dr Barnard was not concerned about its side affects, but many others seemed to be. Some were in favour of a worrisome method know as "sux and an apology". I need not explain this, I think. Seems like a good reason to use etomidate.

So my wish list so far, not taking into account the practicality of price or education:

ACLS
-Adrenaline
-Atropine
-Sodium Bic
-Magnesium Sulfate
-Calcium gluconate
-Vasopressin

OtherCardiac drugs
-ASA
-GTN (SL and IV [we don't currently have IV GTN at any level, which I think is a bit poor, I'm sure a good MICA paramedic could handle an nitro infusion)
-Clopidogrel
-Heparin (probably not LMWH on account of its age limit and creatinine clearance guided dosage..might be bit problematic in th prehospital environment).
-Amiodarone
-Lignocaine
-Tenecteplase.
-Metaraminol
-Verapamil
-Perhaps dobutamine & noradrenaline

Asthma/COPD
-Salbutamol (neb and IV)
-Ipratropium
-Heliox

Analgesia, Sedation & Paralytics
-Fentanyl (IV & IN)
-Morphine
-Midazolam
-Methoxyflurane
-Ketamine
-An NSAID, (preferably IV) which one though I couldn't say, perhaps Parecoxib Sodium
-Etomidate
-Suxamethonium
-Rocuronium
-Sugammadex (not FDA approved as far as I know, so you yanks can't have any)

Volume fillers/infusions fluids
-Lactated Ringers
-Saline
-D5W

Diabetic
-Glucose paste
-Glucagon
-Dextrose 10% (yanks need to get on the 10% band wagon)

Others
-Ceftriaxone
-Dexamethazone
-Haloperidol
-Prochorperazine
-Ondansetron
-Promethazine
-Benzotropine
-Naloxone

 

[MrBrown]

A very good discussion; I would like to ammend my list and add ceftriaxone

 

[Smash]

Would stay away from pancuronium outside of the hospital ICU... Duration is about 2 hours!

I can't find any sources that give 2 hours for duration of pancuronium. 40-60 minutes is what I have been aware of, and this fits in very well with our geography, transport times and so on. Even with shorter transport times in the city center, when you factor in the fact that the patient will have to be intubated (and paralysed) before going to the Donut of Death to be scanned anyway, we still have no concerns over the duration of panc. Keeping in mind of course that we are not sedating, paralysing and intubating Joe Bloggs who bumped his head and is a bit confused therefore requiring neuro assessment immediately; these patients have smashed heads or catastrophic strokes and more than likely are going to need a chunk 'o head pulled out in the near future.

My experience with panc is that the cardiovascular effects are not particularly significant. Of course the demographics of those who are smashing their heads is young and otherwise healthy, and this is the primary population getting paralyzed.

This is not to say that I disagree with having other agents, merely that panc is effective and safe as used here. Vec or Roc should be included for situations or patients in whom other agents are not appropriate.

Some were in favour of a worrisome method know as "sux and an apology".

Surely you kid?! The whole point of RSI in the head injured patient is to minimize further insult to ICP. Unsedated administration of sux is hardly going to achieve that. In fact it is tantamount to torture! Etomidate would be a good option though. Again, solely from my experience, I have not noticed significant cardiovascular effects from versed in these patients when we follow our (very conservative) guidelines. Again, both options would be nice.

Verapamil[/QUOTE

Not adenosine? I realise that the reversion rates are essentially the same, but does not the safety profile of adenosine recommend it more highly?

 

[Melclin]

I can't find any sources that give 2 hours for duration of pancuronium. 40-60 minutes is what I have been aware of, and this fits in very well with our geography, transport times and so on. Even with shorter transport times in the city center, when you factor in the fact that the patient will have to be intubated (and paralysed) before going to the Donut of Death to be scanned anyway, we still have no concerns over the duration of panc. Keeping in mind of course that we are not sedating, paralysing and intubating Joe Bloggs who bumped his head and is a bit confused therefore requiring neuro assessment immediately; these patients have smashed heads or catastrophic strokes and more than likely are going to need a chunk 'o head pulled out in the near future.

My experience with panc is that the cardiovascular effects are not particularly significant. Of course the demographics of those who are smashing their heads is young and otherwise healthy, and this is the primary population getting paralyzed.

This is not to say that I disagree with having other agents, merely that panc is effective and safe as used here. Vec or Roc should be included for situations or patients in whom other agents are not appropriate.

I don't necessarily have a problem with panc, keeping in mind that this is all purely theoretical for me. I mostly like the idea that Roc offers flexibility in that it can be used as the initial paralytic as well, when sux is contraindicated, especially with the suggamadex option of reversing the roc...I really like that idea, but I suppose it remains to be seen if that is a good option.

Surely you kid?! The whole point of RSI in the head injured patient is to minimize further insult to ICP. Unsedated administration of sux is hardly going to achieve that. In fact it is tantamount to torture! Etomidate would be a good option though. Again, solely from my experience, I have not noticed significant cardiovascular effects from versed in these patients when we follow our (very conservative) guidelines. Again, both options would be nice.

Verapamil

Not adenosine? I realise that the reversion rates are essentially the same, but does not the safety profile of adenosine recommend it more highly?
Well, I was not aware of any particular differences other than one interesting article I read once that observed adenosine working better for faster tachys and verapamil working better for slower tachs...or maybe it was the other way round . Anyway, really the only reason I chose verapamil was because our services uses it and in the absence of any further knowledge, I went with their judgment on the drug.

Regarding the Bernard's presentation, it was a while ago now, and you must also remember I'm really well out of my depth when discussing such things seriously. However, on inspection of my notes from the presentation, I see that I have noted the audience member's queries which is convenient:

"- is sux without sedation acceptable to prevent hypotension 2ndry to midaz?
- in a pt with lowered GCS, how do you know they are such because of head injury and not because of hypotension - in which case sedation for RSI would make problem worse"

Would they not be concerned about midaz dropping the BP bellow around 90, what with the increase in mortality in TBI? I understand that if they had a very high BP as you may expect in some TBI, that would be fine and even desirable. I think/assume their concern was for people who weren't necessarily experiencing that hypertension, including pts who were perhaps hypovolaemic from haemorrhage. I realise coma due to haemorrhage is a contraindication to RSI, but I can see that there might be a grey area- where they have been bleeding earlier and they are bordering on hypotension but they would still benefit from RSI for their TBI - that could prove dangerous. As well as the problem suggested in my second dot point - that it may be the hypotension, not the TBI responsible for the low GCS, in which case you are doing more harm than good.

I have looked over the Victorian RSI guidelines and they dictate reduced doses of midaz for lower BPs, which I didn't previously realise (you may already be aware of this if they happen to be your guidelines as well ). So that seems pretty reasonable. Still, as you say, I presume it would be nice to have etomidate as an option, even if midaz is very unlikey to cause problems. This is after all a "wish list", not a realistic request

Ketamine is another induction agent and alternative too etomidate that we haven't really discussed. Seeing as though its in our imaginary bag for analgesia anyway, perhaps we don't need etomidate.

 

[redcrossemt]

I can't find any sources that give 2 hours for duration of pancuronium. 40-60 minutes is what I have been aware of, and this fits in very well with our geography, transport times and so on.

If you are using the lower maintenance dose the duration is 40-60 minutes as you state. If you are using the intubating dose (0.1mg/kg), the duration is ~100 minutes per the prescribing information and 90-120 minutes per several studies.

 

[redcrossemt]

Ketamine is another induction agent and alternative too etomidate that we haven't really discussed. Seeing as though its in our imaginary bag for analgesia anyway, perhaps we don't need etomidate.

I think it's reasonable to carry both ketamine and etomidate. Ketamine can screw with a patient's hemodynamics, although in the opposite way of midazolam, but is a good choice for those with reactive airway disease, and for kids in general.

 

[MrBrown]

I think it's reasonable to carry both ketamine and etomidate. Ketamine can screw with a patient's hemodynamics, although in the opposite way of midazolam, but is a good choice for those with reactive airway disease, and for kids in general.

We carry ketamine and use it both as an RSI induction agent (1.5mg/kg) and as combination analgesia with morphine at lower doses, say 10-20mg prn.

I am not convinced (and am not overly sure why) that ketamine produces the same sort of "sleep" as etomidate/propofol but I stand to be proven either way.

 

[Jon]

I see Versed on the list... don't see Ativan. Why? At least Versed+Ativan? Ativan for agitation/sedation, and Versed for sedation for cardioversion.

Why Pepcid?

I actually don't carry phenergan currently; my only option is zofran, which, much as I like it, is much less effective after the pt has already begun to vomit. Phenergan on the other hand seems to be effective regardless. Of course it's harder on the veins and has some interactions that aren't always the best, so having multiple options would be better.

Same with reglan; I don't carry it, but have had multiple interactions with MD's and PA's who swear by it for treating nausea caused by migraines. And based on my own experiences in treating that type of nausea with zofan...it doesn't always work.

Alright - That was a big question in my mind - trying to figure out justification to carry 3 instead of 1.
If you had to pick one, anyone against Zofran?

<Snip>
Volume fillers/infusions fluids
-Lactated Ringers
-Saline
-D5W

Diabetic
-Glucose paste
-Glucagon
-Dextrose 10% (yanks need to get on the 10% band wagon)

Why D5W, LR, and NSS. What population gets what?

And why D10? I've got D10 for infants... D50 for adults.





I have to agree - this is a GREAT discussion - Espicially with the international discussion.

 

[fma08]

Indeed. I am enjoying this thread.

I agree with you about the panc, redcross.

On inspection of my copy of Robers and Heges Clinical procedures in Emergency medicine, "One consensus panel recommends pancuronium for maintaining paralysis, except in patients with cardiac disease or
hemodynamic instability.[115] The panel recommended vecuronium for the latter patient groups"

For what its worth (from a student), I'm going to go with Sux and Rocuronium on account of roc's increasing popularity in the ED as the initial paralytic in RSI, when sux is contraindicated (which gives us more options) and the possibility of adding suggamadex to the list down the line for reversing its action (if that's possible, you might do away with sux altogether). Also panc causes cardiovascular troubles - "Many patients experience an increase in heart rate, blood pressure, and cardiac output because of the vagolytic effect of the drug...[recommended for use] except in patients with cardiac disease or hemodynamic instability" , which you might think would be a significant portion of our patients.

Fentanyl and midaz for analgesia and sedation here. I was at a conference on trauma last year where RSI came up. An intensivist was concerned with the use of midazolam in the pre-hospital environment for Stephen Barnard's RSI trial in head injured pts for fear of hypotension. Dr Barnard was not concerned about its side affects, but many others seemed to be. Some were in favour of a worrisome method know as "sux and an apology". I need not explain this, I think. Seems like a good reason to use etomidate.

So my wish list so far, not taking into account the practicality of price or education:

ACLS
-Adrenaline
-Atropine
-Sodium Bic
-Magnesium Sulfate
-Calcium gluconate
-Vasopressin

OtherCardiac drugs
-ASA
-GTN (SL and IV [we don't currently have IV GTN at any level, which I think is a bit poor, I'm sure a good MICA paramedic could handle an nitro infusion)
-Clopidogrel
-Heparin (probably not LMWH on account of its age limit and creatinine clearance guided dosage..might be bit problematic in th prehospital environment).
-Amiodarone
-Lignocaine
-Tenecteplase.
-Metaraminol
-Verapamil
-Perhaps dobutamine & noradrenaline

Asthma/COPD
-Salbutamol (neb and IV)
-Ipratropium
-Heliox

Analgesia, Sedation & Paralytics
-Fentanyl (IV & IN)
-Morphine
-Midazolam
-Methoxyflurane
-Ketamine
-An NSAID, (preferably IV) which one though I couldn't say, perhaps Parecoxib Sodium
-Etomidate
-Suxamethonium
-Rocuronium
-Sugammadex (not FDA approved as far as I know, so you yanks can't have any)

Volume fillers/infusions fluids
-Lactated Ringers
-Saline
-D5W

Diabetic
-Glucose paste
-Glucagon
-Dextrose 10% (yanks need to get on the 10% band wagon)

Others
-Ceftriaxone
-Dexamethazone
-Haloperidol
-Prochorperazine
-Ondansetron
-Promethazine
-Benzotropine
-Naloxone

Do you guys routinely administer anitbiotics down there? And any particular reason for the use of a cephalosporin over another class?

 

[Smash]

Verapamil isn't a drug that we see very often any more, does it get used very often? It has a rather nasty side effect profile, hence the use of adenosine these days. Adenosine is also a little more versatile.

"- is sux without sedation acceptable to prevent hypotension 2ndry to midaz?

Holy crap no! If you want to prevent hypotension secondary to versed in the head injured patient, you use etomidate! Paralysis without sedation is criminal and counterproductive.

- in a pt with lowered GCS, how do you know they are such because of head injury and not because of hypotension - in which case sedation for RSI would make problem worse"

Would they not be concerned about midaz dropping the BP bellow around 90, what with the increase in mortality in TBI? I understand that if they had a very high BP as you may expect in some TBI, that would be fine and even desirable. I think/assume their concern was for people who weren't necessarily experiencing that hypertension, including pts who were perhaps hypovolaemic from haemorrhage. I realise coma due to haemorrhage is a contraindication to RSI, but I can see that there might be a grey area- where they have been bleeding earlier and they are bordering on hypotension but they would still benefit from RSI for their TBI - that could prove dangerous. As well as the problem suggested in my second dot point - that it may be the hypotension, not the TBI responsible for the low GCS, in which case you are doing more harm than good.

That is certainly a potential issue, which is why any hemodynamic compromise such as tension pneumothorax needs to be ruled out early in the piece and aggressive BP management undertakne. If the altered GCS is due solely to blood loss then it is probably not a good idea to RSI. If you aren't sure though, sometimes you have to take an educated guess at what the likely cause of the altered LOC is going to be. Interestingly enough a study done on head injury and bleeding showed that the best route is probably still that of permissive hypotension, even bearing in mind the normally poor outcomes with hypotension in TBI. It is thought that improved cerebral blood flow as opposed to pressure is responsible, but I dare say a lot more study is required. Bourguignon in Archives of Surgery I believe, can't remember the date.

Ketamine is another induction agent and alternative too etomidate that we haven't really discussed. Seeing as though its in our imaginary bag for analgesia anyway, perhaps we don't need etomidate.

More options are always better!

And any particular reason for the use of a cephalosporin over another class?

Cephalosporins are effective against a very wide range of bacteria, can penetrate the CSF and other areas well (or at least ceftriaxone can) and are thus a good choice when we suspect sepsis, but don't yet know the specific organism.

I think the link might have been posted elsewhere, but the Surviving Sepsis campaign publishes guidelines periodically, the latest being 2009 Link Here

 

[Shishkabob]

Why don't more people have Nitrous Oxide in there?! Fantastic drug for minor trauma.

 

[Smash]

Why don't more people have Nitrous Oxide in there?! Fantastic drug for minor trauma.

Speak to the FDA about that... Yes it is a very good drug. Like bretylium. No, wait a minute...

 

[Shishkabob]

So you deny that nitrous oxide is a good pain management drug? Explain your reasoning.

 

[Melclin]

Verapamil isn't a drug that we see very often any more, does it get used very often? It has a rather nasty side effect profile, hence the use of adenosine these days. Adenosine is also a little more versatile.

Oh, very interesting. I wonder why it is that we don't use it then. I fear that it maybe to do with our service's apparent fear of short onsets. Thanks for that.


Holy crap no! If you want to prevent hypotension secondary to versed in the head injured patient, you use etomidate! Paralysis without sedation is criminal and counterproductive.

Hey hey, "sux and an apology" isn't my idea. You don't have to tell me.

That is certainly a potential issue, which is why any hemodynamic compromise such as tension pneumothorax needs to be ruled out early in the piece and aggressive BP management undertakne. If the altered GCS is due solely to blood loss then it is probably not a good idea to RSI. If you aren't sure though, sometimes you have to take an educated guess at what the likely cause of the altered LOC is going to be. Interestingly enough a study done on head injury and bleeding showed that the best route is probably still that of permissive hypotension, even bearing in mind the normally poor outcomes with hypotension in TBI. It is thought that improved cerebral blood flow as opposed to pressure is responsible, but I dare say a lot more study is required. Bourguignon in Archives of Surgery I believe, can't remember the date.

Cheers. I'll have a look.

Do you guys routinely administer anitbiotics down there? And any particular reason for the use of a cephalosporin over another class?

Not routinely. Its primarily for mennigococcal septicaemia but listed as, also "for use in other sepsis - consult with clinician" which means we call a especially experienced and well educated medic for a consultation on the severity of the sepsis and the appropriateness of using ceft for the specific infection. The receiving hospital will probably also want to have a say, because we'll ruin their blood cultures if we give ceft, so teh patient has to be super sick to warrant it. Which is why I'd like to see us taking blood cultures, so we can give more ceft and not be upsetting the management of pts later down the track.

Ceftriaxone is a standard first line broad spectrum antibiotic. Its probably also cheap :wacko:

Why D5W, LR, and NSS. What population gets what?

And why D10? I've got D10 for infants... D50 for adults.

The NS vs LR is a contentious issue. I've heard many things and read many papers making good points, but I don't think its a done deal either way even in specific patterns of illness/injury. LR due to its ph and lower sodium levels may be more preferable in large volume infusions. But then pushing a solution containing lactate on a person who's lactate levels are rising because of anerobic respiration...probably not a good idea. LR, so I've read is the fluid of choice in burns + more minor trauma still requiring volume filling. NS in sepsis and severe/moribund trauma, dehydration etc. What I was really getting at in posting both though was that no one had listed fluids under their drug list and I wanted to make a point that the choice of fluids may be just as important as amiodarone vs lignocaine etc.

D5W is for mixing drugs.

D10% -- Moore C, Woollard M: Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial. Emerg Med J. 22(7):512–515, 2005. You get lower post treatment glucose levels which reduces the "seesawing" (what comes up must come down) of the BGL as we would say - so you can titrate to a good BGL. Plus at a lower concentration, you don't have to be too worried about necrosis from a dodgy cannulation.

So you deny that nitrous oxide is a good pain management drug? Explain your reasoning.

I wouldn't want my ambulance filling with nitrous. You must have some sort of filter or something right? I don't need a nitrous/o2 mix because I feel I've got the bases covered with methoxyflurane, IV NSAID, morph, fent and ketamine and it would be a pain in the arse carrying around a bloody great tank of nitrous.

 

[Shishkabob]

The nitrous tank is the same size as an O2 tank on the stretcher.

And the benefit of nitrous is rapid onset, patient administered to desired effect, and no needles. I've had patients in a decent amount of pain but refuse morphine due to an IV needing to be started... I offered them nitrous oxide and they loved it.

 

[Melclin]

The nitrous tank is the same size as an O2 tank on the stretcher.

And the benefit of nitrous is rapid onset, patient administered to desired effect, and no needles. I've had patients in a decent amount of pain but refuse morphine due to an IV needing to be started... I offered them nitrous oxide and they loved it.

Exactly, a whole other bloody tank to carry around. Methoxyflurane and IN fent are both rapid onset, Methoxyflurane just as much as nitrous (but I realise you can't use it in the states). IN fentanyl can control quite severe pain, its quick, and no needles.

Not to mention the OH&S problems caused by an ambulance full of nitrous. Do u have some kind of filter or something?

 

[Bloom-IUEMT]

So you deny that nitrous oxide is a good pain management drug? Explain your reasoning.

Too many medics where getting high :glare:

 

[Smash]

So you deny that nitrous oxide is a good pain management drug? Explain your reasoning.

Reading comprehension FTW!

 

[Shishkabob]

Reading comprehension FTW!

No, you failed at phrasing sentences, not the other way around.

Yes it is a very good drug. Like bretylium. No, wait a minute...

You said it was good like Bretylium, which is obvious sarcasm considering you think Bretylium isn't good, which means you think Nitrous-oxide isn't good.


That may not have been what you meant, but that's exactly how you wrote it.

 

[Melbourne MICA]

Wish Lists

We added Bretylium to our arrest guidelines years ago - and just as quickly dumped it. When studied, it was clearly demonstrated it made no difference to either achieving ROSC or post arrest outcomes. It was also expensive and given how often we used it, not good value for money.

Which brings up the point about value for money. Like it or not, EMS providers have to look at budgeting as much as anything else so EMS services need to see verifiable improvements in outcomes that translate into both well used health dollars and long term cost and patient benefit. The same goes for equipment and procedures.

Safety, practicality and ease of use, storage, evidence based efficacy, ability to manage side effects in the field, security issues etc - lots of things to consider when choosing pharmacology. Personally I'd like to see more emphasis on infective illness management but the issue of "diagnosis" in the field comes into it of course as well as does early treatment really improve the patients lot in the long run? That particular facet of the scenario is an important one and I am sure EMS will have a bigger impact in this area in years to come.

Antibiotic (anti-viral?), anti inflammatory, anti-coagulation/antithrombotic, anti-arrhythmic, anticholonergic, insulin/glucose management - all areas where I think we will see EMS developments - So many of our patients survive the acute event only to perish in the ICU from ARDS, SIS, DIC etc.

Our respective Meds standards committees have their work cut out for them me thinks.

MM

PS Oh... and there is the little issue of having to carry around all these things in a box or bag without doing your back (or your head) in. Our current drug box weighs in at around 10kg fully stocked. Lug that up five flights of steps when you know half the stuff in it is not likley to make the slightest bit of difference to the patient.