Ketamine for RSI in hypertensive patients

Have you ever given Fentanyl to a patient without having Succ available? What happens if they get rigid chest syndrome and you can’t ventilate?

Succ has it’s place in the tool box even if i do think Roc is preferable in most situations. Risk of MH is probably 3rd on the list of my reasons not to use it. As Remi pointed out it’s hard to find much information as the actual incidence as the majority of cases are with concurrent volatile anethestic use but in any case it’s exceedingly rare. And if the very rare case does occur then manage as able, i.e hyperventilate, fluids, bicarbonate, and then divert to the closest facility with dantrelne.
 
E tank said:
Argument from moral superiority...I use it when I have a weak argument.
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Perhaps, but I don’t want to jump to any conclusions quite yet.

Things get wonky trying to sift through everyone’s posts, even my own from time to time:).
 
E tank said:
Immediate, profound paralysis providing optimal intubation conditions that resolves in a few minutes without any intervention at all is of no benefit?
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There has been a strong movement over the past few years in the ED/EMS communities away from using succinylcholine. Ever since Weingart, et al started talking about how "Roc rocks, and Sux sucks" many paramedics and some ED docs have become convinced that succinylcholine is poison and should never be used. I've been involved in many discussions on this both online and in person, and my position is always that about 98% of the time it really doesn't matter what you use, but there is about 1% of the time that sux is a better choice and 1% of the time that roc is a better choice. More than once the response that I've gotten to that was, essentially, that I don't know what I'm talking about and anyone who uses succinylcholine doesn't know what they are doing because it has zero advantages and many disadvantages as compared to rocuronium.

Funny story to illustrate just how cultish this belief is: I was kicked off of the EMS Mentoring Society FB page - easily on the the more intelligent of all online EMS forums that I've participated in - because during a discussion on the topic of roc vs. sux, when one of the regulars (who happened to be one of the admins) was being particularly adamant that sux has no place anymore, my response to that was that while I couldn't care less what people prefer for RSI because you can make pretty much anything work, he and the others who share his very strong opinion probably don't have nearly enough experience using both drugs to be so throughly convinced that they know which one is always best.
 
Remi said:
....he and the others who share his very strong opinion probably don't have nearly enough experience using both drugs to be so throughly convinced that they know which one is always best.
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Funny...or not...I've personally given liters of SCh as have most of the guys I work with and our conversations on the topic have nothing to do with MH. Its a non issue. It's all about myalgias and fasciculations and having to go to the trouble of giving something else when the succs wears off. But even in the age of suggamadex (which I'm not sure even enters into the pre-hospital conversation) guys use SCh regularly for dicey airways or airways out of the controlled environs of the OR.

Oh well...they don't know what they don't know....
 
Yep, myalgia is the main thing I think about when I consider using sux.
 
Remi said:
There has been a strong movement over the past few years in the ED/EMS communities away from using succinylcholine. Ever since Weingart, et al started talking about how "Roc rocks, and Sux sucks" many paramedics and some ED docs have become convinced that succinylcholine is poison and should never be used. I've been involved in many discussions on this both online and in person, and my position is always that about 98% of the time it really doesn't matter what you use, but there is about 1% of the time that sux is a better choice and 1% of the time that roc is a better choice. More than once the response that I've gotten to that was, essentially, that I don't know what I'm talking about and anyone who uses succinylcholine doesn't know what they are doing because it has zero advantages and many disadvantages as compared to rocuronium.

Funny story to illustrate just how cultish this belief is: I was kicked off of the EMS Mentoring Society FB page - easily on the the more intelligent of all online EMS forums that I've participated in - because during a discussion on the topic of roc vs. sux, when one of the regulars (who happened to be one of the admins) was being particularly adamant that sux has no place anymore, my response to that was that while I couldn't care less what people prefer for RSI because you can make pretty much anything work, he and the others who share his very strong opinion probably don't have nearly enough experience using both drugs to be so throughly convinced that they know which one is always best.
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I am inclined to agree with you. One of my systems recently switched to Ketamine (most of the time) or Etomidate (when you think Ketamine is less advantageous), followed by Roc. I can't really say it makes much difference to me, though I think the primary fear of succs was more related to hyperK. Rather than carry succs and another paralytic, they wanted to get rid of that risk and lessen the formulary (more than a few other drugs got tossed, which again I have no issue with).
 
Tigger said:
I am inclined to agree with you. One of my systems recently switched to Ketamine (most of the time) or Etomidate (when you think Ketamine is less advantageous), followed by Roc. I can't really say it makes much difference to me, though I think the primary fear of succs was more related to hyperK. Rather than carry succs and another paralytic, they wanted to get rid of that risk and lessen the formulary (more than a few other drugs got tossed, which again I have no issue with).
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If a system or an individual chooses to only use rocuronium, that's fine. I personally wouldn't do that and I don't think most other anesthesia providers would, but I understand the arguments and I kind of see why people make that choice.

What I take issue with is the people who argue passionately that roc is hands down the best choice in every case, and anyone who disagrees is an idiot - even people with much more experience in the area. For some reason, I've seen A LOT of that surrounding this issue.
 
Bit late on this one, sorry chaps.

My thinking is broadly I'm not overly concerned about it; the balance of risk is going to favour a secure airway and control of ventilation and oxygenation er any transient hypertension even in the case of Nana who we think has had a dirty big subarachnoid haemorrhage ...

In the situation where ketamine was a bad idea ideally I'd be able to use e.g. etomidate or something else but I'm not sure etomidate has made it south of the equator too much just yet.
 
Having recently ran what my non-doctoral-degree self believes was most likely a potine bleed, myself and the hospital staff all seemed content with the Amidate/ Succs combo as well as the decision to withhold post-intubation long-acting paralysis.

While it certainly may not have been the “sexy” FOAM-ed preferred cocktail, it again worked just fine.
 
I personally do not mind using Ketamine in the hypertensive patient. Where I am currently, we have a CRNA that we run questions and scenarios by and he is also a firm believer in using it as well. The one drug that I have seen mentioned a lot in this thread that I absolutely hate is Sux. It is a horrible drug, especially if you are going to paralyze after tube confirmation. Roc should be used in my opinion, due the poor outcomes of using a shirt term paralytic and them a longer one.

Plus, I am a firm believer in using video laryngoscopes to intubate. I believe that should be required on all trucks. Especially since the cost has come down. I know that we still need to know how to intubate the old way, but video scopes give us a much better chance at success and typically with less time in the mouth.
 
Docraven311 said:
The one drug that I have seen mentioned a lot in this thread that I absolutely hate is Sux. It is a horrible drug, especially if you are going to paralyze after tube confirmation. Roc should be used in my opinion, due the poor outcomes of using a shirt term paralytic and them a longer one.
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Why? What if you’re RSI-ing a suspected (non-traumatic) head bleed and you’re wanting to induce intially, but no longer paralyze post-sedation? It wears off fairly quickly, and allows for other post-intubation sedatives to manage the patient without the long-acting effects of, say, Roc or Vec.

Also, if we carried Amidate and Ketamine, I would not subject suspected head injured patients to Ketamine even if it is a “what if” precaution. Each drug has their own pros and cons though I suppose. I don’t know of many (if any) that use it for long-acting induction. Succs is for pre-intubation paralysis.
 
Docraven311 said:
It is a horrible drug, especially if you are going to paralyze after tube confirmation. Roc should be used in my opinion, due the poor outcomes of using a shirt term paralytic and them a longer one.
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Sux’s effectiveness as a post-intubation paralytic shouldn’t ever be an issue when discussing RSI since you should not be redosing it anyway.

And where does it show than patients have worse outcomes after short term then long term paralysis? And even in the transport environment i would argue that the vast majority of patients do not need post intubation paralysis anyway.
 
Docraven311 said:
Roc should be used in my opinion, due the poor outcomes of using a shirt term paralytic and them a longer one.
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Agreed on the VL's but what poor outcomes paralyzing after succs?
 
Docraven311 said:
I personally do not mind using Ketamine in the hypertensive patient. Where I am currently, we have a CRNA that we run questions and scenarios by and he is also a firm believer in using it as well. The one drug that I have seen mentioned a lot in this thread that I absolutely hate is Sux. It is a horrible drug, especially if you are going to paralyze after tube confirmation. Roc should be used in my opinion, due the poor outcomes of using a shirt term paralytic and them a longer one.
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Ugh this again. Really?
 
...Roc rocks!
 
Yeah! We shouldn't change what we are doing to be more evidence based. I'm gonna keep doing the same thing I was a decade ago because it worked okay for me.
 
Peak said:
Yeah! We shouldn't change what we are doing to be more evidence based. I'm gonna keep doing the same thing I was a decade ago because it worked okay for me.
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Exactly what evidence has been provided in this thread?
 
Remi said:
Exactly what evidence has been provided in this thread?
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That's the part were you do more continuing education than just to renew you state license.
 
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