"Outside the norm" paramedic drugs

[jwk]

My current service is very utilitarian but we do have Ketamine for profound agitation and next month, we are going to start using it as a pain adjunct. It is an amazing medication for mental health crisis patients.

I'm curious if this is common use in EMS. Knowing the emergence delirium associated with it's use and the fact that it's a phencyclidine derivative (think PCP) it doesn't seem like a great drug for this indication.

 

[mikie]

Just curious, no MJ here...

Does anyone carry Propofol? Or is that only carried if initiated by a doc (an infusion)?

 

[NomadicMedic]

Does anyone carry Propofol? Or is that only carried if initiated by a doc (an infusion)?

A few of my friends in Washington carry propofol for RSI.

 

[usalsfyre]

Does anyone carry Propofol? Or is that only carried if initiated by a doc (an infusion)?

Protocols were approved by our OMD last week, waiting on the state now. CCT only drug though. Propofol's got some "quirks" regarding its effect on the myocardium though...

 

[WestMetroMedic]

I'm curious if this is common use in EMS. Knowing the emergence delirium associated with it's use and the fact that it's a phencyclidine derivative (think PCP) it doesn't seem like a great drug for this indication.

Is standard in the Minneapolis area. One of our associate medical directors, John Ho, does a lot of speaking on excited delirium and also works with Taser on medical stuff. in addition to being a medical director for my agencyand a neighboring ALS fire department, he works one weekend a month as a sheriff deputy. His research, which, like a typical rube, I cannot cite, is showing that of your available options, Ketamine is the best since it doesn't contribute to the manifestation of malignant hyperthermia and has such a rapid onset compared to the benzos and hypnotics we have traditionally used. There really aren't many decent options to begin with for these patients since the pathophysiology of this process isn't fully known.

 

[medicsb]

I'm curious how frequently these "outside the norm" drugs are utilized. Especially drugs like labetalol, propofol, ceftriaxone, or maalox. I imagine they're being used almost never. Am I wrong in this assumption?

 

[jwk]

A few of my friends in Washington carry propofol for RSI.

Propofol is an anesthesia drug, and there is huge debate about whether anyone besides anesthesia personnel should administer it via IV bolus. RN's in many states are prohibited by their state licensing boards from giving propofol boluses - it's only allowable by infusion with ventilated patients.

IMHO, and I use propofol daily, it's absolutely foolish to try and use this drug in pre-hospital care. It's not reversible - once it's in, it's in. There are numerous side effects, and in the patient population most of you would want to use it in, propofol would not be the drug of choice anyway given it's cardiovascular side effects. There are far better choices.

Lastly - the package insert for propofol states that it is for use by anesthesia personnel only, and that is the way both the FDA and manufacturers want to keep it. If you box someone using propofol in the field, there will be a line of plaintiff's lawyers waiting to talk to the family and someone will be writing checks with lots of zeroes.

 

[triemal04]

I'm curious if this is common use in EMS. Knowing the emergence delirium associated with it's use and the fact that it's a phencyclidine derivative (think PCP) it doesn't seem like a great drug for this indication.

I've never used or carried ketamine but there's been a small amount of talk about looking to use it for sedation due to drug shortages.

I've heard/read that a low to moderate dose of a benzo given at the same time will help blunt the emergence phenomena. Any truth to that?

The other part to that is, in your experience, how often are you seeing that when it's given for a relatively short period of time; say a max of 45 minutes?

 

[jwk]

Is standard in the Minneapolis area. One of our associate medical directors, John Ho, does a lot of speaking on excited delirium and also works with Taser on medical stuff. in addition to being a medical director for my agencyand a neighboring ALS fire department, he works one weekend a month as a sheriff deputy. His research, which, like a typical rube, I cannot cite, is showing that of your available options, Ketamine is the best since it doesn't contribute to the manifestation of malignant hyperthermia and has such a rapid onset compared to the benzos and hypnotics we have traditionally used. There really aren't many decent options to begin with for these patients since the pathophysiology of this process isn't fully known.

Hmmm - I'm constantly amazed at how willing people are to risk their careers with off-label use of medications. The use of ketamine is psychiatric crises is not well studied, most reports are purely anecdotal, and the ones I've read come nowhere close to justifying it's use for this indication. It is not a widely recognized or accepted use for the drug. Sure it works (as do a lot of other drugs) but there are tons of side effects and considerations that come along with it, and using it on top of a bunch of other anti-psychotic potions (as in several of the published articles) is just baseless. "We tried everything else and this is the only thing that worked" is hardly justification for routine use.

 

[jwk]

I've never used or carried ketamine but there's been a small amount of talk about looking to use it for sedation due to drug shortages.

I've heard/read that a low to moderate dose of a benzo given at the same time will help blunt the emergence phenomena. Any truth to that?

The other part to that is, in your experience, how often are you seeing that when it's given for a relatively short period of time; say a max of 45 minutes?

I always give midazolam when I'm giving ketamine. The post-procedure delirium is not that common (it's more common in kids) but it can be extremely impressive when it does happen.

Most of the procedures I give ketamine for are short - I give an initial bolus and maybe a smaller bolus 20 minutes later if the procedure is still going. But it's never ever my sole agent - propofol/ketamine is more typical with a little midaz along the way. I personally don't use it by infusion although I know a lot of people that do, especially mixed with propofol, which is referred to as "ketafol".

 

[Doczilla]

As long as you have a benzo, ketamine is fine. And the ICP stigma was pretty much debunked.

 

[medicsb]

Hmmm - I'm constantly amazed at how willing people are to risk their careers with off-label use of medications.

I imagine it has to do with not many physicians (or medics, or nurses) losing their careers over off-label use of meds, but I don't doubt that a number of docs have been sued and lost.

Anyhow, I think you made some pretty good points regarding prehospital propofol and ketamine for psych/agitated delerium.

 

[triemal04]

I'm curious how frequently these "outside the norm" drugs are utilized. Especially drugs like labetalol, propofol, ceftriaxone, or maalox. I imagine they're being used almost never. Am I wrong in this assumption?

I know of a few places that carry various beta-blockers. They're used more for rapid afib than anything, or occasional for very refractory vf. If the numbers were really crunched, my guess is that they could be removed and there wouldn't be a problem.

Look up the results of COMMIT. The use of early IV beta-blockers in MI has been greatly narrowed because of this study. Their routine administration has largely been abandoned in many practices.

As it should be. That's the real point that that study should enforce. Indiscrimenently giving every patient with an MI a beta-blocker and then continueing that treatement post-repurfusion just doesn't sound like a good idea to begin with. But that doesn't change the fact that there are some patients who will respond to, and should be given beta-blockers during an MI. Like everything, it just means that a little more thinking needs to be done before pushing a med.

 

[NomadicMedic]

One of the most informative threads I've read in a while.

Thanks to all participating!

 

[Melclin]

I'm curious how frequently these "outside the norm" drugs are utilized. Especially drugs like labetalol, propofol, ceftriaxone, or maalox. I imagine they're being used almost never. Am I wrong in this assumption?

We carry ceftriaxone. Predominantly for meningoccal meningitis. I don't know that its ever been given accurately for this, if it has I suspect you could count the number of times on one hand. We can also give it for severe sepsis "on consult" (which means speaking with an experienced intensive care paramedic in the control rooms regarding the appropriateness of its use in cases where transport exceeds 1 hour. If they don't wanna take responsibility for that, we can theoretically speak with the hospital that we plan on transporting too, but I've never done this, its very rare, and I don't really know how it works.). I've never given it but called for it once and was denied on the basis that the person on the line didn't feel the person was sick enough for prehospital empiric abx. I've had quite a few other pts who would have qualified had the tranport time been longer.

I've been interested for a while in expanding sepsis management to include lactate measurement and drawing of cultures to remove the main barrier to prehospital abx. We bang on (and spend lots of money) all the time about fluid resuscitating hypotensive trauma pts of whom we see very few (lets leave aside the fact that we're probably not doing them any favours by giving them 3L of cold fluid that neither carries oxygen nor clots), while rarely focusing on sick sepsis pts of whom we see many and in whom the benefits of early abx have been well established. I hope that the few services I've heard of in the US doing lactates publish in peer reviewed journals so we can add to the evidence (hopefully in favour) behind prehospital sepsis management.

 

[stallion]

I've had a little experience with the use of cef...given it twice in the past year, both times for severe sepsis. As Melclin pointed out, there's lots good (and maybe ongoing) research on the topic. Obviously there's no sense in giving anti-biotics out to everyone meeting SIRS criteria, especially when you're only 10minutes from hospital, however when considering extended transports times with severely septic patient, it definitely has its place.

 

[NomadicMedic]

We're currently performing POC lactate testing, with a lactate of >4.0 mmol/L along with clinical signs/suspicion of sepsis for entrance into the sepsis protocol.

• Core temperature greater than 38°C or less than 36°C
• Heart rate greater than 90 bpm
• Respiratory rate >20
• Hypotension

We're not doing ABx, but infusing a liter of NS, with a second liter if hypotension continues, followed by dopamine and a "sepsis alert" to the ED.

 

[rwik123]

Propofol is an anesthesia drug, and there is huge debate about whether anyone besides anesthesia personnel should administer it via IV bolus. RN's in many states are prohibited by their state licensing boards from giving propofol boluses - it's only allowable by infusion with ventilated patients.

IMHO, and I use propofol daily, it's absolutely foolish to try and use this drug in pre-hospital care. It's not reversible - once it's in, it's in. There are numerous side effects, and in the patient population most of you would want to use it in, propofol would not be the drug of choice anyway given it's cardiovascular side effects. There are far better choices.

Lastly - the package insert for propofol states that it is for use by anesthesia personnel only, and that is the way both the FDA and manufacturers want to keep it. If you box someone using propofol in the field, there will be a line of plaintiff's lawyers waiting to talk to the family and someone will be writing checks with lots of zeroes.

Isn't it just as dangerous as other meds such as paralytics that agencies that RSI have on the truck? It's not reversible but so aren't a whole lot of other drugs... Yet it's a relatively short acting drug that can be titrated to effect.

I'm by no means knowledgable on it, just wanna hear others experience with it.

 

[Doczilla]

Succinylcholine has 13 contraindications; only a handful of which apply to the prehospital setting. Malignant hyperthermia for example , which does not manifest until they are in the hospital for a while. Others, like burns and crush injuries are only pertinent if the injury is >24 hours old, and even then only causes a serum potassium increase of about .5. Unless it was 7.9 when you give it to them, not really a big deal. Im sure the clenched jaw, and seizures that make succynlcholine so valuable in head injuries make it worth it.

Remember, etomidate wears off in less than 10 mins. Not providing maintenence sedation is barbaric. Propofol is pretty stable, and even cardioprotective with strong antiemetic and anticonvulsive properties that make is very desirable. It dosent take a genius to use it.

 

[Melclin]

We're currently performing POC lactate testing, with a lactate of >4.0 mmol/L along with clinical signs/suspicion of sepsis for entrance into the sepsis protocol.

• Core temperature greater than 38°C or less than 36°C
• Heart rate greater than 90 bpm
• Respiratory rate >20
• Hypotension

We're not doing ABx, but infusing a liter of NS, with a second liter if hypotension continues, followed by dopamine and a "sepsis alert" to the ED.

We have identical criteria for sepsis, minus the lactate measurement.

Treatment at what you would call the ALS level, involves saline up 60mls/kg, with adrenaline infusion +/- push doses in whatever combination is required. With notification.

So all in all, quite similar. Do you know if your protocol is being studied for publication? In what way does lactate affect inclusion in the sepsis protocol?