"Outside the norm" paramedic drugs

[mycrofft]

1. Is the malignant hyperthermia from these meds the same as the one which has geographic clusters in some parts of the country and world? (Might affect where you use those drugs sometimes; a couple of those clutters in Nebraska were pretty rural).
2. IV ABX in the field...what about potential for anaphylaxis, are you equipped and ready to cope with the reaction to the reaction to an IV bolus?

Odd how on the one hand we are striving to make antibiotics use more tailored to the proven presence and type of infection on one hand (using technology we developed to detect and react to chem/biological agents), and yet striving to take and start them sooner in the field without such? Not necessarily bad, but sort of ironic.

 

[medicsb]

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.

The onset of malignant hyperthermia is pretty swift and needs to be identified ASAP and cooling measures initiated immediately, and if dantrolene is available it needs to be given ASAP. Fortunately it is quite rare, but as mycroft noted, the genetic mutation predisposing one to it is prevalent in certain geographical regions, and I've heard of paramedics in at least one of those regions using only rocuronium for paralyis).

Also whether or not propofol requires a genius to administer it, I don't see why it would be used in the prehospital setting except for novelty.

 

[NomadicMedic]

I don't believe our lactate/sepsis measurements are being used for any publication. We advise of a "sepsis alert" simply to make the hospital aware of that patient that may need immediate antibiotics and/or fluid resuscitation. And again, a patient must have a lactate of 4.0 mmol/L to meet the "sepsis alert" criteria.

 

[Doczilla]

Results vary. Onset can be delayed as much as a few hours, and the role of succynlcholine in MH has not been clearly defined. My point is, the armchair quarterbacks that play a role in determining what we do in the field do not consider the availability of a detailed history if RSI becomes neccesary. If their condition warrants a pharmalogical control of their airway, chances are we're pretty tied up.

Most exclusionary criteria, using this as an example, are taken straight from the hospital.

Sure, there are many reasonable alternatives to propofol in continuous sedation. I don't advocate one agent over another. However, im skeptical of the stigma surrounding propofol. If you're trained in RSI, you should seek proficiency in every agent you could potentially use.

A little knowledge is a dangerous thing.

The onset of malignant hyperthermia is pretty swift and needs to be identified ASAP and cooling measures initiated immediately, and if dantrolene is available it needs to be given ASAP. Fortunately it is quite rare, but as mycroft noted, the genetic mutation predisposing one to it is prevalent in certain geographical regions, and I've heard of paramedics in at least one of those regions using only rocuronium for paralyis).

Also whether or not propofol requires a genius to administer it, I don't see why it would be used in the prehospital setting except for novelty.

 

[Christopher]

...and I've heard of paramedics in at least one of those regions using only rocuronium for paralysis...

NC just added it to our RSI formulary so I hope we drop succ as soon as the new protocols get Ok'd.

 

[jwk]

Results vary. Onset can be delayed as much as a few hours, and the role of succynlcholine in MH has not been clearly defined. My point is, the armchair quarterbacks that play a role in determining what we do in the field do not consider the availability of a detailed history if RSI becomes neccesary. If their condition warrants a pharmalogical control of their airway, chances are we're pretty tied up.

Most exclusionary criteria, using this as an example, are taken straight from the hospital.

Sure, there are many reasonable alternatives to propofol in continuous sedation. I don't advocate one agent over another. However, im skeptical of the stigma surrounding propofol. If you're trained in RSI, you should seek proficiency in every agent you could potentially use.

A little knowledge is a dangerous thing.

I'm not sure where you're getting your information on malignant hyperthermia and succinylcholine, but you're way off.

MH is a rare but extremely high mortality syndrome that is caused my two things - halogenated anesthetic agents and succinylcholine. The link between MH and sux has most certainly been clearly defined and a HX of MH is an absolute contraindication to the use of sux in any situation.

As far as propofol, there is a big difference between giving it by infusion to a ventilated patient for long transports (not unusual at all) and giving it for RSI or intiation of sedation by paramedics (a questionable practice at best and not supported by any controlled studies that I'm aware of.)

 

[NomadicMedic]

Here's a paramedic service protocol that uses it. (available freely on the Internet)

Grays Harbor Emergency Medical Services Patient Care Procedure Protocol
RAPID SEQUENCE INTUBATION


DOSE

0 - 10 minutes

Preparation

0 - 5 minutes

Preoxygenation to an O2 Sat of >90%

0 - 3 minutes
Pretreatment: ~Lidocaine for reactive
airways or ICP ~Atropine for children < 8 years old

Adult: 1.0mg/kg IV
PEDS: 0.02mg/kg IV

Zero minutes
Paralysis with induction: Pre-medication:
~Propofol OR
~Versed
Paralysis:
~Succinylcholine

Adult: 1.0-2.5mg/kg IV
PEDS: 2.5-3.5mg/kg IV
Adult: : 1-4mg IV to max 0.1mg/kg
PEDS: 0.1mg/kg (up to 5.0mg)
Adult: 1.0 - 1.5mg/kg IV
PEDS: 1.0-2.0mg/kg IV
Zero plus 25 seconds

Protection - Sellick's Maneuver
Zero plus 45 seconds

Placement- intubate, check placement

After confirmed placement
For sedation:
~ Propofol OR
~Versed OR ~Valium
If Versed or Valium used, also use Fentanyl 50mcg.
For continued paralysis: ~Vecuronium OR
~ Pancuronium

Adult: 1.0-2.5mg/kg IV
PEDS: 2.5-3.5mg/kg IV
Adult: 1-4mg IV to max 0.1mg/kg
PEDS: 0.1mg/kg ( 5.0mg max)
Adult: 5-10mg slow IV
PEDS: 0.1-0.3mg/kg IV
Adult: 0.1mg/kg IV
PEDS: >9 y/o 0.1mg/kg IV
Adult: 0.06-0.1mg/kg IV
PEDS: 0.04-0.1 mg/kg IV

 

[Smash]

As far as propofol, there is a big difference between giving it by infusion to a ventilated patient for long transports (not unusual at all) and giving it for RSI or intiation of sedation by paramedics (a questionable practice at best and not supported by any controlled studies that I'm aware of.)

Questionable: why? How much of EMS is supported by controlled studies? For that matter, how much of medicine in general is supported by controlled studies?

Our medics who work a combination of HEMS and ground response (chase cars) use propofol for RSI on a regular basis with good success and very few complications.
The options we have are fentanyl+midazolam, or ketamine, or fentanyl+propofol. Neuromuscular blockers include suxamethonium, rocuronium, pancuronium and vecuronium.
Ongoing sedation is then with morphine+midazolam or propofol+morphine (fentanyl can obviously be substituted for the morphine)

 

[Doczilla]

Jwk, no one said anything about using propofol as an induction agent. And feel free to cite some studies.

 

[medicsb]

Questionable: why? How much of EMS is supported by controlled studies? For that matter, how much of medicine in general is supported by controlled studies?

Our medics who work a combination of HEMS and ground response (chase cars) use propofol for RSI on a regular basis with good success and very few complications.
The options we have are fentanyl+midazolam, or ketamine, or fentanyl+propofol. Neuromuscular blockers include suxamethonium, rocuronium, pancuronium and vecuronium.
Ongoing sedation is then with morphine+midazolam or propofol+morphine (fentanyl can obviously be substituted for the morphine)

I imagine your ICPs are for more experienced and educated/trained than the average medic in the US, which is where I imagine JWK's experience with medics is centered.

The idea of RSI or propofol, etc. gets scary when medics in places like Grays Harbor County are allowed to use such drugs. New medics there are only required to get 4 tubes per year over their first 3 years, and then only 2 per year there after. Considering that the majority of ETI candidates would be cardiac arrests, I bet the average medic would be lucky do one RSI in a year, especially considering the number of medics that seem to be in that particular system.

 

[Doczilla]

Alright, I'm not posting from my phone anymore. :angry:

I'm not trying to quibble on every contraindication of succynlcholine. My point is, there's times where you have absolutely no way of determining if somoene meet every little bit of criteria for a drug to be class I.

If MH triggers based on a 1:5000 reaction among people with the genetic trait, then certianly it would be horrible. Core temps of 110 are not pleasent. But if you have a head injury with a clenched jaw that is actively seizing, I guarantee succynlcholine users won't be asking "Does anyone know if he has Myasthenia gravis, malignant hyperthermia, narrow angle glacouma, [list goes on...]?"

What are you going to do, wait till you're satisfied to push the drug? But even if you do, there will always be someone to read you a list of exclusionary criteria and slap you on the pee-pee, regardless if the guy is alive because of that drug or not.

 

[Smash]

I imagine your ICPs are for more experienced and educated/trained than the average medic in the US, which is where I imagine JWK's experience with medics is centered.

The idea of RSI or propofol, etc. gets scary when medics in places like Grays Harbor County are allowed to use such drugs. New medics there are only required to get 4 tubes per year over their first 3 years, and then only 2 per year there after. Considering that the majority of ETI candidates would be cardiac arrests, I bet the average medic would be lucky do one RSI in a year, especially considering the number of medics that seem to be in that particular system.

Yes, you probably have a point there. However there are certainly individuals and services that run rings around me and mine in the US, so I don't know that blanket statements regarding propofol are that relevant. Unless one can cite some specific studies or specific reasons why propofol is a bad drug.

On a sort of side note, my reading of all the literature so far on prehospital intubation doesn't support the idea that intubation is bad and should be done away with. It merely supports the idea that intubation done badly is bad (and should probably be done away with in certain areas or certain circumstances if the will to ensure adequate initial and ongoing education is not there)

Doczilla, I agree with what you are saying with regards to suxs. Most people who get it are not in a position to tell you their history, most probably wouldn't know it anyway, and honestly, if it's a choice between the smashed head blowing bubbles of blood and vomit and the glaucoma, I'm going to deal with the head and airway issues anyway.
However, that is one of the reasons why I think rocuronium is a far better drug for RSI. Sux works great most of the time, but when it doesn't, it really doesn't.

 

[Doczilla]

Agreed. I use vecuronium more anyway, onset time is comperable, maybe another min tops.

 

[jwk]

Doczilla, I agree with what you are saying with regards to suxs. Most people who get it are not in a position to tell you their history, most probably wouldn't know it anyway, and honestly, if it's a choice between the smashed head blowing bubbles of blood and vomit and the glaucoma, I'm going to deal with the head and airway issues anyway.
However, that is one of the reasons why I think rocuronium is a far better drug for RSI. Sux works great most of the time, but when it doesn't, it really doesn't.

I'm not arguing against the use of sux pre-hospital. I was simply pointing out that Doczilla's statement about the connection between sux and MH is unclear, which was incorrect. I'm much more comfortable with pre-hospital use of sux than I am propofol, and my concern with propofol is because of it's poor hemodynamic profile and my assumption that most patients who might need RSI probably don't need propofol to complicate matters.

And to your point - I'm not sure why you think roc is a better drug for RSI than sux. Roc works fine, but it is never as fast as sux, and sometimes if you need relaxation quickly, roc just isn't fast enough. You can up the dose of roc as much as you want, but it is never going to be as fast as sux, which is why there is so much ongoing research into faster non-depolarizing NMB's. Sux is still the gold standard for true RSI. And I'm curious - when have you had sux not work?

 

[Doczilla]

Great point. Getting pimped by an anesthesia doc is a treat.

I guess I'm partial to vec (same class as roc as we all know) because I've had to sit on dudes for a while. When I do use sux, ill follow up with an "anesthesia bag" for continuous sedation consisting of ketamine, versed, and vec running at a weight-dependent rate.

While its true that propofol might cause a B/P dip initially, I haven't seen it much. Then again, I've only used it a few dozen times for these purposes (I'm not counting fracture reductions or dental extractions). I'm sure as an anesthesiologist you've used it more--- but don't you think that the anticonvulsant, antiemetic, and cardioprotective effects are desirable in trauma? (Head injuries especially).

Sure, you won't see someone seizing when you successfully RSI someone without an EEG; but a seizing brain is still in danger due to the cellular mechanisms that take place and enhance/accellerate the injury process. I think its relatively safer compared to using high-dose quinidines and barbituates, with a much lower cardiovascular side effect profile.

Plus, serial maintenance doses of etomidate or versed can be difficult to time if you haven't been fully trained in I.V anesthesia, and haven't been granted permission to hang drips of ketamine, versed, or fentanyl. Correct me if I'm wrong please.

 

[medicsb]

On a sort of side note, my reading of all the literature so far on prehospital intubation doesn't support the idea that intubation is bad and should be done away with. It merely supports the idea that intubation done badly is bad (and should probably be done away with in certain areas or certain circumstances if the will to ensure adequate initial and ongoing education is not there)

I agree. Though I'd add "suffiecient hands on experience". Initial and ongoing education will only go so far if you are only seeing real patients very rarely (though you would get good at managing the difficult to intubate sim-man).

 

[Aidey]

And I'm curious - when have you had sux not work?

My agency has had at least 3 incidents as of March where sux didn't work. I haven't heard if there have been any more since then. In all 3 cases adequate doses were given through patent IV lines. I'm not sure that they ever figured out what happened.

 

[Veneficus]

I'm not arguing against the use of sux pre-hospital. I was simply pointing out that Doczilla's statement about the connection between sux and MH is unclear, which was incorrect. I'm much more comfortable with pre-hospital use of sux than I am propofol, and my concern with propofol is because of it's poor hemodynamic profile and my assumption that most patients who might need RSI probably don't need propofol to complicate matters.

Interestingly enough, all of the anesthesiologists I met in Britian use propofol almost exclusively on trauma patients.

Not suggesting it is right or wrong, just food for thought.

 

[jwk]

My agency has had at least 3 incidents as of March where sux didn't work. I haven't heard if there have been any more since then. In all 3 cases adequate doses were given through patent IV lines. I'm not sure that they ever figured out what happened.

If you're satisfied the IV's were patent then really the only explanation for that would be a bad lot of sux. Probably too late now, but you could see if the lot numbers on the bottles were the same. We occasionally get a batch of drugs where the effect isn't nearly what you expect it to be. This has happened on numerous occasions with rocuronium. Whether related to the manufacturer (several different generic brands) and their quality controls, or it being out in a room temp or higher environment for too many weeks, I don't know.

If the problem is they just don't relax, it's probably bad drug. If the problem is something like a trismus, where they really lock up their jaws, that's different, and that is occasionally seen along with MH.

BTW - to the poster who mentioned geographic pockets of MH - this most certainly happens, and it's good to know if you're in one of those areas. It tends to occur in (how can I say this delicately) a more homogeneous population than might normally be found in an urban area.

 

[jwk]

Interestingly enough, all of the anesthesiologists I met in Britian use propofol almost exclusively on trauma patients.

Not suggesting it is right or wrong, just food for thought.

I'm actually a ketamine fan for trauma, unless there's concern about head injuries. I do use propofol for some trauma and for sick patients, but greatly decrease the dose. You'd be surprised how little it sometimes takes to produce unconsciousness (if you're patient). Most of our elective cardioversions are done with propofol, and I rarely give more than 40mg even for bigger patients.