"Outside the norm" paramedic drugs

[Aidey]

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.

I don't know any more about it than what I posted. It was investigated above my head. The only reason I know about it is because I used sux during that time and they wanted to know if it worked or not. I wanted to know why they wanted to know.

 

[WestMetroMedic]

If we want to keep a medication assisted intubation process like RSI and legitimize its presence in EMS to our hospital counterparts, then perhaps we should start pumping put some good research and not the crap that San Diego has pumped out...

My understanding of Propofol, which is limited to education received and some brief interfacility trips to out HBO chamber, is that it is not the best medicine for the non ICU or surgical setting as the hubbub that exists outside of those environments causes a lower response to the dose being administered and requires a higher dose and in a med that is BP effecting like Propofol, perhaps this isn't the best idea, especially when there are perfectly acceptable options already in wide acceptance.

But I suppose, we as EMS providers think we are the best practicioners in the field, so we should be able to do whatever we feel like.

 

[usalsfyre]

It's all in how you treat the patient on Propofol. Loud noises, lights and low doses due to crappy volume status are the enemy.

Using it for induction is a different kettle of fish though.

 

[Smash]

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.

Most, but not all. We typically use propofol for people with a normal GCS who are not hemodynamically compromised but who require a secure airway - for example, airway burns. If the patient is hemodynamically compromised we opt for ketamine, otherwise our standard drugs are midazolam and fentanyl. There's no one size fits all regimen.

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?

At 1.2mg/kg of roc compared with 1.5mg/kg of sux there is no appreciable difference in intubating conditions between the two. If the roc is underdosed (0.6 - 1.0mg/kg) then yes, there is a delay. Although I have had sux not work on a couple of occasions, my point was more to the fact that there are a large number of contraindications to sux and a large number of adverse effects as well, none of which are seen with roc.
Roc gives the same intubating conditions in the same time, increases safe apnea time, has no side effects and has no contraindications (discounting allergy of course) - what's not to like?

 

[MHAUS]

Malignant Hyperthermia Association of US

Did you know about the MH Hotline 1-800-644-9737
See mhaus dot org for more information.

 

[MHAUS]

The MH Hotline is 1-800-644-9737
More at mhaus dot org

 

[jwk]

At 1.2mg/kg of roc compared with 1.5mg/kg of sux there is no appreciable difference in intubating conditions between the two. If the roc is underdosed (0.6 - 1.0mg/kg) then yes, there is a delay. Although I have had sux not work on a couple of occasions, my point was more to the fact that there are a large number of contraindications to sux and a large number of adverse effects as well, none of which are seen with roc.
Roc gives the same intubating conditions in the same time, increases safe apnea time, has no side effects and has no contraindications (discounting allergy of course) - what's not to like?

If roc was THE drug for RSI, we wouldn't use sux at all because of the potential complications that go along with it. There's a reason it hasn't gone away, and that is speed of onset. There IS a difference.

In the average 70kg patient, your dose of roc is 84mg. I've never given that much in my life. You can increase the dose of roc as much as you want, but it's not going to speed up your onset time appreciably. Even your definition of underdosing would be high for us, but then we're using it for different purposes.

The other big drawback of roc, and will be until sugammadex is widely available in the US, is that once it's in, you can't reverse it immediately, so if you can't intubate your patient and can't ventilate them, you're screwed. That's why sux is still the drug of choice for potential difficult intubations as well (my definition of difficult ). If you can't intubate and can't ventilate, your patient will be breathing again in a couple minutes.

 

[Smash]

If roc was THE drug for RSI, we wouldn't use sux at all because of the potential complications that go along with it. There's a reason it hasn't gone away, and that is speed of onset. There IS a difference.

Except that difference is not statistically significant and arguably not clinically significant either.

Pantawala, AE et al (2011) Comparison of succinylcholine and rocuronium for first-attempt intubation success in the emergency department. Acad Emerg Med.

Perry JJ et al (2008) Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database of Systematic Reviews

Mallon, W. et al. (2009) Rocuronium vs. succinylcholine in the emergency department: A critical appraisal J Emerg Med.

The other big drawback of roc, and will be until sugammadex is widely available in the US, is that once it's in, you can't reverse it immediately, so if you can't intubate your patient and can't ventilate them, you're screwed. That's why sux is still the drug of choice for potential difficult intubations as well (my definition of difficult ). If you can't intubate and can't ventilate, your patient will be breathing again in a couple minutes.

That is the same rationale that the above two reviews use to come to the conclusion that sux is the superior drug despite the lack of difference in intubating conditions.

However there are a couple of problems with that philosophy.

First of all, it isn't true. Critical desaturation will occur prior to sux wearing off even in healthy patients. In unhealthy patients (i.e. the ones we are intubating, not the ones in the OR for an elective procedure) that is even more so the case. Sux will actually hasten desaturation, presumably through increased O2 consumption due to fasciculations. Rocuronium on the other hand prolongs the period of safe apnoea you have, allowing more time for intubation attempts or alternative airways to be used.

Tang, L. et al (2011) Desaturation following rapid sequence induction using succinylcholine vs. rocuronium in overweight patients. Acta Anaesthesiol Scand.

Heier, T et al (2001) Hemoglobin desaturation after succinylcholine-induced apnea: a study of the recovery of spontaneous ventilation in healthy volunteers. Anesthesiology.

Benumof JL et al (1997) Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology

Naquib, M et al (2005) Succinylcholine dosage and apnea-induced hemoglobin desaturation in patients. Anesthesiology

Taha, SK et al (2010) Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction. Anaesthesia

The other major issue I have with that approach for in-field RSI is: If you are about to RSI a patient, and your back up plan if you can't intubate is to just let them breath up on their own, why are you trying to RSI them in the first place?

 

[WestMetroMedic]

I'm not sure what everyone else has for an RSI protocol, but when I worked at a service that did RSI, we had a backup device like the CombiTube (I haven't RSI d in over 5 years). A BLS airway is a good airway but an RSI provides you definitive control if you are successful, it also streamlines your processes. If you can't get three tube because they look slightly less jowely than Larry king, you will still have top roll old school but at least you tried.

Moral of the story is- everyone should have a backup device if you want RSI.

 

[jwk]

Except that difference is not statistically significant and arguably not clinically significant either.

Pantawala, AE et al (2011) Comparison of succinylcholine and rocuronium for first-attempt intubation success in the emergency department. Acad Emerg Med.

Perry JJ et al (2008) Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database of Systematic Reviews

Mallon, W. et al. (2009) Rocuronium vs. succinylcholine in the emergency department: A critical appraisal J Emerg Med.

I don't review EMS literature for anesthesia. The literature you quote may be fine for ED and EMS but we have different definitions for RSI in the OR. You'll have to take my word for it - I'd have the tube in with sux while you were still watching the clock with roc. Unless there is an absolute contraindication for sux, for a true RSI, we will always use suc over roc because there is a difference - it may not be apparent to those who only intubate occasionally, but to those of us who do it multiple times every day for years, and who define airway management and RSI, there is.

That is the same rationale that the above two reviews use to come to the conclusion that sux is the superior drug despite the lack of difference in intubating conditions.

However there are a couple of problems with that philosophy.

First of all, it isn't true. Critical desaturation will occur prior to sux wearing off even in healthy patients. In unhealthy patients (i.e. the ones we are intubating, not the ones in the OR for an elective procedure) that is even more so the case. Sux will actually hasten desaturation, presumably through increased O2 consumption due to fasciculations. Rocuronium on the other hand prolongs the period of safe apnoea you have, allowing more time for intubation attempts or alternative airways to be used.

Tang, L. et al (2011) Desaturation following rapid sequence induction using succinylcholine vs. rocuronium in overweight patients. Acta Anaesthesiol Scand.

Heier, T et al (2001) Hemoglobin desaturation after succinylcholine-induced apnea: a study of the recovery of spontaneous ventilation in healthy volunteers. Anesthesiology.

Benumof JL et al (1997) Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology

Naquib, M et al (2005) Succinylcholine dosage and apnea-induced hemoglobin desaturation in patients. Anesthesiology

Taha, SK et al (2010) Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during apnoea following rapid sequence induction. Anaesthesia

The other major issue I have with that approach for in-field RSI is: If you are about to RSI a patient, and your back up plan if you can't intubate is to just let them breath up on their own, why are you trying to RSI them in the first place?

Again, we have different definitions for RSI. I never said the SaO2 wouldn't drop with sux and no ventilation - it most certainly will. However, if you can't intubate/ventilate, and you've given roc, your option is to cut the neck. Not necessarily so with sux. One of the paths down the ASA Difficult Airway Algorithm is "awaken the patient". Can't be done with roc - it can be done with sux (although you may be puckering along the way). We use sux as opposed to roc for bariatric patients as well and for the same reason. Can't intubate? Wake 'em up.

 

[usalsfyre]

Again, we have different definitions for RSI. I never said the SaO2 wouldn't drop with sux and no ventilation - it most certainly will. However, if you can't intubate/ventilate, and you've given roc, your option is to cut the neck. Not necessarily so with sux. One of the paths down the ASA Difficult Airway Algorithm is "awaken the patient". Can't be done with roc - it can be done with sux (although you may be puckering along the way). We use sux as opposed to roc for bariatric patients as well and for the same reason. Can't intubate? Wake 'em up.

Like you say, different setting. ASA algorithms assume better options not often available in the EMS setting. Like Smash says, if "wake'em up" is a viable option in our world I would seriously question your candidate selection. If we get can't get the tube you need to placing some form of alternative airway, even if that involves a scalpel.

 

[TatuICU]

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.

Why dopamine if I may ask? Is it solely because of the central line issue with levo?

 

[TatuICU]

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?

Because getting a lactate measurement allows you to initiate sepsis treatment much sooner. A lot of these patients who are very sick, don't look very sick at first. By the time you start seeing symptoms that would alert you to possible septic shock (hypotension, etc), you've lost time and the patient's morbidity increases dramatically. A lactate above 4 is associated with a very high death rate. With a level above 4 you know the inflammatory cascade has started wreaking havoc on your patient because it is of course produced by anaerobic metabolism and maybe our best lab marker for tissue hypoperfusion.

 

[NomadicMedic]

Why dopamine if I may ask? Is it solely because of the central line issue with levo?

Because Dopamine is the only pressor we carry.

 

[TatuICU]

Because Dopamine is the only pressor we carry.

gotcha

 

[Melclin]

Because getting a lactate measurement allows you to initiate sepsis treatment much sooner. A lot of these patients who are very sick, don't look very sick at first. By the time you start seeing symptoms that would alert you to possible septic shock (hypotension, etc), you've lost time and the patient's morbidity increases dramatically. A lactate above 4 is associated with a very high death rate. With a level above 4 you know the inflammatory cascade has started wreaking havoc on your patient because it is of course produced by anaerobic metabolism and maybe our best lab marker for tissue hypoperfusion.

Well yeah. I understand why they're doing lactates.

But my question was how it fits into the sepsis protocol eg do they have to have a certain ammount of SIRS criteria + lactate or is it an either/or thing, do they have to have an elevated lactate to be included etc. 4 is quite high. Does it have to be above 4 to go down that pathway?

My point being that people meeting those criteria would be getting fluid anyway +/- a pressor depending on their numbers, so I'm interested in how lactate fits into the picture in this particular trial.

 

[Smash]

I don't review EMS literature for anesthesia. The literature you quote may be fine for ED and EMS but we have different definitions for RSI in the OR.

I appreciate that, however this is an EMS website discussing EMS issues, I would have thought it somewhat apposite to look at EMS literature. Which, incidentally, these studies aren't, they are all in ER or OR settings. I understand that you may have different definitions for RSI in the OR; but again we are discussing EMS issues.

You'll have to take my word for it - I'd have the tube in with sux while you were still watching the clock with roc.

I'm sorry, I mean no disrespect, but rather than take the word of a pseudonym on a website I will take my own experience combined with what published data I can find. I appreciate that there is much I can learn from yourself and from others on this site, but that learning must be filtered through my own experience and knowledge and modified by the system in which I work.

Unless there is an absolute contraindication for sux, for a true RSI, we will always use suc over roc because there is a difference - it may not be apparent to those who only intubate occasionally, but to those of us who do it multiple times every day for years, and who define airway management and RSI, there is.

And therein lies a great deal of the problem as I see it. We are typically dealing with the complete unknown and won't know if there is a contraindication to sux. I don't have a history to consult and I can't talk to the patient before the procedure: I'm flying by the seat of my pants.

Do they have hyper-K? I can hazard a guess from the situation and the ECG, but I don't know. Malignant hyperthermia? No idea. Duschene muscular dystrophy? Maybe someone is around who can let me know, maybe not. Sux apnea? Could have used roc after all!

Every time we use sux in the EMS setting we are playing the odds. The odds might be long, but eventually they are bound to catch up. I might not intubate multiple times a day, only multiple times a month, but those odds still play on my mind. With roc I don't have those worries and I know that I have a bit longer to get that airway secure before things go south.

Again, we have different definitions for RSI. I never said the SaO2 wouldn't drop with sux and no ventilation - it most certainly will. However, if you can't intubate/ventilate, and you've given roc, your option is to cut the neck. Not necessarily so with sux. One of the paths down the ASA Difficult Airway Algorithm is "awaken the patient". Can't be done with roc - it can be done with sux (although you may be puckering along the way). We use sux as opposed to roc for bariatric patients as well and for the same reason. Can't intubate? Wake 'em up.

And again, different scenario from what I am doing (and why I am doing it) in the field.

 

[ditchdoc125]

In Alberta, we have dimenhydrinate, metoclopramide and ondansetron for antiemetics, the use of each drug is based on the suspected underlying cause of the n/v. There's the odd cowboy out there that will use haldol SQ, but we don't talk about that.....

The use of Ketamine is standard when your hypotensive patient requires RSI and maintenance of sedation. We also have it available for pain refractory to fentanyl/morphine or profound hypotension with on-line consult.

Some other not so "norm" drugs we have are tenecteplase, tetracaine, ketorolac and transexamic acid (this one is new, it is an antifibrinolytic used in the setting of traumatic hemorrhage) .

 

[Smash]

Are you studying TXA or just going ahead with it on the basis of CRASH2 and MANERS? What are your criteria for administration?

 

[Handsome Robb]

Word on the street is we will be getting Ketamine on standing orders in the near future for first line sedation and pain management along with what we already have (fentanyl, morphine and versed). Also I heard talk and read in our clinical meeting minutes about beta blockers (either labetolol and/or metoprolol) for hypertensive crisis, CVA and AMI along with calcium channel blockers for new onset AF with RVR and with associated hypotension.

We have a CQI meeting coming up in the near future and I will report back when I hear the official word.