fast65
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Now we really haven't gone over chemical restraint yet, so forgive me if I'm incredibly off track. But, wouldn't you just use Haldol and Droperidol for chemical restraint?
Paralytic Question
- Thread starter samiam
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You're kidding? Mind posting the SOP/ guidelines?
Shishkabob
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Smash
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So you give intramuscular sux to someone and hope you can tube them?
Smash
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Yes you would. Or a an agent like midazolam or lorazepam. I would respectfully suggest that giving a neuromuscular blocking agent in the setting the OP describes is not on the verge of malpractice, it is off the verge, down the bank, in the creek at the bottom, upside down and on fire.
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I can't fathom IM sux... Too much unpredictability in absorption, and probably requires a ridiculous dose to be effective. Despite what Tom Clancy says.
I'm pretty sure Linuss would be referring to the use of RSI in a combative patient in general.
I'm pretty sure Linuss would be referring to the use of RSI in a combative patient in general.
Combative head injuries are VERY different than a medication non-compliant knife wielding schizophrenic.
Smash
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Indeed, but no less in need of sedation to go with the paralysis!
I completely agree. I'm just questioning whether or not the system Linuss works in can RSI psychological emergencies.
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Shishkabob
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Heck no, just saying we can RSI someone to facilitate treatment....usually head injury, but still.
Will I paralyze the run of the mill psych patient? No.
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samiam
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Etorphine (Immobilon or M99) semi-synthetic opioid possessing an analgesic potency approximately 1,000-3,000 times that of morphine. Used to knock out elephants takes seconds and can be lethal to humans to a point that an equivalent amount of human antidote comes in the package just in case. Its the drug of choice in the show Dexter
Cite: http://en.wikipedia.org/wiki/Etorphine
Cite: http://en.wikipedia.org/wiki/Etorphine
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samiam
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A 4 mg dose will immobilize a 5000 kg African elephant; 1 mg will knock out a 2000 kg rhino.
Cite: http://www.chm.bris.ac.uk/motm/etorphine/etorphinec.htm
Cite: http://www.chm.bris.ac.uk/motm/etorphine/etorphinec.htm
There was a case study presented at I believe AMTC one year about a crew using IM sux in a patient who was threatening the crews with either a Lifepack or O2 bottle. Sux, tube, followed by sedation.
I work in the same system as Linuss and although I haven't heard of one of our crews doing it I watched one of our OMDs do exactly what is described in the ED one day. The patient was a danger to himself and all of us from a PCP overdose, he got 10mgs of vec (odd choice I thought but I can see a hyperkalemia concern) through an IV that the EMS crew had somehow established, a tube followed by a midaz bolus and infusion.
I've also used rocc and sux extensively in crash airways (followed by immediate sedation once the airway was secure), and there's a very valid line of thinking in anethistist circles that eliminates sedation entirely ("sux and an apology") in the profound shock patient who is extremely catocholemine dependent.
It's critical that most of these patients get sedation IMMEDIATELY upon the airway being secured and the danger being somewhat mitigated. But paralysis without sedation is not malpractice in the appropriate setting, and properly followed up. The problem is way too many people lack the critical thinking skills to determine the appropriate setting.
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Seems to me like quite a few people here need to do a but more learning on the difference between sedation, paralyzation, RSI, and chemical restraint...some people seem to be using these terms interchangeably, which they are not.
RSI - a carefully sequenced administration of medication that will first sedate, then paralyze the patient, in order to facilitate securing an airway.
Sedation - administration of a medication that results in an altering of the patient's LOC for the purposes of calming them down, helping them tolerate pain, helping them tolerate being intubated, etc.
Chemical restraint - administering enough sedation to alter the patient's LOC to the point they are no longer combative, and generally unconscious. Sometimes this requires intubation to manage the airway, at which point you may need paralyzation also.
Paralyzation - administration of a paralytic agent for the sole purpose of eliminating muscular movement in the patient. There are only a few medically appropriate situations that call for this that i can think of. Relieving trismus in order to facilitate intubation, eliminating diaphragm movement to facilitate intubation or to increase ventilator compliance. Paralyzation is not, has never been, and never will be appropriate to control combative patients, punish patients who are combative, control seizure activity, relieve pain....blah blah blah. It amazes me still how many people still don't understand paralytics.
Most of the time, at least the places I have worked...a patient in extremis who needs their airway controlled will be RSId appropriately, intubated, and then sedation is maintained appropriately. To maintain sedation to need to keep in mind your medication dosage range, duration of action, peak time, and also monitor you patient's vitals and watch for signs of them not being adequately sedated.
Typically the only time we will continue paralyzation is if their compliance with the vent is so poor it effects proper ventilation. I have seen some medics go to reparalyze the patient because they were reaching for the tube...which absolutely boggles my mind. Patients who are trying to self extubate need sedation. Paralyzation should really only be administered for control of diaphragm movement to increase compliance....
Sorry to go so off track here, but it really disturbed me some of the stuff I was reading.
Anyone feel free to add or chime in on anything I've mentioned...I don't claim to be 100% right, but I have had a pretty good run with RSI and sedation, and typically get good results from my patients.
RSI - a carefully sequenced administration of medication that will first sedate, then paralyze the patient, in order to facilitate securing an airway.
Sedation - administration of a medication that results in an altering of the patient's LOC for the purposes of calming them down, helping them tolerate pain, helping them tolerate being intubated, etc.
Chemical restraint - administering enough sedation to alter the patient's LOC to the point they are no longer combative, and generally unconscious. Sometimes this requires intubation to manage the airway, at which point you may need paralyzation also.
Paralyzation - administration of a paralytic agent for the sole purpose of eliminating muscular movement in the patient. There are only a few medically appropriate situations that call for this that i can think of. Relieving trismus in order to facilitate intubation, eliminating diaphragm movement to facilitate intubation or to increase ventilator compliance. Paralyzation is not, has never been, and never will be appropriate to control combative patients, punish patients who are combative, control seizure activity, relieve pain....blah blah blah. It amazes me still how many people still don't understand paralytics.
Most of the time, at least the places I have worked...a patient in extremis who needs their airway controlled will be RSId appropriately, intubated, and then sedation is maintained appropriately. To maintain sedation to need to keep in mind your medication dosage range, duration of action, peak time, and also monitor you patient's vitals and watch for signs of them not being adequately sedated.
Typically the only time we will continue paralyzation is if their compliance with the vent is so poor it effects proper ventilation. I have seen some medics go to reparalyze the patient because they were reaching for the tube...which absolutely boggles my mind. Patients who are trying to self extubate need sedation. Paralyzation should really only be administered for control of diaphragm movement to increase compliance....
Sorry to go so off track here, but it really disturbed me some of the stuff I was reading.
Anyone feel free to add or chime in on anything I've mentioned...I don't claim to be 100% right, but I have had a pretty good run with RSI and sedation, and typically get good results from my patients.
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Also, I will add...in regards to those talking about extremely dangerous patients who were given paralytics, intubated and then immediately sedated...I guess I could see it happening. I have never done it and likely never would. I have run some extremely out of control patients and never been in a situation where I thought giving a paralytic first was beneficial.
As long as you sedate them with something that will cause some retrograde amnesia, I guess all is well that ends well. Still, paralyzation then sedation is probably not generally considered best practice.
I agree with you USAL that there is some literature and science out there that indicates that in some very very specific and uncommon circumstances, paralyzation before, or paralyzation solely is appropriate.
The only reason I wrote what I did in such general terms is that most services will never have a provision for paralysis only intubation. Frankly in the pre hospital setting I don't see a place for it...
Like I said, I am not trying to call anyone out, so hopefully nobody takes it that way.
As long as you sedate them with something that will cause some retrograde amnesia, I guess all is well that ends well. Still, paralyzation then sedation is probably not generally considered best practice.
I agree with you USAL that there is some literature and science out there that indicates that in some very very specific and uncommon circumstances, paralyzation before, or paralyzation solely is appropriate.
The only reason I wrote what I did in such general terms is that most services will never have a provision for paralysis only intubation. Frankly in the pre hospital setting I don't see a place for it...
Like I said, I am not trying to call anyone out, so hopefully nobody takes it that way.
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firecoins
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I just recovered. I missed the keyboard.
medic417
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I just wonder if the OP really wanted the info to "prank" someone or worse to actually try and kill someone. So all the info provided may have helped someone commit a crime.:unsure:
WTEngel, I agree with most of what you said, but want to discuss a couple of points.
First, the only reason, as it was put to me, for the paralytic in RSI is to prevent active regurgitation in the non-NPO patient. With enough sedative you could probably even get trismus to release, and there's some services out there using an insane amount of sedative (I recently had heard of one in north east Texas that routinely uses 100mgs of Etomidate :blink
. However neuromuscular blockers prevent emptying one's gastric contents, meaning you can stimulate the gag reflex all you want, the patient can't physically gack.
The unconscious patient who needs airway control right freakin' now(hypoxemia is present and/or active regurg is going on) but has trismus/other barriers to manual airway control and ventilation is EXACTLY the kind of patient in which I'm likely to push a paralytic with no sedative. Generally waiting around to do a full RSI sequence will result in a bad outcome. It's well supported under the National Emergency Airway Algorithms (Crash Airway). I personally have run across a couple of these, the paralytic facilitates manual and advanced airway control and stops the puking. Just sedate immediately afterward to prevent/blunt as much of the ICP spike as you can. However, I agree MOST patients can wait for a full sequence.
I've also seen way to many people push vec when someone goes for the tube, I don't understand it either.
As far as seizure control, sometimes it's a matter of the lesser of evils. In my career I've run across exactly two patients who benzos did not control seizures (I gave upwards of 20mgs of midaz to an 8 year old one day, no dice). I would very much prefer some levetiracetam or fosphenytoin in this case, but we don't carry it. There's part of my service area that are 30+ minutes from either a hospital or a HEMS service that has better meds available. I understand completely I'm not really "controlling seizures" by intubating and paralyzing a patient. However I AM reducing metabolic demand thereby hopefully preventing hypoperfusion, facilitating ventilation and getting rid of any airway concerns which allows me to empty every drop of benzodiazapine in my box into this patient, and hopefully provide SOME control of the underlying seizure disorder until I can get to better meds.
Patient restraint is the lesser of evils again, I'd much rather use BIG doses of benzos in our system, but if I'm 20+mgs/500mcgs of midaz and fentanyl in (which is actually a massive protocol violation here but this is one of the times it's probably better to beg forgiveness as asking permission would be difficult) and still getting my butt kicked then it's time to go a different route. We don't have haloperidol available.
Finally, the folks who talk of "punishing" patients, this is crap. There's NEVER a reason to punish any patient. Grow up, or get the hell out of medicine.
First, the only reason, as it was put to me, for the paralytic in RSI is to prevent active regurgitation in the non-NPO patient. With enough sedative you could probably even get trismus to release, and there's some services out there using an insane amount of sedative (I recently had heard of one in north east Texas that routinely uses 100mgs of Etomidate :blink
. However neuromuscular blockers prevent emptying one's gastric contents, meaning you can stimulate the gag reflex all you want, the patient can't physically gack. The unconscious patient who needs airway control right freakin' now(hypoxemia is present and/or active regurg is going on) but has trismus/other barriers to manual airway control and ventilation is EXACTLY the kind of patient in which I'm likely to push a paralytic with no sedative. Generally waiting around to do a full RSI sequence will result in a bad outcome. It's well supported under the National Emergency Airway Algorithms (Crash Airway). I personally have run across a couple of these, the paralytic facilitates manual and advanced airway control and stops the puking. Just sedate immediately afterward to prevent/blunt as much of the ICP spike as you can. However, I agree MOST patients can wait for a full sequence.
I've also seen way to many people push vec when someone goes for the tube, I don't understand it either.
As far as seizure control, sometimes it's a matter of the lesser of evils. In my career I've run across exactly two patients who benzos did not control seizures (I gave upwards of 20mgs of midaz to an 8 year old one day, no dice). I would very much prefer some levetiracetam or fosphenytoin in this case, but we don't carry it. There's part of my service area that are 30+ minutes from either a hospital or a HEMS service that has better meds available. I understand completely I'm not really "controlling seizures" by intubating and paralyzing a patient. However I AM reducing metabolic demand thereby hopefully preventing hypoperfusion, facilitating ventilation and getting rid of any airway concerns which allows me to empty every drop of benzodiazapine in my box into this patient, and hopefully provide SOME control of the underlying seizure disorder until I can get to better meds.
Patient restraint is the lesser of evils again, I'd much rather use BIG doses of benzos in our system, but if I'm 20+mgs/500mcgs of midaz and fentanyl in (which is actually a massive protocol violation here but this is one of the times it's probably better to beg forgiveness as asking permission would be difficult) and still getting my butt kicked then it's time to go a different route. We don't have haloperidol available.
Finally, the folks who talk of "punishing" patients, this is crap. There's NEVER a reason to punish any patient. Grow up, or get the hell out of medicine.
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samiam
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If you read the whole thread you will see it is in response to something a doc said... a "prank" using any form of medication is not a "prank" it is battery.