RSI Medications and Use

chaz90

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Solution to an RSI patient beginning to spontaneously breathe through the tube one minute after 200 mg of succinylcholine? Evidently 20 mg of Nimbex followed by a Nimbex drip.
 

Handsome Robb

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Solution to an RSI patient beginning to spontaneously breathe through the tube one minute after 200 mg of succinylcholine? Evidently 20 mg of Nimbex followed by a Nimbex drip.
Oh wow....why nimbex rather than roc or vec?
 

chaz90

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Oh wow....why nimbex rather than roc or vec?
You'd have to ask my medical director. He was the one ordering drugs and intubating in the ED. Honestly, I don't even know the finer points of differences between Nimbex and vec. I transported the patient but had zero interest in intubating him.
 

Handsome Robb

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You'd have to ask my medical director. He was the one ordering drugs and intubating in the ED. Honestly, I don't even know the finer points of differences between Nimbex and vec. I transported the patient but had zero interest in intubating him.
I really don't either. Just not one you usually hear.
 

TransportJockey

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You'd have to ask my medical director. He was the one ordering drugs and intubating in the ED. Honestly, I don't even know the finer points of differences between Nimbex and vec. I transported the patient but had zero interest in intubating him.
Ah I was just about to ask WHY you carried Nimbex in the field... It's not the most field friendly drug out there.
 

Handsome Robb

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It's got a long duration right? Like longer than roc or vec long. I'm trying to remember everything I read in the pharma section of my CCP book yesterday. Some of the NDMBs were new to me.
 

TransportJockey

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It's got a long duration right? Like longer than roc or vec long. I'm trying to remember everything I read in the pharma section of my CCP book yesterday. Some of the NDMBs were new to me.
It's been a while since I read about it, so I could be wrong. But it's similar to vec and roc on duration ,but has some issues with histamine release and hypotension.
 

STXmedic

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Solution to an RSI patient beginning to spontaneously breathe through the tube one minute after 200 mg of succinylcholine? Evidently 20 mg of Nimbex followed by a Nimbex drip.
Oxygen. Well, the cylinder of oxygen...
 
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Handsome Robb

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It's been a while since I read about it, so I could be wrong. But it's similar to vec and roc on duration ,but has some issues with histamine release and hypotension.
It's kinda sad how little detail this text goes into about pharm.
 

TransportJockey

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It's kinda sad how little detail this text goes into about pharm.
I actually bought an anesthesia pharm book to study. Most of my texts are not paramedic level
 

Handsome Robb

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I actually bought an anesthesia pharm book to study. Most of my texts are not paramedic level
How do you like it? Some of the advanced texts are so damn dry.
 

TransportJockey

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STXmedic

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How do you like it? Some of the advanced texts are so damn dry.
Almost all of my advanced texts are dry. The quality and quantity of information far outweighs it, though. I've got other books for when I want entertaining writing (Although most of those just collect dust...)

JT, which anesthesia book did you use? I've got Katzung, which is a great overall pharm book, but that's really my only source.
 
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STXmedic

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I think I'll use all of my old paramedic-level texts as picture books for my kiddo...
 

Handsome Robb

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I think I'll use all of my old paramedic-level texts as picture books for my kiddo...
Lol!

I've got a decent A&P text, a multitude of ECG books no good pharm or airway book though.

I'm told the airway section in the UMBC text is pretty solid though but another book can never hurt.
 

Remi

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Cisatracurium
It's got a long duration right? Like longer than roc or vec long. I'm trying to remember everything I read in the pharma section of my CCP book yesterday. Some of the NDMBs were new to me.
Cisatracurium is a benzilisoquinolone; it is an isomer of atracurium and is 4x as potent. Rocuronium and vecuronium are aminosteroids. These are, to my understanding, the only 4 non-depolarizers in clinical use in the US, with atracurium being only rarely used.

The onset and duration of cis is similar to roc or vec. In order of speed of onset of an ED95 dose, it would go roc>cis>vec. Cis is also faster than vec and similar to roc at a 2x ED95 dose. Duration is also comparable between the three, with a time to 25% twitch height recovery of 30-40 min for roc and cis, and 35-45 min for vec.

The primary pharmacologic difference between the 4 is that the steroids are eliminated primarily in the biliary and renal systems (about 70-90% biliary / 10-30% renal for roc and 50-60% biliary / 40-50% renal for vec), whereas the qiunolones are eliminated by hoffman elimination in plasma, at normal physiologic ph and temperature (they will be renally excreted if not metabolized in the plasma). Also, a metabolite of the quinolines is laudanosine, a chemical with pro-convulsant properties.

Clinically, the 3 drugs are very similar. None cause significant changes in HR, BP, or histamine release. None block autonomic ganglia. Most who use them routinely will tell you that vec is the most reliable and predictable of the 3 (and is also dirt cheap), but unfortunately the slowest at onset, which limits it's usefulness to routine (non-RSI) induction and maintenance.

The only times I have used cis is for fragile renal patients. The general consensus seems to be that cis is much more expensive than the other two, without having any clinical advantages.
 
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TransportJockey

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Cisatracurium


Cisatracurium is a benzilisoquinolone; it is an isomer of atracurium and is 4x as potent. Rocuronium and vecuronium are aminosteroids. These are, to my understanding, the only 4 non-depolarizers in clinical use in the US, with atracurium being only rarely used.

The onset and duration is cis is similar to roc or vec. In order of speed of onset of an ED95 dose, it would go roc>cis>vec. Cis is also faster than vec and similar to roc at a 2x ED95 dose. Duration is also comparable between the three, with a time to 25% twitch height recovery of 30-40 min for roc and cis, and 35-45 min for vec.

The primary pharmacologic difference between the 4 is that the steroids are eliminated primarily in the biliary and renal systems (about 70-90% biliary / 10-30% renal for roc and 50-60% biliary / 40-50% renal for vec), whereas the qiunolones are eliminated by hoffman elimination in plasma, at normal physiologic ph and temperature (they will be renally excreted if not metabolized in the plasma). Also, a metabolite of the quinolines is laudanosine, a chemical with pro-convulsant properties.

Clinically, the 3 drugs are very similar. None cause significant changes in HR, BP, or histamine release. None block autonomic ganglia. Most who use them routinely will tell you that vec is the most reliable and predictable of the 3 (and is also dirt cheap), but unfortunately the slowest at onset, which limits it's usefulness to routine (non-RSI) induction and maintenance.

The only times I have used cis is for fragile renal patients. The general consensus seems to be that cis is much more expensive than the other two, without having any clinical advantages.
Is atecurium the one with histamine release and hypotension then? Or am I just remembering things weird?
 

Remi

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As far as pharm texts, I have several but my most commonly used pharm resources are my anesthesia texts, which I wouldn't suggest anyone buy because they are expensive and would mostly be useless to someone not in anesthesia.

The exception to that might be Morgan & Mikhail's Clinical Anesthesiology.....it has a really good pharm section that goes into decent depth but is much easier reading than most, and is not too expensive at around $70 (I think) for the ebook. Stoelting's Physiology and Pharmacology for Anesthetic practice is solid and probably a better buy (than an anesthesia text) for someone in EMS or critical care, but it's a little on the heavy side and uses some different terminology than other references, which can sometimes make it a little confusing. Anesthetic Pharmacology by Evers is hands down the most in-depth, grandaddy of them all but is correspondingly difficult to digest, so I rarely use it unless I'm digging for something really in depth. For a quick look-up of a med I haven't used in a while, you can't beat Sota Omoigui's Anesthetic Drugs Handbook.

For airway I have Benumoff & Hagberg's Airway Management, Manual of Emergency Airway Management, and a few others......Manual of Emergency Airway Management is a great text that I highly recommend.
 

Remi

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Is atecurium the one with histamine release and hypotension then? Or am I just remembering things weird?
Yeah, you are probably thinking of atracurium, though several of the older ones are known to release histamine. Sux is probably the worst for that.
 

TransportJockey

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Yeah, you are probably thinking of atracurium, though several of the older ones are known to release histamine. Sux is probably the worst for that.
Cool. Thank you for the info. We actually carry sux but everyone at my service tends to prefer Roc for the most part
 
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