Just curious if you guys are allowed to give medications such as etomidate, ketamine (or anything similar) to manage a patient with severe injuries to induce amnesia/unconsciousness. The scenario I'm thinking of is an arm or leg "bent the wrong way" or a patient entrapped with severe injuries. I'd love to have something similar but at the moment my service doesn't.
Sedation/Anesthesia in the Field
- Thread starter Fox800
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Yes, we have a rapid sequence intubation program for Intensive Care Paramedics using fentanyl, ketamine, suxamethonium and vecuronium; they are also able to use midazolam for conscious sedation.
We also have PRIME Doctors capable of RSI (sort of like BASICS in the UK) who are able to anaesthetise and I suspect they would be more likely to knock somebody out for traumatic injury in the absense of neurological or oxygenation defecit since they have more medicolegal flexibility.
We also have PRIME Doctors capable of RSI (sort of like BASICS in the UK) who are able to anaesthetise and I suspect they would be more likely to knock somebody out for traumatic injury in the absense of neurological or oxygenation defecit since they have more medicolegal flexibility.
We have all the meds you mentioned. Now for ROSC we give Rocs to stop shivering. W can give versed for anxiety. Because of the shortages of sucs we only use rocs for RSI. Our Med director is pretty aggressive and let's us do just about everything without calling for orders which us great. More time pro-longing death and less time talking to the Doc on the box.
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Melclin
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Not as such.
However, you can just keep dropping morphine or fentanyl on the person until you don't have a problem pain wise. Then you deal with any conscious state/airway issues when you get to them. I suppose you are limited by BP.
I have a picture in my head of attending a pt with severe, extensive burns and drawing 600mcg of fentanyl into a 60ml syringe and just keep pushing it slowly into a free flowing IV line until the pain drops off. After a quick chat to a more experienced paramedic on the radio of course.
I'd be interested to what extent MICA have the ability do this and tube to deal with the airway consequences.
However, you can just keep dropping morphine or fentanyl on the person until you don't have a problem pain wise. Then you deal with any conscious state/airway issues when you get to them. I suppose you are limited by BP.
I have a picture in my head of attending a pt with severe, extensive burns and drawing 600mcg of fentanyl into a 60ml syringe and just keep pushing it slowly into a free flowing IV line until the pain drops off. After a quick chat to a more experienced paramedic on the radio of course.
I'd be interested to what extent MICA have the ability do this and tube to deal with the airway consequences.
Nothing here, other than the note in our protocols that management of severe pain is an indication for RSI.
In the case of the patient trapped I would think long and hard about going ahead and securing an airway while the patient was trapped as long as it could be safely/effectively done. Many of these patients crap out the moment they get disentangled, and your now behind the curve if you don't have one. With an airway secure I could give fentanyl till it ran out the patients ears with the only caveat of I must not completely knock out sympathetic stimulation. It's highly situation dependent though.
Ketamine would seem to be ideal for the situation with the broken limb, but there's still a lot of people scared to death of it.
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Melclin
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I don't know that I'd care to use it in smaller analgesic doses without the option for the addition of some midaz. But I have no hands on experience with it.
Anyone ever had trouble with ketamine analgesia?
Paging Doc Brown, some idiot paramedic call Oz has Ketamined a bi-lat femure fracture and now he's higher than you on promethazine. We need a doc for sedation.
We use ketamine in low (10-20mg bolus) doses for analgesia and big (1.5mg/kg) doses for anaesthesia.
Now interestingly here you cannot give ketamine to somebody who has been given midaz but you can give midaz for post-ketamine sedation management.
I am not a fan of just pouring morphine into people hoping the pain goes away because the pain is likely to stay and thier blood pressure is the only thing thats going to go away.
After 20mg of morphine if it is having no effect then its time to try something else.
Oh and Oz you clean your own mess up, Brown is at his friends house in Box Hill making lunch. If memory serves MICA 5 is just round the corner.
Now interestingly here you cannot give ketamine to somebody who has been given midaz but you can give midaz for post-ketamine sedation management.
I am not a fan of just pouring morphine into people hoping the pain goes away because the pain is likely to stay and thier blood pressure is the only thing thats going to go away.
After 20mg of morphine if it is having no effect then its time to try something else.
Oh and Oz you clean your own mess up, Brown is at his friends house in Box Hill making lunch. If memory serves MICA 5 is just round the corner.
Fent is a lot more hemodynamicly stable, and the patient's LOC will go away before B/P normally.
My understanding of ketamine anaesthesia is that it doesn't induce unconsciousness so much as disassociation (please correct me if I'm wrong, it's a drug I'm only aware of, not intimately familiar with). This would seemingly be ideal for the situation stated above, as the patient could be awake and protecting their own airway, have an arm that hurt like hell, was bent the wrong way, but really doesn't give a crap and won't remeber it when the med wears off.
Ketamine is not a traditional anaesthetic so to that end you are correct sir; it is an NMDA inhibitor whereas propofol for example inhibits GABA.
The result however is the same - the patient does not remember, which if Brown is treating them is a really good thing
The result however is the same - the patient does not remember, which if Brown is treating them is a really good thing
Smash
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Exactly right. The way it was once described to me was that it chemically amputates the limbic system. The patient remains aware of the pain at the time, but is not bothered by it. It really is wonderful stuff.
Midazolam has shown to be of no additional benefit when using ketamine as an analgesic. There used to be (and sometimes still is in some places) concern about emergence phenomena, but midaz does not have any effect on this anyway. The key is to make the environment as nice as possible for the patient, which may be tricky obviously, but I have not seen anyone have any particular adverse effects from ketamine.
Smash
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Brown asked the anaesthetist for ketamine but I dno what happened about that, the drugs they gave Brown made him remember not so well
And unfortunately it appears that it also made him refer to himself in the third person all the time. Tragic what happens when medicine goes wrong!
And unfortunately it appears that it also made him refer to himself in the third person all the time. Tragic what happens when medicine goes wrong!
Technically it is the fourth person since Brown does not really exist and is the alter-ego of his creator
Brown is a big proponent of RSI for both medical and trauma, provided it is used appropriately by sufficently knowledgable providers with a robust monitoring framework
swissmedic
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Ketamine is not a traditional anaesthetic so to that end you are correct sir; it is an NMDA inhibitor whereas propofol for example inhibits GABA.
The result however is the same - the patient does not remember, which if Brown is treating them is a really good thing
We also do / use ketamine RSI for any status asthmaticus patients, it works great (keatmine is not only for analgetics it is works also very good as a bronchdilatation)
Matt
emtchick171
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We carry diazepam...however it is ONLY used for seizure patients. You can call medical direction to request the administration of diazepam for sedation...but every time I've seen it requested for sedation it has been denied.
At this time our county is not allowed to do RSI..but it is a working-process and is on the verge of being allowed. Of course when we do get RSI, we will have to be able to administer something to make the PT unconscious.
At this time our county is not allowed to do RSI..but it is a working-process and is on the verge of being allowed. Of course when we do get RSI, we will have to be able to administer something to make the PT unconscious.
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swissmedic
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We still use versed i.v. or i.o. and temesta p.o. (it's lorazepam) for seizures, RSI and any anxiety patients to clam down...
Matt
Matt
Our current guidelines (about to expire) do have a pain management/anxiety protocol with options for fentanyl, diazepam, and midazolam all off-line, at provider discretion. I am quite liberal with my benzos if I feel it's going to help the patient in situations that are extremely distressing (especially bad fractures).
Our new clinical guidelines have absolutely no provision for anxiety management. We don't even have a page for it. The medication formulary doesn't even have "anxiety" listed as an indication for diaz or midaz any more. I guess it'll be a consult with an ER physician, unfortunately.
Our new clinical guidelines have absolutely no provision for anxiety management. We don't even have a page for it. The medication formulary doesn't even have "anxiety" listed as an indication for diaz or midaz any more. I guess it'll be a consult with an ER physician, unfortunately.