Succinylcholine - Prehospital Abuse/Misuse

[TomB]

I am aware of one situation where a rotor wing EMS service in AZ used an IM shot of succinylcholine to take down a patient who did not want to go to the hospital. I don't remember what was wrong with the patient. I only remember that he didn't possess decisional capacity (but he was agitated and adamantly refusing transport) and online medical control said, "Bring him in." I was surprised when I heard the story but I know the guy who did it and he's an awesome paramedic. In fact he's a nurse anesthetist now.

 

[MrBrown]

....online medical control said, "Bring him in.".

Ah music to my ears ..... its no longer my *** on the chopping block

 

[Melbourne MICA]

Yeah, but we don't have Ronaldo .... so no wonder we are now out of the World Cup. I must say we have spent a fair amount of time infront of the telly at work watching the highlights of Ronaldo hmmmmmmm



How much midaz are you using? I am not so much concerned about the 1mg or so you give somebody who is traumatically brain injured with a GCS of 3 vs the amount you are going to have to pour into that catatonic asthmatic who is still conscious so he won't remember.

We used to use midazolam but now we use 1.5mg/kg of ketamine (unless the patient is traumatically brain injured or has neurogenic cause for coma with GCS < 10)

Mind you I am no anaesthetics consultant (one day......) but I hear that midazolam is great for wrecking people's blood pressure and other nasty things when given in any significant dose.

Although you are using sux too so it's probably only a small dose to give amnestic effect rather than any serious neuromusclar relaxation.

*Brown goes back to reading his anaesthesia textbook in an effort to obtain more knowledge

(On the football - AH but what you showed was you don't need Ronaldo to be competitive. Beside look where it got Portugal? The guy score one goal in the whole tournament).

On the RSI stuff. RSI has been one of MICA's biggest successes in decades.

The sux is for tube placement in the traumatic or non-traumatic head injured pt with intact airway reflexes or trismus and GCS <10. Hence the need for paralysis. Its not for sedation. The Midaz and Fentanyl are for that (plus the fentanyl provides analgesia as well) - Paralytics and sedation are a hand and glove - never one without the other.

For the RSI we use Midaz 0.1mg/kg IV or half dose for age, low BP etc. We also add 8mg Panc after induction. In the HI trauma pt this is the key. The RSI is really for MAP control and therefore cerebral perfusion pressure control - None of those nasty spikes in BP (like when you stick a bloody big layryngo blade down the pts gullett without any paralysis on board which kills off more brain cells). You can cover secondary brain injury issues by controlling ventilation ETCO2/SPO2 etc after induction.

Sedation continues post intubation and Panc - Morph and Midaz infusion here 30and 30.

Your'e right about the Midaz trashing BP - most Benzos do when given in large IV doses. So there is a healthy 10ml/kg fluid load prior to the procedure. This covers both the Midaz hypotension side effect and also covers hypovolaemic issues - almost guaranteed in the multi-trauma pt.

We are only using Ketamine for analgesia in long bone fractures post Morph management - a trial at this stage. There's been no talk about using it for induction/sedation in our guidelines.

For the asthmatic pt who gets tubed - well if they are that far down the track i.e hypoxic - a late sign in severe asthma - then they need a tube and will need sedation to pass it. The hypoxic asthmatic is a stones throw from pushing up the daisies. We never paralyse an asthmatic - if you can't get the tube they are dead - no ventilations of their own.

Having said this the preference is not to tube the asthmatic if avoidable as management of the pt with a hyperinflated obstructed chest becomes problematic and dangerous. A pneumothorax is an easy complication of high pressure ventilation. It's also difficult to manage Co2 with ventilation measures in the asthmatic pt.

But life threat is life threat. Sedate to tube can certainly be lifesaving in such pts. I've seen it many times. The midaz is never an issue really.

Now I have to wait 4 more years for the Roos and Whites to play in the world cup but play they will. My tip for this one is Argentina or maybe Germany (if they beat them tonight).

Speaking of which, it's 20mins to kick off so I need to grab a beer and a chair and settle in.

MM

 

[MrBrown]

I concur with most of your points here. We have been trialing selected Intensive Care Paramedics with RSI for almost four years and have consistently achieved over 97% success so it's being rolled out nationally, still only to selected ICPs.

It is interesting you had not had significant problems with sedation only to intubate, we withdrew it about midway through the 00s because it was causing M&M to go up.

 

[Melbourne MICA]

I concur with most of your points here. We have been trialing selected Intensive Care Paramedics with RSI for almost four years and have consistently achieved over 97% success so it's being rolled out nationally, still only to selected ICPs.

It is interesting you had not had significant problems with sedation only to intubate, we withdrew it about midway through the 00s because it was causing M&M to go up.

We did have early problems going back to the 1990's principally because we were not given the right tools for the job. For all pts where a drug assisted intubation was needed we only had Diazepam and Morph to do the job. Wow thanks for that. Guys were, funnily enough, having to give big doses and trashing BP's in the process. In my first head injured pt intubation attempt I needed just 20 and 20 of Morph and Diaz to place the tube. I was lucky. There wasn't even a mandatory pre - induction fluid loading in the protocol so no wonder the BP's were shredded. There was speculation we might lose drug assisted intubations altogether. The RSI HI pt trial saved us from that and we have never looked back since.

With Midaz and Fentanyl for our sedation only to intubate we have had no such problems. We always fluid load and the two drugs in combination are very effective. Our medicos I think sensibly limited drug assisted tubes to sedation only for certain pt groups such as severe respiratories. Besides you really don't see that many moribund asthmatics these days where we are and profoundly hypoxic pts like sick APO's and end stage COPD's you could knock over with a feather anyway. the guys assess very well and doses are carfeully titrated so overmedication is rarely a problem. The most difficult issue is of course choosing when you need to sedate to tube the pt.

As for the sedate to tube drugs we have measures to correct benzo/narcotic side effects; ventilation for resp depression, fluid loading/inotropes for hypotension, naloxone for narcotic overdose issues etc. There is a much wider margin of safety so a good move by our medicos as far as I see it. As for the RSI's - absolutely brilliant. Problems occur occasionally and we all make mistakes but such is the MICA standard overall our success rates are 97-99%. Not too shabby at all.

Good education, good training, good audit, good review, good crews (and a fair bit of pride in your work to boot). Now if we could just get our organisation to stop cutting the rug from underneath us life might be a bit better still.

MM

 

[wyoskibum]

The real reason.......

Well, one of the things that was reported was that Succinylcholine was being used to essentially chemically restrain patients (drunk patients, mental disabilities, etc). So basically, because a patient was being unruly, or difficult, the attending paramedics were taking away this patients ability to breath.

I would use Versed or Etomidate before Suxs! ;-D

Seriously though, proper oversight and QA/QI would prevent such abuses. The only reason why Medic don't have a skill/drug/etc... is that the Physician Medical Director does not want or support it. Any other reason is just an excuse.

It could be a trust issue, as the PMD doesn't trust the Medics or it could be ignorance as not all PMD have emergency medicine backgrounds.

 

[MrBrown]

Good education, good training, good audit, good review, good crews (and a fair bit of pride in your work to boot). Now if we could just get our organisation to stop cutting the rug from underneath us life might be a bit better still.

You must be referring to the days when you rolled around in Ford F-100s, before a Degree became mandatory and the hardest part of MICA was following Frank's diagrams on the whiteboard

It sounds like you have a really good setup and we are in pretty much the same boat except we use ketamine and fentayl. Fluid and adrenaline (inotropy) form part of other guidelines which are appropriate before we think about RSI (eg in APO) and not part of the RSI guideline itself.

 

[LondonMedic]

Has someone mentioned 'sux races' as a way of brightening up a dull on-call? h34r:

 

[Melbourne MICA]

Sux Races?

Has someone mentioned 'sux races' as a way of brightening up a dull on-call? h34r:

I shudder to think what you are referring to. Sux races - almost sounds like an oxymoron.

MM

 

[Melbourne MICA]

To be Frank

You must be referring to the days when you rolled around in Ford F-100s, before a Degree became mandatory and the hardest part of MICA was following Frank's diagrams on the whiteboard

It sounds like you have a really good setup and we are in pretty much the same boat except we use ketamine and fentayl. Fluid and adrenaline (inotropy) form part of other guidelines which are appropriate before we think about RSI (eg in APO) and not part of the RSI guideline itself.

Arghh - those were the days. And yet most of the current MICA guys >5yrs all trained under Frank and we have had most of our greatest successes in the last 10yrs or so. That must say something about having to decode Franks' diagrams. He was a good stick and utterly devoted to his ambos.

MM

 

[MrBrown]

Arghh - those were the days. And yet most of the current MICA guys >5yrs all trained under Frank and we have had most of our greatest successes in the last 10yrs or so. That must say something about having to decode Franks' diagrams. He was a good stick and utterly devoted to his ambos.

MM

I have seen some of his old "CP" (?) videos from MICA Stage 1 in 1993 on the DVD that John Till from AV is handing out. They are bloody fantastic! Like being belted over the head with a lump of 4x2 with brilliance written on it.

One of my friends is at Monash so gets to work with him sometimes.

Oh we did have an interesting RSI job I should mention a while ago ... guy with a severed trachea and sternal/rib fractures after man vs horse. Ick!