Versed as a sole RSI agent

[rhan101277]

Considering it's one of the leading agents for post-intubation sedation, I'm not sure where this is coming from. Hypotension is contraindicated in head-injury, not midaz specifically.

Well it is at least a relative contraindication. Giving the medication may cause hypotension and I would not want to take a chance on possibly reducing perfusion to the brain. If I suspect someone has increased ICP due to head injury, and they needed sedation, I think I would call med control to make that call.

 

[usalsfyre]

Well it is at least a relative contraindication. Giving the medication may cause hypotension and I would not want to take a chance on possibly reducing perfusion to the brain. If I suspect someone has increased ICP due to head injury, and they needed sedation, I think I would call med control to make that call.

Assuming you use some brain power in titrating, it's not a problem. I've done it dozens of times and never had a problem. I know ICU nurses who have done it 1000s of times without an issue. Delaying treatment of the agitation in the intubated patient can cause an increase in ICP which in itself will cause CPP to be reduced.

I will agree it's maybe not an ideal agent for the initial sedation during RSI in the head injured patient but it's used nationwide daily in EDs and ambulances for this purpose. It has a well established safety profile. If your providers can't use it effectively then it's a systemic problem, not a problem with the medication itself.

 

[MrBrown]

If I suspect someone has increased ICP due to head injury, and they needed sedation, I think I would call med control to make that call.

Careful mate, that sounds dangerously like Parathinktheyare talk

Now, if Brown may point out that the midazolam only protocol posted excluded head injuries as it is a contraindication for midazolam. Hmmm which patients are likely to significantly benefit from rapid sequence intubation? Brown rests his case against sedation only intubation.

 

[bonedog]

I'm not sure how midaz only could be considered RSI, rapid maybe, sequence, hmmm, would that be the flumazenil arm?

 

[mikie]

Side question...

• Absolute contraindications:
b. Paraplegics/quadriplegics or

I take pharm. next semester so perhaps it'll come up then; but with what little info I know about RSI (Sedation & Paralysis) why is that an absolute contraindication?

 

[MrBrown]

I take pharm. next semester so perhaps it'll come up then; but with what little info I know about RSI (Sedation & Paralysis) why is that an absolute contraindication?

Brown believes it has something to do with suxamethonium

 

[boingo]

Brown believes it has something to do with suxamethonium

Brown would be correct.

 

[NomadicMedic]

Brown believes it has something to do with suxamethonium

Yes, there is a potential for severe hyperkalemia in patients with motor neuron damage.

 

[Fish]

We've been fighting with our medical director for years to get RSI protocols. He's resisted the whole time, despite the fact that every single ALS agency around us now has it. In any case, he recently signaled that he would relent and allow us to have RSI protocols. But what he's come up with has sort of thrown me for a loop. He says he won't give us Anectine because of liability issues and because of concerns expressed by local anesthesiologists. He says he'll allow us to use Versed to intubate patients, and he says it's safer since we carry romazicon that we can use to reverse it if we can't get the tube.

I'm curious if there are any other agencies out there that are using or have used Versed as a sole intubation agent. I've read several accounts from people saying that Versed doesn't knock them down far enough, and I also have concerns about our doc's assertion that romazicon can "easily" reverse them. I used Anectine in my old department for years, and the worst I ever had to worry about was bagging them for 5 minutes if I couldn't get the tube.

Thoughts?

Couple things here sounded strange to me, If someone needed to be RSI'd then they are usually a critical patient needing there airway to be taken over, why then would your Medical Director have you push versed and oops we can't get the tube reverse the versed with Romazicon and bag instead of keeping the patient sedated and insert a BLS airway like a King or Combitube? Also, do you guys have the Bougie? I think every agency that RSI's needs to carry the Bougie or some form of difficult airway device. Romazicon is a contreverisal drug, not to sure if I would be knocking down patients and then reverseing it as often as it sounds like you guys might end up doing. Why is he against Succs, Roc, or Etomidate? Medical Directors are far more knowledgeable than I so I am sure he has sound reason to these questions I have asked. But for purpose of discussion I wanted to ask them.

To answer your question, we have an RSI protocol, and the only time we do not use a paraylitic is if the pt. is less than 2, so for these pt.s we just use Versed. For every pt. over 2 we use versed to sedate, succs to paralyize, and roc and versed for maintence.

 

[usalsfyre]

To answer your question, we have an RSI protocol, and the only time we do not use a paraylitic is if the pt. is less than 2, so for these pt.s we just use Versed. For every pt. over 2 we use versed to sedate, succs to paralyize, and roc and versed for maintence.

Without getting into too much of a rant on the subject, why even bother with succs if you've got roccuronium on the truck already? Same rapid onset, much better side effect profile. We got rid of succs about a year ago and I can't tell you I've missed it even once.

 

[Aidey]

We have Succs and Vec, with Roc as a back up because of the Succs shortage. We are not allowed to use Vec or Roc as first line paralytics becuase of their longer duration unless we call for orders. We are to use Succs, and then use Vec as a maintenance. When we only had Vec and Roc on the ambs we had to call for orders to RSI period. I flat out told my supervisor the conversation was going to go something like "Hi doc, I'm RSIing this person, what do you want me to use Roc and Vec?.....No, I'm not asking for orders to RSI, I'm going to RSI this person, I just need you to tell me what med to use because we are out of Succs right now."

Don't ask me to explain it.

 

[Fish]

Without getting into too much of a rant on the subject, why even bother with succs if you've got roccuronium on the truck already? Same rapid onset, much better side effect profile. We got rid of succs about a year ago and I can't tell you I've missed it even once.

Roc is a lot slower than succs, and longer acting. That is our systems reasoning

 

[usalsfyre]

Roc is a lot slower than succs, and longer acting. That is our systems reasoning

Granted is andecotal, but I haven't noticed Rocc to be significantly slower clinically.

Short action is a crappy argument for sux. If they can wake up and maintain their own airway, did they need prehospital RSI in the first place, or could we have optimized their ability to maintain their own airway?. Doing an RSI with anything other than the attitude that you will secure an airway, even by way of scapel, is accepting failure, which your patient can ill afford.

Another question, what happens when you patient has a pseudocholinesterase deficiency, and won't burn the sux off for a few hours?

Sorry for the rant, this is one of the big attitude issues I see with prehospital RSI.

 

[Aidey]

I think the theory is that breathing badly is better than not breathing at all.

I'm with you. If I'm going to RSI someone I am going to get an airway, period. If I end up crich-ing* someone I RSId I better be prepared to explain, but my hope is that by RSIing the patient I'm avoiding letting things get that bad (thinking of burn and anaphylaxis patients here).


*How the heck do you spell that?

 

[Shishkabob]

I think the theory is that breathing badly is better than not breathing at all.

Luckily, usalfyre and I have bougies, LMAs, Kings, needle crichs and surgical crichs.


If they need an airway, they're getting an airway. Preferably one that won't make me go "Oh God oh God oh God" in the process.

 

[usalsfyre]

I think the theory is that breathing badly is better than not breathing at all.

I'm with you. If I'm going to RSI someone I am going to get an airway, period. If I end up crich-ing* someone I RSId I better be prepared to explain, but my hope is that by RSIing the patient I'm avoiding letting things get that bad (thinking of burn and anaphylaxis patients here).


*How the heck do you spell that?

Cricothyrotomy, that's too much of a keyboard full so I usually just put in cric .

Maybe it's just me, but I take control on airway only when U anticipate they're not going to be breathing if I don't intervene, which puts you in a worse position post sux, as your that much farther behind the 8-ball.

The exception to this is combative patients that can't be controled by other means, but that's another issue altogether.

 

[Fish]

Cricothyrotomy, that's too much of a keyboard full so I usually just put in cric .

Maybe it's just me, but I take control on airway only when U anticipate they're not going to be breathing if I don't intervene, which puts you in a worse position post sux, as your that much farther behind the 8-ball.

The exception to this is combative patients that can't be controled by other means, but that's another issue altogether.

As far as the succs or Roc and which should be used or which should come first, I don't have enough experience with to argue. The system I work for now is the only one I have worked for that RSI's, so for me it is our way goes(Not to mention it seems to be the way of most systems around us). Our Medical Directors Reputation, 30yrs+ experience, and Book shelf filled with Medical Director of the year awards vastly outways another medics thoughts on his RSI protocol in my mind(that was in no way attended to be rude). That being said, when it comes to RSI in our system, it is a big deal you DO NOT RSI for the hell of it, it is a must do basis. And after an RSI we have a review with our Medical Director to go over the reason, and need. Also, we do have Bougies, Crics, and kings, so if we RSI the pt. WILL have an airway.

 

[Aidey]

Cricothyrotomy, that's too much of a keyboard full so I usually just put in cric .

Maybe it's just me, but I take control on airway only when U anticipate they're not going to be breathing if I don't intervene, which puts you in a worse position post sux, as your that much farther behind the 8-ball.

The exception to this is combative patients that can't be controled by other means, but that's another issue altogether.

Cric/Crich I was close, lol.

My last 2 RSIs were both unconscious with complications. One guy went into status seizure after giving him narcan, and the other had been strangled and was posturing and combative with blood in his airway. I wasn't so much worried about either of them not breathing at all, but the adequacy of their breathing.