Versed dosing for RSI

[Aprz]

Ya, I was trying to make a point since the original topic was Versed. I do not think there is a need for it in EMS but I was curious if anyone carried it. It usually causes more problems than it solves but it does have it uses in extreme cases. I guess if you are using high dose Benzos as your main RSI drug then it might be a consideration.

I have only given Romazicon once during a code.

I'll bite. We carry it, but on CCT for IFT, and I've never seen it used. I only what it is used for, reversal of benzodiazepine (eg Midazolam (Versed), Diazepam (Valium), Lorazepam (Ativan)), and I think the dose 1st attempt 0.2 mg/kg over 15 seconds, 2nd attempt 0.3 mg/kg over 30 seconds, and 3rd attempt 0.5 mg/kg over 30 seconds.

I've heard it's bad, but when I asked why, I was told "cause it just is, trust me". I've never really been told or know why Flumazenil (Romazicon) is really bad? What's really the con with it? I get we can just ventilate the patient if they are hypoventilating if they are overdosed on a benzo, and it's contraindicated if you are trying to reverse it for somebody who has overdosed on multiple drugs (likely intentionally, they don't want it to be pushed similarly to naloxone (narcan)).

 

[Carlos Danger]

I've heard it's bad, but when I asked why, I was told "cause it just is, trust me". I've never really been told or know why Flumazenil (Romazicon) is really bad? What's really the con with it? I get we can just ventilate the patient if they are hypoventilating if they are overdosed on a benzo, and it's contraindicated if you are trying to reverse it for somebody who has overdosed on multiple drugs (likely intentionally, they don't want it to be pushed similarly to naloxone (narcan)).

I bet most of the people who say "flumazenil is bad - trust me" have never used it, and are just repeating the urban legends that were passed down to them.

Just like nalaxone and every other med, flumazenil is not inherently "good" or inherently "bad". It is a chemical with indications, contraindications, precautions, and adverse effects. When used inappropriately it can be harmful. When used properly it can be potentially life saving. Remember that intubation and mechanical ventilation carry significant risks, too, especially in the field.

The big things to keep in mind about flumazenil that might get people into trouble are that it doesn't last as long as some of the benzos - meaning re sedation can occur after it wears off - and if the benzos were given for seizures and you then use flumazenil to reverse the benzos, then seizures can start again if no other anti-seizure meds were given.

Ok, since this is my thread I'm going to be snippy and picky. I'm looking for versed doses period. Not opinions on the best RSI drugs or anything else about RSI or sedation. If you use high dose, I especially want to hear from you.

What do you mean by "high dose"?

I previously had midazolam in my protocols as an option (or adjunct) for induction. The dose was 0.15 - 0.3 mg/kg, if I recall correctly. I use midazolam on a daily basis and have access to many anesthesia and pharm references, so I might be able to help you find the specific info you are looking for.

 

[Aidey]

What do you mean by "high dose"?

I previously had midazolam in my protocols as an option (or adjunct) for induction. The dose was 0.15 - 0.3 mg/kg, if I recall correctly. I use midazolam on a daily basis and have access to many anesthesia and pharm references, so I might be able to help you find the specific info you are looking for.

That qualifies. Anything where the pt gets say more than 2mg as an induction dose.

 

[Christopher]

I bet most of the people who say "flumazenil is bad - trust me" have never used it, and are just repeating the urban legends that were passed down to them.

Just like nalaxone and every other med, flumazenil is not inherently "good" or inherently "bad". It is a chemical with indications, contraindications, precautions, and adverse effects. When used inappropriately it can be harmful. When used properly it can be potentially life saving. Remember that intubation and mechanical ventilation carry significant risks, too, especially in the field.

The big things to keep in mind about flumazenil that might get people into trouble are that it doesn't last as long as some of the benzos - meaning re sedation can occur after it wears off - and if the benzos were given for seizures and you then use flumazenil to reverse the benzos, then seizures can start again if no other anti-seizure meds were given.

I'm reminded of Kreshak's review of 10 years of poison control data, with 904 patients receiving flumazenil. 13 ended up seizing, and one died (causal? possibly).

Most likely cause of seizing after flumazenil administration? Coingestion or presence of pro-convulsant medications.

I rank Kreshak's article up there with Levine's "Stone Heart" myth buster.

 

[Aprz]

So in the end, Flumazenil (Ramazicon) is probably not as bad as what people make it sound? Pretty much indicated for people you want to wake up/have breathing on their own if given solely too much of a benzodiazepine. May have shorter half life than the benzodiazepine, and problems the patient had prior to having the benzodiazepine, may reoccur.

 

[Smash]

I'll bite. We carry it, but on CCT for IFT, and I've never seen it used. I only what it is used for, reversal of benzodiazepine (eg Midazolam (Versed), Diazepam (Valium), Lorazepam (Ativan)), and I think the dose 1st attempt 0.2 mg/kg over 15 seconds, 2nd attempt 0.3 mg/kg over 30 seconds, and 3rd attempt 0.5 mg/kg over 30 seconds.

I've heard it's bad, but when I asked why, I was told "cause it just is, trust me". I've never really been told or know why Flumazenil (Romazicon) is really bad? What's really the con with it? I get we can just ventilate the patient if they are hypoventilating if they are overdosed on a benzo, and it's contraindicated if you are trying to reverse it for somebody who has overdosed on multiple drugs (likely intentionally, they don't want it to be pushed similarly to naloxone (narcan)).

You sir, are awarded eleventy billion internets for the use of proper drug names. God bless you.