Anyone here had issues giving versed IN. Very recently I've seen two patients given versed IN, one to treat seizure and the other to sedate for intubation. Both times the versed had no visible effects. Both were given 5mg, a dose that I expected to have some effects. Also, does anyone have protocols for IM versed, if so, how well does it work for seizure patients?
Versed IN verses IM
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was an atomizer used?
IV is obviously the best but I have seen IM valium and IM versed work well on seizures. I have also seen IN Versed work quite well and fast though I am not sure of the dose (IN) used.
IV is obviously the best but I have seen IM valium and IM versed work well on seizures. I have also seen IN Versed work quite well and fast though I am not sure of the dose (IN) used.
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IM midazolam should work fine for seizures once it is absorbed, but keep in mind that you are looking at 10-15 minutes for full effect via the IM route. If giving IM, I would increase the IV dose by 50% to compensate somewhat for the slower absorption. In a seizure, it is probably much better to place an IO and give an IV dose.
I have no experience with IN midazolam. In theory it works well, but I hear that patients often snort it out before it is absorbed.
Curious why IN versed was given for intubation, rather than IV? Also, 5mg is a very small dose for intubation. The normal intubating dose is 0.1 - 0.3 mg/kg, and even at that dose it doesn't work as well as other sedatives, which is why you don't see it used as much for intubation as other drugs. I would not expect to see anything approaching adequate RSI sedation in an adult with only 5mg, so it sounds like the lack of effect that you observed there could have been simply due to underdosing.
I have no experience with IN midazolam. In theory it works well, but I hear that patients often snort it out before it is absorbed.
Curious why IN versed was given for intubation, rather than IV? Also, 5mg is a very small dose for intubation. The normal intubating dose is 0.1 - 0.3 mg/kg, and even at that dose it doesn't work as well as other sedatives, which is why you don't see it used as much for intubation as other drugs. I would not expect to see anything approaching adequate RSI sedation in an adult with only 5mg, so it sounds like the lack of effect that you observed there could have been simply due to underdosing.
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NomadicMedic
I know a guy who knows a guy.
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I gotta think it would be pretty messy if you didn't use an atomizer. 
I've used intranasal versed with varying amounts of success. It's very patient dependent. Sometimes, it works like a champ. Other times… Not so much.
It's important to have a vial of versed that's 5 mg/1ml, with 0.5ml per nare, otherwise the atomized versed just becomes liquid and runs down the back of the naspharynx. And if your seizure patient is spitting and snarfing, they'll just spit it out.
I've used intranasal versed with varying amounts of success. It's very patient dependent. Sometimes, it works like a champ. Other times… Not so much.
It's important to have a vial of versed that's 5 mg/1ml, with 0.5ml per nare, otherwise the atomized versed just becomes liquid and runs down the back of the naspharynx. And if your seizure patient is spitting and snarfing, they'll just spit it out.
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The proper dose range for an 80kg patient would be 8-24 mg, preferably towards the higher end.
Unfortunately, this is not the first time I've heard of protocols calling for a really low dose of midazolam as part of an RSI protocol. I don't understand why that is.
All I can say is, get used to seeing it not work.....:sad:
Unfortunately, this is not the first time I've heard of protocols calling for a really low dose of midazolam as part of an RSI protocol. I don't understand why that is.
All I can say is, get used to seeing it not work.....:sad:
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We don't even have RSI protocols for our ground medics. We have a sedation protocol for intubation, but it's no good. However, once a person is intubated, a good versed drip, 4mg/hr infusion rate usually does the trick, works better than any other sedation drip I've seen, including propofol.
Outbac1
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I've only used it once IN on a combative pt. 5mg IN with an atomizer. It took the better part of 5 min to work and the pt was out. But only for about 5-7 min. Then they woke up and became just as combative. It was taking 4 cops to hold him down.
I don't know if IM would have been more effective. But IN certainly was safer than trying to poke a kicking squirming pt with a sharp needle.
I don't know if IM would have been more effective. But IN certainly was safer than trying to poke a kicking squirming pt with a sharp needle.
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This has been my problem with it. Our QA/I and MD are pushing for IN over IM although like you said IV would be preferred and is but if we don't have that option they prefer IN.
Narcan has worked fantastically IN for me, versed not so much. I've only given it a handful of times but it seemed like a waste since most patients were slobbering and "sneezing"(can't think of a better term at the moment) all over themselves during the seizure and blew it all right back out. One of those experiences though isn't really fair to use considering after the IN I maxed out my protocol IV and she was still seizing.
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That's interesting. Do you know why they prefer IN? Do you guys do IO's?
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I don't know of any places that want to see IO access on seizure patients that you can't immediately get an IV on. Way too many IOs would be placed on relatively stable patients that could have easier venous access after you stopped the seizure with another route.
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Generalized seizures are a perfect indication for IO.
A patient doesn't need to be in extremis in order for an IO to be appropriate. An IO is indicated in any patient who needs meds more quickly than you can get an IV.
A patient doesn't need to be in extremis in order for an IO to be appropriate. An IO is indicated in any patient who needs meds more quickly than you can get an IV.
I've used IN versed & it works very well & very quickly through the MAD. My first inclination is that you should start double checking your company's narcotic policy, backstock & start watching for other signs if ineffective narcotics.. Stay vigilant, it happens. :|
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I'll echo n7. I've had very varying results with IN midaz (and IN Fent for that matter). The last 4-5 times I've used IN midaz I have had little to no response. For a kid I'll absolutely use it first line. For an adult, I prefer to take a quick look for an IV first.
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Have you guys read the RAMPART Study regarding IV vs. IM benzodiazepine administration during seizures? They compare IM Versed to IV Ativan and their speed and effectiveness at stopping active seizures. I would have preferred to see them use Versed by both routes, but it still produced some interesting data. Basically, an IM dose of Versed was found to be more effective in stopping active seizure than IV Ativan when you took into account the additional time to start an IV. Our protocols give us the option of IM or IN Versed if we don't have an IV, so I choose to go with IM most of the time based on the problems mentioned with IN administration during seizures.
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We do have IOs.
I could see it in a status epilepticus situation where you really couldn't get a line it in most seizure patients I don't see jumping to an IO being a good decision.
I haven't heard a reason, just coworkers saying they've had the IN route suggested to them, I've had the same. If we justify why we chose a certain route it's not like they're throwing a horsy fit because we didn't give it IN.
This sums it up for me. I love atomizing things just because I love sticking things up peoples nose, but all my IN Versed has been really iffy. It works eventually but it takes longer to have its full effect than with IM.
Narcan works like a dream nasally.
Mirrors my experience exactly.
I'm surprised no one's reached up, snatched the layrengoscope out of a medics hand and beat them with it....
Trust me, I try several other treatments before I even consider sedating someone to intubate them.