Versed vs. Ativan

[Emtpbill]

So Friday night I am 20 hours into a 24 hour tour. Get hit out for seizures. Arrive o/s with 3 pd officers to find a 50 yom sitting on a computer desk chair that is on wheels. Family sts that they were awakened by pt not acting right and talking disoriented. Wife says she had to "wrestle with pt to get him to sit". He is leaning against a wall. Family sts he is a IDDM who also has dialysis 3 times a week but didn't go today cause his ride never came. When I try to talk to pt all he says is I want a drink of water.
Glucometer shows BS at Hi, doesn't give a number. Try to wheel chair to steps but it doesn't move. Get the reeves set up an pt onto it, pt starts to seize, approx 15 seconds grand mal.
Expedite to MICU . Hi flo 02, vitals EKG. All wnl.
Pt arms are scarred from years of IV drug use. Finally am able to thread a 20 in the right internist vein.
NSS wide to try to dilute the sugar(I know not really helpful, but he needs insulin and I don't have any).
Anyways halfway into a 25 minute transport time he starts to become combative. I am alone in back and PD is too far to rendezvous.
So I give Ativan. 1mg, vitals. Another 1mg and so on. Call command and give report. Total of 4mg ativan and this guy is still combative.
Would I have been better to have gone with versed. I have only used versed to facilitate intubation an that was about 10 years ago. Worked great 5mg but that was on a 100 lb. woman.
What's is everyone's experience with using versed for seizures or to settle down combativeness.


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I am here: http://maps.google.com/maps?ll=40.089019,-74.979306

 

[mycrofft]

2 preliminary questions:

1. What is your working diagnosis (yeah, I know, "assessment").
2. What are your protocols for this assessment?

 

[Shishkabob]

Anecdotally, i much prefer versed to Ativan. I like that it can be given IN, IM, and IV and still haven't a good rate of onset, and for me atleast, I've been better able to control people with it. It's my personal first line benzo that I go to between the two.

Obviously each patient is different. If I've given one benzo and it's not working, I'm doing the other.

 

[Emtpbill]

2 preliminary questions:

1. What is your working diagnosis (yeah, I know, "assessment").
2. What are your protocols for this assessment?

Well I have several problems I have to work with. First is the elevated blood sugar. I'm not sure what the cutoff for the hluceter is to read just "hi" but I have been told 500. Secondly is the missing dialysis. If his kidneys are completely shot then even missing 1 dialysis could cause seizures. Also ther is a hx of drug abuse and from what PD told me the whole family has an abuse hx. So besides what they have told me, what else could I be dealing with that they haven told me.
Protocols are pretty standard for altered mental status. I called command when I needed more Ativan than usual.

 

[Aidey]

Well, ativan can become toxic in high doses in renal patients so I would have gone with versed. I also question the value of high volume fuid administration in a dialysis pt who skipped dialysis. Especially if he doesn't have signs of dehydration. Chances are he is going to become fluid overloaded long before there is any impact on his blood sugar.

 

[Emtpbill]

Well, ativan can become toxic in high doses in renal patients so I would have gone with versed. I also question the value of high volume fuid administration in a dialysis pt who skipped dialysis. Especially if he doesn't have signs of dehydration. Chances are he is going to become fluid overloaded long before there is any impact on his blood sugar.

I was thinking about that also, but the amount of fluid I could get into him with a 20g wasn't gonna overload him. Thats a good point about the Ativan in hi doses. That's exactly why I threw this call out there. Good point.

 

[STXmedic]

I was thinking about that also, but the amount of fluid I could get into him with a 20g wasn't gonna overload him.

Que?

A standard 20g cath can flow about 65ml/min. In a 15 minute transport, that's just shy of 1L. That's a decent amount of fluid in a dialysis patient...

 

[Emtpbill]

Que?

A standard 20g cath can flow about 65ml/min. In a 15 minute transport, that's just shy of 1L. That's a decent amount of fluid in a dialysis patient...

In a patient who is calm and keeping his arm straight so the fluid could flow freely, yes.
Ok, let's focus on my Ativan versed part. I didn't fluid overload this guy, he maye got 150cc total after fighting me.

 

[Veneficus]

Fluid issues already addressed, so I will not harp on it.

I am rather fond of versed myself, for the ever important reason of "provider comfort."

One of my mentors in anesthesia likes to say:

"there are so many ways to do the same thing that its best to pick only a handful and be good at them rather than inexperienced with a bunch."

I cut it down to 4.

Plan A
Plan B
Plan C
Call for help

In any renal failure patient, toxicity and potentiation can be an issue in any medication excreted by the renal system.

If it was that much of an issue, why not just use fentynal to knock the guy down? It is excreted by fecal route and you can get anesthetic dosage out of it.

 

[Emtpbill]

Only have 200mcg of fentanyl on truck, normally we have 4-500 mcg but the ALS coordinator had not been to pharmacy.

 

[Aidey]

Plan A - Versed
Plan A.1 - Physical restraints.
Plan B - Fent
Plan C - Etomidate
Plan C.1 - Just RSI already, avoiding succs.
Plan D - Call the specialist with way more drugs than I have.

Edit - yes Etomidate is excreted in urine, but it has a half life of about an hour and a half vs 14 hrs for ativan.

 

[Shishkabob]

200 of fentanyl should slow him down a bit. I premeditated my RSI patients with 250 of fentanyl and they went out, almost negating etomidate. Plus you have the benefit of intra-nasal route and using narcan if something goes wrong.

Bebadryl is another decent one, if your protocols allow? Same with haldol if need be.

 

[mycrofft]

Parsing

Busy thread! Good one.

So your assessment is altered mental state (obtunded or not oriented/reactive to verbal stimuli), and you have elevated blood glucose.

Don't answer these unless you want to, a mental exercise.

You also have bystander history of diabetes and noncompliant dialysis, unconfirmed hx of IVDU (IV drug use), and bystander account of seizure.

FOG hint #1: bystanders call everything from waking up from a faint to a grand mal, to orgasm, a seizure. If active seizing is not observed/present, it is a "subjective", not "objective". Good call on dialysis predisposing pt for a seizure, but once the pt is breathing and assessed for incidental injuries (falling down, etc.) be ready and mindful of potential for seizures, get a line started. Was there a line in place before attempting to move?

Question: is "diluting the sugar" a standard or improvised treatment? (I'm thinking "no", but that's because I've never heard of it before now; also, no place for that much fluid to go since kidneys aren't working, if that is true, right?).

Q: Was there a pulse ox or clinical sign indicating hypoxia and need for "hi flow" O2? (I'm thinking yes there was postictal, but not needed once seizures done and pt is pink).

Q: What is pt approx, weight (to determine dosage) and, how long will your ativan, via it's administration route (IV, IM, intratracheal?) take to work? (Issue: if you are using ativan to snow the pt and you go past the dosage because it isn't working fast enough* you may be overdosing and probably again outside the protocols. The pt may have simply been postictal. Or a combative bozo).

Being in your care and having benzodiazepine titration to vitals, was the best way that scenario could evolve.

I've no idea about versed other than looking it up.

*I call that sort of drug dosage the "Thermostat Effect"; some people don't understand that turning the thermostat further does not make it cool or heat faster, it makes it run longer. I've seen it with Ativan, Valium, and Glucagon a number of times.

 

[Akulahawk]

My own experience with Ativan in sz situations, granted only a couple times I've seen it used, is that it doesn't seem to be all that effective. I have seen Versed and Valium used in sz management and they seem to be more effective, longer. One patient I had would have breakthrough sz after about 10 min with the Ativan, while the Valium we gave lasted >1 hour before physical seizing started up again. I don't doubt that ativan works, I just don't think it's well suited for this usage, based on my (very) limited experience with it.

 

[18G]

Overall, it sounds like you did the best you could especially with being by yourself trying to handle a combative patient. This guy had quite a few issues going on it sounds like and you addressed them all.

First is the blood sugar issue. Most glucometers from my experience read "HI" between 500-600mg/dl. How long has the patient been "HI" is the question. Any blood sugar this high is gonna make me think DKA with profound dehydration and electrolyte abnormalities. Now given the renal failure and being a dialysis patient, this creates other issues with the DKA and the patient probably won't be able to output enough urine to become dehydrated and will be already overloaded.

Fluid replacement is important in the DKA patient to treat the profound dehydration that is normally present. The renal threshold for glucose spilling over into the urine is commonly stated at 180mg/dl. When this happens, it pulls water with it and causes frequent urination. Polyuria = dehydration. Yes, IV fluids can cause dilution of the glucose and lower blood sugar but that is not the primary reason for fluid administration. In this case a good point for fluid restriction is made.

All seizure patients should have high-flow oxygen during the active phase and during the postictal phase. The diaphragm is impaired during tonic-clonic seizures with reduced ventilation (sometimes apnea) and reduced oxygen delivery to the brain. I have noticed faster recovery time with high-flow oxygen and I believe I have read some evidence supporting this also.

I really like Versed. It works fast and very well. Ativan is good too but has a little longer onset. So for quick action in your case, Versed probably would have been a little better choice. Versed is shorter acting though compared to Ativan. Our protocols allow 1-2mg of Ativan or 1-5mg of Versed for seizures. Chemical restraint we have to call.

Definitely sounded like a case for online consult with the doc.


Here is a great article outlining how to handle your patient type... suspected DKA with renal/dialysis patient.

http://www.cjem-online.ca/v6/n4/p281

 

[NYMedic828]

To the OP, be happy you are permitted to standing order administer benzos on your own judgement.

Id have to get on the phone to call the doctor while fighting the patient...

Only standing order is for an active seizure.

 

[STXmedic]

To the OP, be happy you are permitted to standing order administer benzos on your own judgement.

Id have to get on the phone to call the doctor while fighting the patient...

Only standing order is for an active seizure.

That sucks. We've got standing orders for valium and midaz for several circumstances, which is great when you don't want to fight with one hand and call with the other! Get a good relationship between you and your med director going. They tend to be a lot more forgiving when you ask for "forgiveness" rather than permission That, or get them to fix your protocols!

 

[NYMedic828]

That sucks. We've got standing orders for valium and midaz for several circumstances, which is great when you don't want to fight with one hand and call with the other! Get a good relationship between you and your med director going. They tend to be a lot more forgiving when you ask for "forgiveness" rather than permission That, or get them to fix your protocols!

When you have over 20 medical directors, its tough to get a good relationship going. Never know who is going to answer that phone. Some people are so incompetent that the doctors will get fed sometimes and assume everyone is that way.

 

[STXmedic]

When you have over 20 medical directors, its tough to get a good relationship going. Never know who is going to answer that phone. Some people are so incompetent that the doctors will get fed sometimes and assume everyone is that way.

Ahh... Yes, I could see how that would be an issue...

 

[Conanboris]

If it was that much of an issue, why not just use fentynal to knock the guy down? It is excreted by fecal route and you can get anesthetic dosage out of it.

Was just wondering on this? It's the first time I'd heard that and I best of my recollection, fentanyl is excreted predominantly in the urine (somewhere around 70-75%). Fecal excretion is much lower (around 10%)..

As always, I stand correctly and am really just here to learn...