EZ-EMT.org has very strong opinions about RSI Medications.
The evidence has driven our opinions.
I have no sympathy for providers who use propofol and versed.
Yes this is an attempt at bad EMS humor, but with experience and evidence certain medications when used for certain reasons can really hurt a patient's chances. This leads to the...
The compensation argument discussion. Yes it sounds a little wordy, but let me explain. When a intubation will most likely improve the chances of a patient's outcome: CVA, Septic Shock, Severe Trauma, COPD/ASTHMA complications. I often discuss the idea of helping the body compensate in anyway it can. I don't want to blunt my patient into a jello coma, and take away any compensation that they might have. I don't want them to suffer by under sedating either. So there is a balance. Lets take Ketamine for a moment. Ketamine has various applications of anesthesia and analgesia. It also has properties that squeeze a little sympathetic drive. When my patient is severely hypotensive and needs everything to keep them perfusing, I'll never reach for a sympathetic blunting combination.
Etomidate is a wonderful medication, however EMS needs to know to notify the hospital that we used Etomidate. Etomidate causes a renal suppression. In a case when renal concerns are present, Trauma to abdomen, Sepsis, Cancer, do not use Etomidate. Or you can use use my go to line. Etomidate is to sepsis what a clot is to the heart. It may not kill them, but it has a very good chance of doing damage.
Versed, Propofol. Let me be very clear before you start messaging me about the 100,000 times we use these medications without an issue. I hate Versed and Propofol in the EMS setting. I love them in the controlled procedure setting. When a CRNA comes to the ER to help put a guy's stable hip back in place. Propofol and Versed are amazing for this. A patient who is severely septic and has trash BPs (MAPS) and tachycardia does not need further depressive medication. I can tell you I transported a severely septic patient with pneumonia and pulmonary edema wanting to come out the tube. The CRNA did a great job of stabilizing the patient before transport. the CRNA gave multiple push dose pressors and fentanyl and started a propofol drip. There was a bag of NS with an antibiotic running, and a levophed drip. I was told this was the 2nd liter of fluid and that the patient had been in their hospital for a day. Shortly after leaving the facility, the patient started having severe drops in BP. My partners and I had to work really hard on chasing a perfusing MAP. We increased the Levophed drip to close to therapeutic maximum. Still not much improvement. We pulled the Propofol and intiated a Ketamine drip. Patient's status changed sigificantly. With all the pressure we were giving with the ventilator and fluids being given, this patient needed no sympathetic blunting. We didn't change anything else and the patient improved significantly over the next hour.
I can't tell you how fast my perceptions of RSI sedation have changed in the last 10 years but I can tell you I started with Versed and succinylcholine followed by more versed and vecuronium. I like the concept of they can't remember it with versed so why not. I will confess when I started I didn't do much in the way of pain management. This took a drastic change in a few years to patients do better in ICU stays and time when we don't use so much versed. Fentanyl is the way to go. Weirdly using fentanyl as a sedation drug just seems to blunt everything and take away and desire to breath. (sound like our opioid issues today)? Then I started researching medications and their long term effects. I learned to take concepts like, succinylcholine depolarizes the cells. This is also uses O2, so we may actually be causing desaturation issues by using a depolorizing medication. If given the choice, I will use rocuronium and often let the paralytic wear off with the patient being sedated and be treated for pain. Another thing I noticed is that some places would use Versed and Propofol with vecuronium. I had a younger male patient with persistent seizures. At first I thought the seizures were controlled. Then after 30 minutes my patient started seizing uncontrollably. Propofol and Versed have both been used to treat seizures, but with vecuronium on board, the patient is unable to move, so therefore they could be seizing and unable to tell. There is also the case of patients be so blunted by versed and propofol that we can't see changes in vital signs significant to show us changes in status. There for we must rely on timing to tell us when to push additional pain management. Knowing this can improve patient outcomes.
The compensation argument discussion. Yes it sounds a little wordy, but let me explain. When a intubation will most likely improve the chances of a patient's outcome: CVA, Septic Shock, Severe Trauma, COPD/ASTHMA complications. I often discuss the idea of helping the body compensate in anyway it can. I don't want to blunt my patient into a jello coma, and take away any compensation that they might have. I don't want them to suffer by under sedating either. So there is a balance. Lets take Ketamine for a moment. Ketamine has various applications of anesthesia and analgesia. It also has properties that squeeze a little sympathetic drive. When my patient is severely hypotensive and needs everything to keep them perfusing, I'll never reach for a sympathetic blunting combination.
Etomidate is a wonderful medication, however EMS needs to know to notify the hospital that we used Etomidate. Etomidate causes a renal suppression. In a case when renal concerns are present, Trauma to abdomen, Sepsis, Cancer, do not use Etomidate. Or you can use use my go to line. Etomidate is to sepsis what a clot is to the heart. It may not kill them, but it has a very good chance of doing damage.
Versed, Propofol. Let me be very clear before you start messaging me about the 100,000 times we use these medications without an issue. I hate Versed and Propofol in the EMS setting. I love them in the controlled procedure setting. When a CRNA comes to the ER to help put a guy's stable hip back in place. Propofol and Versed are amazing for this. A patient who is severely septic and has trash BPs (MAPS) and tachycardia does not need further depressive medication. I can tell you I transported a severely septic patient with pneumonia and pulmonary edema wanting to come out the tube. The CRNA did a great job of stabilizing the patient before transport. the CRNA gave multiple push dose pressors and fentanyl and started a propofol drip. There was a bag of NS with an antibiotic running, and a levophed drip. I was told this was the 2nd liter of fluid and that the patient had been in their hospital for a day. Shortly after leaving the facility, the patient started having severe drops in BP. My partners and I had to work really hard on chasing a perfusing MAP. We increased the Levophed drip to close to therapeutic maximum. Still not much improvement. We pulled the Propofol and intiated a Ketamine drip. Patient's status changed sigificantly. With all the pressure we were giving with the ventilator and fluids being given, this patient needed no sympathetic blunting. We didn't change anything else and the patient improved significantly over the next hour.
I can't tell you how fast my perceptions of RSI sedation have changed in the last 10 years but I can tell you I started with Versed and succinylcholine followed by more versed and vecuronium. I like the concept of they can't remember it with versed so why not. I will confess when I started I didn't do much in the way of pain management. This took a drastic change in a few years to patients do better in ICU stays and time when we don't use so much versed. Fentanyl is the way to go. Weirdly using fentanyl as a sedation drug just seems to blunt everything and take away and desire to breath. (sound like our opioid issues today)? Then I started researching medications and their long term effects. I learned to take concepts like, succinylcholine depolarizes the cells. This is also uses O2, so we may actually be causing desaturation issues by using a depolorizing medication. If given the choice, I will use rocuronium and often let the paralytic wear off with the patient being sedated and be treated for pain. Another thing I noticed is that some places would use Versed and Propofol with vecuronium. I had a younger male patient with persistent seizures. At first I thought the seizures were controlled. Then after 30 minutes my patient started seizing uncontrollably. Propofol and Versed have both been used to treat seizures, but with vecuronium on board, the patient is unable to move, so therefore they could be seizing and unable to tell. There is also the case of patients be so blunted by versed and propofol that we can't see changes in vital signs significant to show us changes in status. There for we must rely on timing to tell us when to push additional pain management. Knowing this can improve patient outcomes.
Delayed Sequence Intubation should Replace Rapid Sequence Intubation
The EZ-EMT.org basic approach:
Make sure all supplies are with in reach and discuss your plan with your partner out loud so that the patient/staff/family will understand what your goal is. See supplies list below*
Pre oxygenation of patient-Ventilate and Oxygenate until we reach a sustained 94% O2 saturation for at least 1 minute.
Start with sedation of ketamine. Draw up 500mg ketamine and NS into a 60cc syringe or a 50 cc NS bag. Make sure to remove the ml amount of ketamine from the 50cc bag. This establishes a 10mg of ketamine for every 1ml of fluid. Establish on a transport pump.
Start with 2mg/kg dose (if no sever sepsis or hemorrhage) and start pump at 999ml/hr. This will provide a nice slow IV push and sedate the patient. Do not paralyze at this time.
Additional sedation and analgesia is up to providers and should be considered on a case by case basis. I like allowing patients to ween off their paralytic and initiate their own breaths if they can. Again a case by case scenario, work within your protocols and guidelines to establish good ventilation for proper gas exchange. This is often not allowed in the transport setting, but it is good to monitor times for ER staff to continue therapies.
Versed, Etomidate and Fentanyl are widely excepted as usable sedation and analgesic options.
Many Rural EMS organizations and hospitals still implement succytyincholine as a paralytic. Remember that depolarizing cells uses energy and burns Oxygen. We’ve been monitoring the literature on Sux harming head injury patients and haven’t found enough info to make an opinion.
EZ-EMT recommends that if fentanyl is to be used in a RSI/DSI situation and is to be used at dissociative doses that the agency carry succytyincholine for the rare occasion of ridged chest syndrome. EZ-EMT does not educate the use Fentanyl in this setting.
Sam personally does not use anything for ET tube placement other than Etomidate and or Ketamine for sedation and roccuronium (EKR combo) for paralytic. “ I have ran into problems in the past of Versed, Propofol, and Fentanyl causing major pulmonary and sympathetic blunting. I have used far less pressor support with etomidate, ketamine, and roccuronium, and have seen far better long term outcomes in my own practice with extended ICU stays and surgical interventions.
***THE FOLLOWING IS OPINION ONLY AND HAS NO EVIDENCE TO SUPPORT OTHER THAN 3 SEPARATE OBSERVATIONS***
I have watched 3 different patients all with multi-system traumas head injuries receive succytyincholine and propofol along with mannitol, result in massive drops in BP followed by a total loss of any sympathetic tone and blood eventually being found in the folly catheter. All three patients had to be placed on 1 or more pressors along with receiving large amounts of fluid causing hemoglobin dilution. I believe in all 3 cases, that no blame should be placed on the providers for the medications used. There was a time where I would have followed those orders without question. I have rarely seen a patient desaturate or have a drop in MAP with use of EKR or just KR. Slightly off topic, I now also push heavily for the use of hypertonic saline over the use of mannitol for multisystem traumas. Evidence is strong that hypertonic saline works as well if not better than mannitol for reduction in ICP while protecting renal and adrenal profusion. Mannitol is a very large crystalline osmotic medication that can result in damage to sympathetic tone and decrease profusion to adrenal glands. If the patient has blood in the urine, HTNS is far safer and provides better outcomes.
Make sure all supplies are with in reach and discuss your plan with your partner out loud so that the patient/staff/family will understand what your goal is. See supplies list below*
Pre oxygenation of patient-Ventilate and Oxygenate until we reach a sustained 94% O2 saturation for at least 1 minute.
Start with sedation of ketamine. Draw up 500mg ketamine and NS into a 60cc syringe or a 50 cc NS bag. Make sure to remove the ml amount of ketamine from the 50cc bag. This establishes a 10mg of ketamine for every 1ml of fluid. Establish on a transport pump.
Start with 2mg/kg dose (if no sever sepsis or hemorrhage) and start pump at 999ml/hr. This will provide a nice slow IV push and sedate the patient. Do not paralyze at this time.
- Start ventilation by taking 2 nasal pharyngeal adjuncts an placing them in the nose.
- Cut a nasal cannula on either side of the nose bride so you have 2 floppy NC lines that are smooth and place them an inch or so in to the NPAs.
- Turn on O2 to high flow.
- Place a BVM over the patient’s mouth and provide additional high flow O2. (The patient may slow respiration’s but should still voluntarily breath.
- Wait for 1 minute of 94% or greater oxygen saturation.
- Draw up 1mg/kg roccuronium and push it.
- Once proper placement of ET tube is established with good capnography waveform. Establish a good BVM seal and ventilate patient to desired ETCO2 and O2 readings.
- Discuss with partner about additional sedation and paralysis.
- If ventilator is to be used, make sure to have setting established for patient.
Additional sedation and analgesia is up to providers and should be considered on a case by case basis. I like allowing patients to ween off their paralytic and initiate their own breaths if they can. Again a case by case scenario, work within your protocols and guidelines to establish good ventilation for proper gas exchange. This is often not allowed in the transport setting, but it is good to monitor times for ER staff to continue therapies.
Versed, Etomidate and Fentanyl are widely excepted as usable sedation and analgesic options.
Many Rural EMS organizations and hospitals still implement succytyincholine as a paralytic. Remember that depolarizing cells uses energy and burns Oxygen. We’ve been monitoring the literature on Sux harming head injury patients and haven’t found enough info to make an opinion.
EZ-EMT recommends that if fentanyl is to be used in a RSI/DSI situation and is to be used at dissociative doses that the agency carry succytyincholine for the rare occasion of ridged chest syndrome. EZ-EMT does not educate the use Fentanyl in this setting.
Sam personally does not use anything for ET tube placement other than Etomidate and or Ketamine for sedation and roccuronium (EKR combo) for paralytic. “ I have ran into problems in the past of Versed, Propofol, and Fentanyl causing major pulmonary and sympathetic blunting. I have used far less pressor support with etomidate, ketamine, and roccuronium, and have seen far better long term outcomes in my own practice with extended ICU stays and surgical interventions.
***THE FOLLOWING IS OPINION ONLY AND HAS NO EVIDENCE TO SUPPORT OTHER THAN 3 SEPARATE OBSERVATIONS***
I have watched 3 different patients all with multi-system traumas head injuries receive succytyincholine and propofol along with mannitol, result in massive drops in BP followed by a total loss of any sympathetic tone and blood eventually being found in the folly catheter. All three patients had to be placed on 1 or more pressors along with receiving large amounts of fluid causing hemoglobin dilution. I believe in all 3 cases, that no blame should be placed on the providers for the medications used. There was a time where I would have followed those orders without question. I have rarely seen a patient desaturate or have a drop in MAP with use of EKR or just KR. Slightly off topic, I now also push heavily for the use of hypertonic saline over the use of mannitol for multisystem traumas. Evidence is strong that hypertonic saline works as well if not better than mannitol for reduction in ICP while protecting renal and adrenal profusion. Mannitol is a very large crystalline osmotic medication that can result in damage to sympathetic tone and decrease profusion to adrenal glands. If the patient has blood in the urine, HTNS is far safer and provides better outcomes.
Sedation for non-RSI/DSI patients aka the combative or delirious patient.
Realizing every agency has policies that need to be followed and not all agencies allow for aggressive use of medications, We educate the concept that we aren’t paid to “get into fights”. Anything that can help us safely transport a patient to a hospital is a tool that should be considered.
As an opinion only, We try to avoid the use of B52 combos, Haldol, or Benadryl as any type of sedation. In our world we believe there are safe ways to “drop” a patient depending on the situation. Before this continues realize having a conversation with your agency directors, medical directors, and even legal consults about the invasive nature of sedating a potential vs and actively combative patient.
At this time we recommend local protocols with the use of ketamine or benzo’s.
Ketamine, Ativan, Valium, Versed, Droperidol, Haldol are all options that are used.
As an opinion only, We try to avoid the use of B52 combos, Haldol, or Benadryl as any type of sedation. In our world we believe there are safe ways to “drop” a patient depending on the situation. Before this continues realize having a conversation with your agency directors, medical directors, and even legal consults about the invasive nature of sedating a potential vs and actively combative patient.
At this time we recommend local protocols with the use of ketamine or benzo’s.
Ketamine, Ativan, Valium, Versed, Droperidol, Haldol are all options that are used.