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sihi

Midazolam for intubation (Have U used midaz. anaesthesia?)

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I agree Suxamethon creates good condition for intubation. If use paralytics Midazolam sedation is ok, better with opiate premedication.

I work in two services in the "south" and in the "north". In the south we have suxamethon, pipicuronium, propofol, midazolam, Sodium Oxybate, morphine. But some leader phisicians say that we - nurses, shouldnt use propofol or paralytics for intubation.

Here I have used anestetics. Comatose patient in septic shock, hyperventilating. I ensured vasopressive and inotrope support and inducted anesthesia with ~15 mg Midazolam (less hypotensive drug) and 40 Propofol (although pretty hypotnsive and cardiodepressive drug) ---> I got good condition for intub. I didnt used suxamethon becouse didnt want to have problems with "leader" phisicians:) For this patient I would better use 15 midazolam and suxamethon ofcourse.

Next he got anesthetic Sodium Oxybate - very good in shock.

In the north we have Propofol, Fentanyl, Na Oxybate, Midaz. but no paralytics and I can use all.

Propofol usually creates good conditions for intubation also without paralytics, but is very hypotensive.

I like to combine Midazolam with propofol = less of hypotensive side efect.

Edited by sihi

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Not faulting your method but just generally I am very, very against intubating people without suxamethonium or another paralytic agent, yes it can be done, but should it? I don't think so

Will they let you have ketamine? That'd be a far better anaesthetic than midazolam or propofol

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I wouldn't say far better or even better. Ketamine has it's own side effects profile and some of the side effects can be very bad.

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I wouldn't say far better or even better. Ketamine has it's own side effects profile and some of the side effects can be very bad.

It does yes but it is an excellent anaesthetic that does not posses the cardiovascular risk profile of midazolam or propofol

The common argument of emergence phenomena is not something that has been a problem here in NZ and I've never seen it

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Have you ever had to deal with haemodynamic consequences associated with ketamine? There is a certain clarity that develops when considering these agents when your patient becomes profoundly tachycardic and hypotensive after administering ketamine. It's sobering when the onus falls on you to select a certain agent. None of the agents mentioned here are a silver bullet. None of the agents excel in every situation and they all are potentially dangerous.

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Have you ever had to deal with haemodynamic consequences associated with ketamine? There is a certain clarity that develops when considering these agents when your patient becomes profoundly tachycardic and hypotensive after administering ketamine. It's sobering when the onus falls on you to select a certain agent. None of the agents mentioned here are a silver bullet. None of the agents excel in every situation and they all are potentially dangerous.

I have only had one bad patient experience with ketamine and that was some bad dreams at low dosage for analgesia

Yes, it is well known that ketamine causes transient increases in blood pressure and cardiac work; it would therefore be contraindicated in patients where these alternations in physiology would be bad anybody who doesn't keep that in mind is a muppet who should not be allowed to administer it.

No one agent is best but I certainly think we can agree the good old ambo trick of pouring midazolam into people until they are unconscious enough to accept a tube is not the way to go, as to whether propofol or etomidate or ketamine or thiopentone are acceptable it depends on the patient you have and their individual circumstances.

Certainly I think in the pre hospital environment we should keep it simple; fentanyl for premedication and either ketamine or midazolam; some places are using etomidate but etomidate has some pretty bad adrenojulu attached to it

So is ketamine better than midazolam? In patients who are shocked or are not deeply unconscious the answer is yes however in patients who have pathology where increased blood pressure or cardiac work would be bad the answer is no (95% CI, p < 0.00001*)

* numbers made up, not validated by any actual scientific thingamagig

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Intubations in the ED or field that require an "induction agent" require muscle relaxant for the vase majority of cases. What that induction agent is really doesn't matter in these cases, as long as the proper dose is given. Hypotension after an induction of anesesthesia (which is what is called for prior to direct laryngoscopy) is an expected event that should be anticipated and treated accordingly if necessary. If the patient meets medical criteria for intubation, short full arrest or an otherwise flaccid patient, muscle relaxant should be mandatory.  Versed is as stable as any other agent with the possible exception of etomidate, and even then, hypotention can occur. The caveat is that the proper dose needs to be given which is about .2 to .3 mg/kg. Otherwise, don't use it.

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I use Midazolam (versed) almost exclusively. I generally give 5mg fast IV. That is usually enough to put anyone down. My preference it to keep the patient light even breathing if possible and put them is assist mode on the vent in our ambulance. Although, I did have a case last night I had to use SUX. The order went 5 of versed 15 of Etomidate and 50 of Sux. I always use versed prior to Etomidate to prevent myoclonus and although we carry versed ativan and valium my preference in adults is versed, and I only use sux as a last resort when I have trismus.

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I have seen Versed assisted intubation used in the past. They would apply both a nasal cannula & face mask connected to oxygen. Then they would place some Lidocaine in a small volume nebulizer to help blunt the cough & gag reflex. Then proceed with Versed usually 5mg IV (0.05mg/kg) titrated slowly every 5 minutes up to a maximum 0.1mg/kg. Then they would give Morphine usually 2mg IV every 5 minutes up to a maximum of 10mgs.

 

 

Edited by 1EMT-P

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These are nice comments, all based upon clinical experience which should never be minimized.  That said, if you look at the literature, versed as a sole induction agent is not supported and has been associated with increased mortality and morbidity.  There is no substitute for true RSI (induction agent and paralytic) when faced with an emergent airway crisis.  I have used versed and fentanyl for intubation in the ambulance and etomidate or propofol alone in the hospital with good success but that is only because I have around 10,000 intubations under my belt.  Give me enough time to anesthetize an airway, I can intubate an awake patient.  

Prehospital staff are being dealt a raw deal when it comes to intubating a patient not in cardiac arrest but you must remember that if you have poor first pass intubation success rates, RSI is not the answer.

May the tube be with you.

Spock  

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