sedation prior to pacing

[zzyzx]

I'm a new medic and have never had to pace anyone yet. So I have a question for you guys. If the patient is hypotensive, say with a BP at or below 80 systolic, Versed is contraindicated, right? So you give Versed only once the BP has come up after you've started pacing the patient, right? How much of an effect does Versed actually have on lowering the BP? I have seen someone getting paced w/o sedation, and they were not happy.

[chbare]

Zzyzx, I do not know that you could say Versed is strictly contraindicated with low B/P. Are you allowed to give Fentanyl? This is an option until the hemodynamic status improves and you can give Versed. In addition, you can always give less Versed and give Fentanyl along with your decreased dose of Versed.

Take care,

chbare.

[AZCEP]

If you are pacing someone, you need to consider the discomfort that you are causing while you are doing it.

None of the BZD's have any analgesic properties, they are good to help the patient forget, but do nothing for pain. As the blood pressure comes up, and the patient becomes more aware of what is happening, you need to treat the agitation and the pain. Fentanyl is the best choice for pain relief, Etomidate can work in this setting but has a short duration, Ketamine is another good choice if available.

[zzyzx]

We don't carry fentanyl. We have Versed and morphine, but we're only allowed to give Versed when we pace.

[ALERT Medic]

I guess you have to ask yourself the question....'Which of his/her problems will kill him/her faster, unstable bradycardia not paced or pain caused by pacing?'.

Our service does not carry versed but we do carry valium and the way the protocol is written states that if time permits, pre-medicate before pacing. As far as once you get them going with the juice, it's a question of what is comfortable for the patient. I agree that benzo's don't have any analgesic properties but I see it like this, if they're doped up with a good sedative and don't seem to be bothered by the pain, they can wait the 10-12 min it's gonna take me to get them to a MD for further care/treatment.

[fiznat]

Also a new medic (medic student, actually) here, but I was under the impression that at least as benzos go, versed is a fairly weak muscle relaxant and therefore only minimal precautions for hypotension are necessary? I understand that hypotension is still a precaution and a relative contraindication, but am I correct in understanding that we need to worry a little less about those kinds of effects with this drug?

Obviously - as always - this is a "how does your patient present" kind of situation, but am I correct in understanding that versed in particular is less likely to worsen hypotension (as compared to other benzos like Valium, or an opiate analgesic like Morphine) for this already unstable patient?

[tomcbad]

The people I have paced could handle the pacing with out sedation. Yes it is uncomfortable, but can be tolerated. In your situation, I would initiate pacing and sedate once bp was adequate. Treat the life threatening rhythm before comfort. That can be achieved after successful pacing.

[AZCEP]

Also a new medic (medic student, actually) here, but I was under the impression that at least as benzos go, versed is a fairly weak muscle relaxant and therefore only minimal precautions for hypotension are necessary? I understand that hypotension is still a precaution and a relative contraindication, but am I correct in understanding that we need to worry a little less about those kinds of effects with this drug?

Obviously - as always - this is a "how does your patient present" kind of situation, but am I correct in understanding that versed in particular is less likely to worsen hypotension (as compared to other benzos like Valium, or an opiate analgesic like Morphine) for this already unstable patient?

Some pretty good points there.

The danger with Versed is not so much it's muscle relaxation, as the blunting of the sympathetic discharge through CNS depression. Brain goes to sleep, adrenals slow adrenergic release, vasodilation, hypotension. Versed is very good at depressing the CNS, so hypotension is a definite possibility.

The use of either Morphine or a BZD can, and probably will, drop the BP in the patient that is fighting to compensate. Waiting a bit to get the perfusion improved prior to using these agents might just be the best option.

[Nate]

The pacing itself can cause stress, which will cause the BP to rise as well. :wink:

We have valium and versed.

[medic001918]

Also a new medic (medic student, actually) here, but I was under the impression that at least as benzos go, versed is a fairly weak muscle relaxant and therefore only minimal precautions for hypotension are necessary? I understand that hypotension is still a precaution and a relative contraindication, but am I correct in understanding that we need to worry a little less about those kinds of effects with this drug?

Obviously - as always - this is a "how does your patient present" kind of situation, but am I correct in understanding that versed in particular is less likely to worsen hypotension (as compared to other benzos like Valium, or an opiate analgesic like Morphine) for this already unstable patient?

Fiznat, remember that in our service versed isn't the only benzo we carry. So this opens up another option for sedation using ativan which doesn't have as much of a hypotensive property. It tends to work well, and I've used it for sedation on multiple occassions. Ativan tends to be faster acting and shorter lasting then the versed as well. Remember to consider all of your options and their potential effects and choose the one that fits the overall picture of your patient to provide the most benefit.

Shane

NREMT-P