Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Changes to Pennsylvania Protocols – Post-Resuscitation Care – Part II

Continued from Part I on Pennsylvania’s updated Post-Resuscitation Care protocol.

The sedation of post-resuscitation patients contains similar confusion between treating the patient by weight and treating the patient by the weight of some ideal patient.[1]

According to this protocol, midazolam may only be given in 1 mg-5 mg increments as long as that works out to 0.05 mg/kg. For a 100 kg patient, 0.05 mg/kg = 5 mg. For a patient who weighs 150 kg, 5 mg = 0.03 mg/kg.

Does this mean that we must violate protocol no matter which part we choose to follow?

This is a problem that is much more common than just this one protocol. Perhaps this is intended as an homage to Joseph Heller’s Catch-22. 🙄

The repeat of 0.05 mg/kg means that the maximum dose of 0.1 mg/kg will be reached with only one more dose, so the every 5 minutes part is somebody’s idea of a joke. 😈

We have stepped through the looking-glass into the world of EMS protocols, but we seem to have ended up in Wonderland, where the Red Queen is always looking to chop off someone’s head for violating protocols – protocols that sometimes cannot be obeyed without a heavy dose of cognitive dissonance.

Then there is the dropping of one significant digit. Since the initial dose is 0.05 mg/kg, the maximum dose should also have two significant digits.[2] The maximum dose is 0.1 mg/kg, not 0.10 mg/kg, that means that the dose is anywhere from 0.05 mg/kg to 0.15 mg/kg. Apparently precision is not something that is understood by the authors. Why not use doses that allow for a rounding error of 50% of the maximum dose?

This might be acceptable, if this were a reflection of the understanding of the wide variability of appropriate doses with benzodiazepines. However, there is no reason to believe that is the case. 😳

To be continued in Part III.

Footnotes:

[1] Post-Resuscitation Care
Pennsylvania Statewide Advanced Life Support Protocols
3080 – ALS – Adult/Peds
Pages 34-36/128
Free Full Text PDF of All ALS Protocols

[2] Significant digits
Wikipedia
Article

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