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

- Rogue Medic

The Debate on tPA for Ischemic Stroke at EMCrit – What Does the Research Really Say?

Fri, 31 Jan 2014 14:00:02 -0500 by

It puts the tPA in the patient, or else it gets the hose, again!

Should we look only at the so-called positive studies?

The proponents of tPA (Alteplase) are not trying to defend the other studies. They have a hard enough time putting a positive spin on the studies they want us to look at – just not too closely.[1]

Dr. Scott Weingart decided to bring two doctors together to discuss the problems with the research and whether those problems can be rationalized away (Not his description). I do not have the possibility of giving, or withholding tPA, so I do not have to worry about being punished for violating clinical policies – at least not when it comes to tPA. 😉
 

The debate seemed relevant because ACEP, a major US emergency medicine organization, released clinical guidelines markedly increasing stress on thrombolysing stroke. These clinical guidelines were sent back by ACEP’s council for further commentary and assessment, a move unprecedented in the history of the organization.[2]

 

Dr. Andy Jagoda presents the pro argument.

The research is not really that bad, just don’t suggest that the studies should be repeated with proper research methodology, because it would be improper to withhold the standard of care.

Organizations have looked at the research and made this a recommendation, so you have to justify not giving tPA, or you face punishment.
 


 

Bad standards of care are still bad medicine.
 

A decision not to use Alteplase in the appropriate setting is acceptable but clinical decision making must be well supported in the medical record[2]

 

Allow me to put that in perspective.
 

A decision not to use Alteplase in the appropriate setting is acceptable expected but clinical decision making must be well supported is taken for granted in the medical record.
 

Should any treatment be given without justification?

This is probably the biggest problem with medicine.

All treatment should require justification, every time.

Should treatment be justified with flawed research?

Dr. Anand Swaminathan gave the con argument.
 


 

The research is flawed.

The failure of the recommending organizations to identify these flaws does not mean that the flaws do not exist or that the flaws are insignificant.
 


IST-3 time to treatment randomization and outcomes.[3]
 

What is the magic that causes a good outcome when tPA is given at 0-3 hours, a reversal to a bad outcome at 3-4 1/2 hours, and another reversal back to a good outcome at over 4 1/2 hours?

The longer we wait, the more effective it is?

Isn’t this just a variation on the nonsense of homeopathy? The less we give, the greater the effect.

Here is the detail of the effect of time on outcomes, when giving tPA.
 


IST-3 time to treatment randomization and outcomes detail with my edits for clarity.[3]
 

Magic™
 

A decision not to use Alteplase Magic™ in the appropriate setting is acceptable but clinical decision making must be well supported in the medical record.
 

Go watch/listen to the debate.
 

Also view the pro and con slides and read the detailed review of tPA for acute ischemic stroke at EM Lyceum[4] and Dr. David Newman’s much shorter review of the guideline problems at Smart EM.[5]

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Footnotes:

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[1] The raw data of the NINDS trial should be made public
Dr. Jeffrey Mann
BMJ
Rapid response letter

Unfortunately, it has been years since Dr. Mann discontinued his EM Guidemaps site, where he posted the raw data that the NINDS investigators finally sent him in 2003 (8 years after the study was published), and I no longer have a copy of what he posted.

Researchers should not keep their data secret.

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[2] Podcast 116 – the tPA for Ischemic Stroke Debate
EMCrit
January 28, 2014
Dr. Andy Jagoda (pro) vs. Dr. Anand Swaminathan (con).
Podcast/Videocast page with links to the slides used by both doctors.

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[3] The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial.
IST-3 collaborative group, Sandercock P, Wardlaw JM, Lindley RI, Dennis M, Cohen G, Murray G, Innes K, Venables G, Czlonkowska A, Kobayashi A, Ricci S, Murray V, Berge E, Slot KB, Hankey GJ, Correia M, Peeters A, Matz K, Lyrer P, Gubitz G, Phillips SJ, Arauz A.
Lancet. 2012 Jun 23;379(9834):2352-63. doi: 10.1016/S0140-6736(12)60768-5. Epub 2012 May 23. Erratum in: Lancet. 2012 Aug 25;380(9843):730.
PMID: 22632908 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.

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[4] tPA in ischemic stroke, “answers”
Posted on August 30, 2013
EM Lyceum
Article

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[5] The Guideline, The Science, and The Gap
Wednesday, April 17, 2013
Dr. David Newman browngorilla540
Smart EM
Article

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Filed Under: Critical Judgment, EMCrit, Evidence, Heresy, Research, tPA

Post-Intubation Package and Alarms

Thu, 18 Oct 2012 15:05:35 -0400 by
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What do we do after the tube is in?

 

No. It is not time to use the laryngoscope blade as a bottle opener. There is a lot still to do.

The quotes are some of the points Dr. Weingart makes. The comments here are mine.
 

Achieve Adequate Analgesia and Sedation
 

I won’t belabor this, because I’ve discussed it in so many other podcasts, such as the one about not leaving your patient in a nightmare[1]

 

Even a hypotensive trauma patient, who is not adequately sedated, will be worse off without sedation.

Pain is not an appropriate pressor.
 

Hook Up the ETCO2
 

You read NAP4 right? Continuous waveform ETCO2 until the ET tube gets pulled[1]

 

Maybe we can get away with the carelessness of not using continuous waveform capnography for a long time, but carelessness often shows up in other areas of patient care.

The foolishness of not recognizing the benefit of continuous waveform capnography is the bigger problem.

Alarms do not make up for incompetence.
 

Have a Plan for Vent Alarms
 

Treat them like a cardiac arrest announced overhead.[1]

 

Alarms are annoying.

That is the idea. If the alarm is not annoying, we tend to ignore it.

Why do we ignore alarms?

There are a variety of reasons.

We may leave all of the alarms on – even the ones we know that we do not care about.

If we are not going to do something about an alarm, because we do not think that the alarm is warning of anything important, we are only training ourselves to ignore alarms.

We become accustomed to alarms going off almost continuously, so the alarms become ironic. They are anything but alarming, when they are alarming.

If an alarm is not going to produce an instant response from staff, turn it off.

The purpose of an alarm is to produce a response.

The response is not to ignore the alarm.

The response is also not to just reset the alarm.

As with pulse oximetry, the response is not to just do something temporary, like turn up the oxygen in response to a low oxygen saturation.

The response is to address the cause of the alarm.

If the sat is low, why is it low?

Why is the same amount of oxygen no longer producing adequate oxygenation?

Or is something decreasing the amount of oxygen the patient is receiving?

Is the patient agitated and in need of more sedation, rather than just turning the oxygen up to meet the increased oxygen demands of an agitated patient?

If we want people to ignore alarms, the best way is to put alarms on every function possible. If it can alarm, it will alarm – then nobody will take alarms seriously.

If those of us responding to the alarms are not smart enough to be able to decide which alarms we should have turned on, then we aren’t smart enough to respond appropriately to the alarms.

Some places already require this level of continuous alarm incompetence.

Alarms on everything – dumbing down patient care to the point where competence is punished.

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Footnotes:

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[1] Podcast 84 – The Post-Intubation Package
by EMCRIT
October 16, 2012
Web page with links to supporting information and link to mp3 download of podcast

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Filed Under: Airway Management, EMCrit, Heresy, Intubation, NAP4

How to Torture Patients

Fri, 18 May 2012 08:00:58 -0400 by
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Perhaps, you have watched all of the parts of Saw and wished that you could have some of that kind of fun, too. Even though we are supposed to be having the opposite effect on patients, some of us do cause that kind of pain and psychological abuse.

Dr. Weingart gives us a piece of his mind on this topic in Pain and Terror as Effective Pressors.

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Does this go well with scrubs, or with an EMS uniform?
 


Image credit.

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But what about the hypotension and hypoxia that occur with fentanyl?

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Click on images to make them larger.[1] [2]

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There is a 97% chance that, after administration of fentanyl to a critical trauma patient who is not hypotensive, the patient will still be not hypotensive.

There is a 47% chance that, after administration of fentanyl to a critical trauma patient who is hypotensive, the patient will stop being hypotensive.

If we did not have so much anxiety about fentanyl, we might consider making it the standard of care for hypotension following trauma.

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Should we be double-teaming these patients with both pain and the terror of awareness during intubation with a long-acting paralytic? It probably isn’t any worse than what the traumatically paralyzed patient experiences with intubation, but that should only encourage us to be more aggressive with pain management for these patients. This is not an excuse to be tolerant of iatrogenic pain and anxiety.

Pain management in EMS seems to keep improving, but we still have a long way to go.

Pain management in the ED (Emergency Department) seems to keep improving, but we still have a long way to go.

I currently do have a protocol that allows me to give post-intubation sedation. This was only added to my protocols in the past 5 years, but it is a start. Before that, medics had to be aggressive enough to ask for medical command permission for a treatment that was outside of protocol. Treatments that are outside of protocol are discouraged.

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The problem with post-intubation pain (and the expected agitation that goes with pain) this pain management sedation is not a recent development.

In an earlier podcast, Dr. Weingart describes the problems with using sedatives, rather than pain medicine, for post-intubation PAIN.

EMCrit Podcast 7 – Sedation Tirade – and listen to his other sedation podcasts.

Why do we think that a patient does not have pain unless that patient is writhing in pain?

With a paralytic on board, especially a long-acting paralytic, and even more so with a large dose of a long-acting paralytic, these patients will not writhe.

This brings up some questions –

How much evidence do we need that many of our patients are in a lot pain?

How easy is it to ignore the severe pain of our patients?

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I do have one criticism.

The dose of sarcasm could be increased. This is no time to be stingy with the sarcasm treatment. I could be wrong.

Go listen to the brief Wee podcast and decide for yourself.

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Footnotes:

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[1] Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia.
Krauss WC, Shah S, Shah S, Thomas SH.
J Emerg Med. 2011 Feb;40(2):182-7. Epub 2009 Mar 27.
PMID: 19327928 [PubMed – in process]

Full Text PDF Download at medicalscg.

Fentanyl Study: EMS Research Episode 9
EMS Research Podcast
Podcast page

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[2] Chart Version – Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia
Sun, 05 Jun 2011
Rogue Medic
Article

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Filed Under: EMCrit, Heresy, Pain Management, Sedation

Comments on Cardioversion – 2010 ACLS – Part II

Mon, 16 Apr 2012 15:35:01 -0400 by
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In response to Cardioversion – 2010 ACLS – Part II, there are some new comments. Chris from Sweden, had written –

What meds do you use in the hypotensive, but still conscious patient for sedation? Could ketamine and low dose of midazolam be of use here?

Gerardo GastĂ©lum comments –

Not Ketamine for cardioversion. Ketamine rises heart rate and coronary O2 requirements.

Benzos like Midazolam or Diazepam + Opiates such as Fentanyl or Morphine can do the works. AHA also recomends etomidate, thiopental and propofol, but out of these I chose etomidate due to itÂŽs cardiovascular stability.

I disagree.

There may be more of a desire to avoid sedatives that vasodilate and depress cardiac activity. This is one of the reasons that etomidate is recommended. I think that either effect is going to be short-term – if the cardioversion, or series of cardioversions, works.

Some people discourage sedation. One of the things that they do not appear to consider is the possibility of needing to cardiovert more than once.

I can get away with shocking her without sedation, justify it as saving her life, and sedate her afterward to deal with the side effects of such brutal treatment, but the idea of appropriate sedation prior to cardioversion almost scares me into an unstable tachycardia.

Fortunately, nobody here is recommending that we not sedate for cardioversion.

With comments on this topic, I tend to wonder, Has this been covered in an EMCrit podcast? What would Dr. Scott Weingart do? Maybe he can make up some EMCrit screensavers with the slogan WWWD? (What Would Weingart Do?). Dr. Weingart is trying to smooth the transition from treatment in the ED (Emergency Department) to treatment in the ICU (Intensive Care Unit) and possibly take over the world of emergency education.

I think the clever something to give is probably a low dose of etomidate, maybe 5 or 7 mg of etomidate. They’re not going to be fully unconscious, like when we gave the 10 or 15 mg, but it’ll take the edge off.

They’re getting no pain control whatsoever from that, so if you were really a smart guy, give a little etomidate with some ketamine, or even just ketamine alone.[1]

Listen to the whole podcast – all 9 minutes of it. I just copied a few sentences, but this very short podcast covers a lot of material that is very important to understand before dealing with the unstable tachyarrhythmia patient.

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Image credit.

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In the second comment, Gerardo Gastélum provides a quote from the 2010 ACLS guidelines that is important for the understanding of the difference between unstable and just symptomatic.[2]

Thank you for the great description from ACLS.

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Footnotes:

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[1] EMCrit Podcast 20 – The Crashing Atrial Fibrillation Patient
by EMCRIT on FEBRUARY 12, 2010
Podcast page

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[2] Management of Symptomatic Bradycardia and Tachycardia
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.3: Management of Symptomatic Bradycardia and Tachycardia
Free Full Text from Circulation

Unstable and symptomatic are terms typically used to describe the condition of patients with arrhythmias. Generally, unstable refers to a condition in which vital organ function is acutely impaired or cardiac arrest is ongoing or imminent. When an arrhythmia causes a patient to be unstable, immediate intervention is indicated. Symptomatic implies that an arrhythmia is causing symptoms, such as palpitations, lightheadedness, or dyspnea, but the patient is stable and not in imminent danger. In such cases more time is available to decide on the most appropriate intervention. In both unstable and symptomatic cases the provider must make an assessment as to whether it is the arrhythmia that is causing the patient to be unstable or symptomatic. For example, a patient in septic shock with sinus tachycardia of 140 beats per minute is unstable; however, the arrhythmia is a physiologic compensation rather than the cause of instability. Therefore, electric cardioversion will not improve this patient’s condition. Additionally, if a patient with respiratory failure and severe hypoxemia becomes hypotensive and develops a bradycardia, the bradycardia is not the primary cause of instability. Treating the bradycardia without treating the hypoxemia is unlikely to improve the patient’s condition. It is critically important to determine the cause of the patient’s instability in order to properly direct treatment. In general, sinus tachycardia is a response to other factors and, thus, it rarely (if ever) is the cause of instability in and of itself.

One of my earliest posts was a variation on the distinction between unstable and symptomatic –

Cardioversion – I’m not doing that, you do it!

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Filed Under: 2010 AHA Guidelines, Cardioversion, EMCrit, Heresy, Ketamine, Pharmacology, Sedation

EMCrit Wee – Abandon Epinephrine?

Fri, 06 Apr 2012 08:00:11 -0400 by
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Dr. Weingart has a mini wee podcast about the recent epinephrine research and whether EMS should be using epinephrine. Maybe the EMCrit logo is too big for a wee podcast.

One of the EMCrit listeners, the medical director for a major EMS agency, wanted to know what Dr. Weingart thinks about removing epinephrine from their cardiac arrest protocols.

 

EMCrit Wee – Abandon Epinephrine?

 

While Dr. Weingart thinks that the evidence will show that epinephrine is beneficial in cardiac arrest . . .

Well, you’ll have to listen to the podcast, all five and a half minutes of it, to find out the rest of his thoughts on this topic.

He recommends reading what Dr. Radecki (EM Literature of Note) wrote about epinephrine here.

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I think that there may be only isolated indications for epinephrine. I do not think that we will ever know what those legitimate indications are until after we do a large enough well designed randomized controlled trial to separate out any benefit in survival.

ROSC (Return Of Spontaneous Circulation) is not a valid endpoint after 50 years of routine use, but the only evidence we have in humans is ROSC. We would not settle for such flimsy evidence in treating cancer (unless using alternative medicine), so why is it acceptable in cardiac arrest?

While we have not yet reached double digits on studies showing harm from epinephrine, there still is not a single study showing improved survival with epinephrine in cardiac arrest.

Millions of cardiac arrest patients treated with epinephrine, but we still cannot find any valid evidence of improved survival.

Vladimir and Estragon would have stopped waiting long ago.

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Expert recommendations must come with an expiration date.

 

No exceptions.

 

If the expert recommendation is not followed by appropriate research, then the expert recommendation should not be treated better than the patients.

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I completely agree with Dr. Weingart’s recommended approach. We should also study nitrates in cardiac arrest.

 

Go listen to all 5 and a half minutes of the podcast.

 

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Filed Under: 'Alternative' Medicine, ACLS, EMCrit, Epinephrine, Heresy, Pharmacology, Research

Is Ketamine an EMS Wonder Drug

Sun, 01 Jan 2012 06:30:42 -0500 by
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Too Old To Work responded to my description of the benefits of keatamine in What I Wanted from EMS Santa But Did Not Get.

Funny, I’ve used Lidocaine and Amiodarone a number of times to terminate antiarrhythmias, although I still contend that Lidocaine works better than Amio. I’ve only used cardioversion a couple of times and only when there was no other alternative. The last time I used it, we were using Valium for sedation, it’s been that long.

That is why we ignore anecdotal evidence of benefit. When we look at numbers large enough to provide predictable results, the memories of good outcomes from amiodarone and lidocaine are found to be the result of statistical variation, or bad memory, or both. We tend to forget the times that our antiarrhythmics do not work for V Tach (Ventricular Tachycardia).

Different studies show that amiodarone is only 29% effective at terminating V Tach,[1] only 25% effective at terminating V Tach, [2], and only 15% effective at terminating V Tach within 20 minutes, but if we don’t mind waiting an hour it can be as much as 29% effective.[3]

If we are not trying to convert the rhythm promptly, should we even consider V Tach an emergency? If lights and sirens only make a difference of a minute, or two, V Tach is obviously not a lights and sirens emergency. Maybe we need a treatment that works.

Over 60% of the patients were cardioverted, for which they should receive a sedative that does not produce/worsen hypotension. We might as well start acknowledging that our anecdotes often do not match reality.

When the patient is awake and alert with a systolic blood pressure of 70, should we give a vasodilator, such as midazolam, or should we give a drug that does not decrease cardiac output, such as ketamine?

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Image credit.

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Amiodarone works just as well as Ketamine for sedation, Versed or Ativan work better for excited delirium.

Amiodarone can produce hypotension, arrhythmias, and cardiac arrest, but that is not the kind of sedation I want. Was this a typo?

Since you do not appear to have listened to any of the EMCrit podcasts I linked to, here is another opportunity to learn. Dr. Weingart describes the lack of effectiveness of benzodiazepines (midazolam [Versed], lorazepam [Ativan], and diazepam [Valium]). He does not discourage their use to minimize emergence reactions, but he does not suggest that they are appropriate as sole treatments for excited delirium, unless that is all you have available.[4]

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Fentanyl probably works better for pain management, especially cardiac related pain.

Which is great – if the patient does not require doses that produce respiratory depression, or if the only pain we treat is cardiac pain. Let me quote from the anonymous comment that you followed, but do not appear have read.

It facilitates extrication of critical patients who are still awake and who often have compound fractures. Given the choice of struggling to hold a combative head patient down while trying to get them in a c-collar and a backboard vs. IM Ketamine and a cooperative patient within a minute or two, Ill take the latter. It’s a beautiful thing when used responsibly. It certainly is safer than trying to sedate and paralyze a hypoxic patient.

If we want to be very limited in our options, then we should not ask for ketamine from our medical directors.

If we do not like using safe drugs, then we should not ask for ketamine from our medical directors.

I am stating that we should ask for ketamine from our medical directors. Our patients deserve it.

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I’m not following the last part of you post, because you haven’t set the circumstances requiring Ketamine and a NRB.

I linked to the EMCrit podcast covering DSI (Delayed Sequence Intubation). I think that podcast more than adequately describes the circumstances in under 20 minutes.[5]

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Ketamine might be an all in one wonder drug, but why do we need an all in one wonder drug when we can have a selection of wonder drugs?

No drug is a wonder drug.

Ketamine does a lot of things very well – better than the usual EMS drugs. We should not allow our lack of familiarity to discourage us from using this drug that is used frequently, safely, and effectively all over the world.

At Free Emergency Medicine Talks you should listen to Mel Herbert – Updates on Ketamine. Unfortunately, the video is not included, but the information is still very clear and very thorough.

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Ketamine is recommended for use in the patient whose stomach is not empty when, in the judgment of the practitioner, the benefits of the drug outweigh the possible risks.[6]

You may only treat patients who have been fasting, but I end up with patients with full bellies. I would prefer better ways to keep the stomach contents out of the lungs.

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Ketamine has a wide margin of safety; several instances of unintentional administration of overdoses of ketamine (up to ten times that usually required) have been followed by prolonged but complete recovery.[6]

Is any other sedative that safe?

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Footnotes:

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[1] Amiodarone is poorly effective for the acute termination of ventricular tachycardia.
Marill KA, deSouza IS, Nishijima DK, Stair TO, Setnik GS, Ruskin JN.
Ann Emerg Med. 2006 Mar;47(3):217-24. Epub 2005 Nov 21.
PMID: 16492484 [PubMed – indexed for MEDLINE]

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[2] Amiodarone or procainamide for the termination of sustained stable ventricular tachycardia: an historical multicenter comparison.
Marill KA, deSouza IS, Nishijima DK, Senecal EL, Setnik GS, Stair TO, Ruskin JN, Ellinor PT.
Acad Emerg Med. 2010 Mar;17(3):297-306.
PMID: 20370763 [PubMed – indexed for MEDLINE]

Free Full Text from Academic Emergency Medicine.

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[3] Intravenous amiodarone for the pharmacological termination of haemodynamically-tolerated sustained ventricular tachycardia: is bolus dose amiodarone an appropriate first-line treatment?
Tomlinson DR, Cherian P, Betts TR, Bashir Y.
Emerg Med J. 2008 Jan;25(1):15-8.
PMID: 18156531 [PubMed – indexed for MEDLINE]

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[4] On Human Bondage and the Art of the Chemical Takedown
EMCrit
November 13, 2011
Page with podcast and supplemental information

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[5] Delayed Sequence Intubation (DSI)
EMCrit
January 31, 2011
Page with podcast and supplemental information

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[6] Ketamine Hydrochloride (ketamine hydrochloride) Injection, Solution, Concentrate
[Bedford Laboratories]
FDA Label
DailyMed
Label

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Filed Under: Airway Management, Cardioversion, EMCrit, Excited Delirium, Heresy, Intubation, Ketamine, Pharmacology, Research, Sedation

What I Wanted from EMS Santa But Did Not Get

Sun, 25 Dec 2011 06:30:20 -0500 by
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Yesterday, I mentioned a bunch of things that are good, but not at the top of my list. This is what I really wanted. Maybe during my shift last night, when I heard hoof beats on the roof, I shouldn’t have thought of horse or zebras.

There is one change to my protocols that probably would not be used often, but when used would more than make up for the lack of use.

What did this rogue want?

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Ketamine.

Is it safe?

Ketamine is safe.

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Is it effective?

Ketamine is effective – for many different conditions.

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Image credit.

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Excited delirium – IM (IntraMuscular) injection that works in a few minutes and is predictable in absorption.[1]

Airway management – IM or IV and the patient will not fight with a cannula or mask. Also can be used for intubation, although a paralytic would be best to go with it. The stomach contents should remain in the stomach – and we should assume that the stomach is full of chili and beer. Paralytics keep the stomach contents from migrating.[2]

Cardioversion – since we do not carry any effective antiarrhythmics (we have amiodarone and lidocaine – they are about as effective as placebo), we should be sedating patients in preparation for elective cardioversion in the ED, with the ability to emergently cardiovert them if they suddenly deteriorate. Ketamine is less likely than other sedatives to drop the cardiac output.[3]

Pain management – Ketamine alone is used for surgery in some places without complications and without complaints of being awake and feeling the surgery. Ketamine allows the patient to maintain airway reflexes.

DSI – Another abbreviation? RSI, DFI, CFI, and now DSI? Yes. DSI (Delayed Sequence Intubation). The best airway is the one maintained by the patient with intact airway reflexes. Ketamine can allow that to happen.[2]

Imagine the patient who has a neck so short that it seems his head is being sucked into his torso, but he is breathing on his own. We could knock him down and play around with his oropharynx until he has more lunch in his lungs than oxygen, but that would not be good airway management. We could use ketamine and oxygen by mask (maybe with 15 LPM oxygen by cannula in addition to the mask) and transport him to someplace where intubation (if necessary) can be done in a more controlled environment. And when the emergency physician grabs for the video laryngoscope, that is an admission that the right decision was made.

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I know. I am crazy to think that anyone would let EMS do this.

In some places, EMS is already doing this. Safely and effectively.

Maybe I am not so crazy, but I still do not have ketamine to help my patients.

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Footnotes:

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[1] On Human Bondage and the Art of the Chemical Takedown
EMCrit
November 13, 2011
Page with podcast and supplemental information

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[2] Delayed Sequence Intubation (DSI)
EMCrit
January 31, 2011
Page with podcast and supplemental information

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[3] Procedural Sedation – Part I
EMCrit
July 26, 2010
Page with podcast and supplemental information

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Filed Under: Airway Management, EMCrit, Excited Delirium, Heresy, Intubation, Ketamine, Research, Risk Management, Sedation

On Human Bondage and the Art of the Chemical Takedown

Tue, 13 Dec 2011 06:30:30 -0500 by
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For a great podcast on excited delirium listen to the EMCrit podcast on this topic.[1] And read the comments.

Some of Dr. Weingart’s points –

This is not the management of the already medicated patient. At least these patients are generally not taking psychiatric medications.

Martial arts joint locks do not work. He also says that using the patient’s weight against him/her does not work. I think he means throws and other similar moves. Leverage is extremely important for controlling the patient and the patient’s extremities. Using the patient’s weight and momentum against the patient for the purpose of getting a limb into a position where the patient has as little ability to move as possible is part of the goal.

I like to control the head. As Dr. Weingart points out, bites are a problem. I disagree about gloves. They will not offer much protection. Do not expect thick gloves to prevent the patient from biting off a finger, or crushing a finger. The palm of the hand should go against the side of the zygomatic bone (cheek bone) pushing down with the palm of my hand, but curling my fingers back. Do not let up pressure. The best way to control the body is to control the head. If I let up, I make it much more likely that someone will get hurt.

Dr. Weingart likes to just get into a large muscle quickly inject a droperidol and midazolam mixture (probably more than you are comfortable with, but how comfortable are you with wrestling?), and quickly remove the needle and get out of the way. Here is the kind of approach I expect from Dr. Weingart.

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Picture credit. Here’s droperidol!

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Two important warnings.

1. Do not hog tie patients. This video should make it clear how quickly things can go bad when we hog tie people.

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2. Do not give oxygen. This is a topic for a whole series of posts, but listen to him. These patients are hyperventilating, so they should be oxygenating well. Rather than oxygen, use waveform capnography to assess the quality of ventilation.

And read the comments. There is a great dialogue among the doctors there.

One important part of one comment is this from Dr. Minh Le Cong –

Common mistakes are usually underdosing the patient with an ineffective agent and this risks subsequent overdosing the patient with repeated doses.

This is the biggest problem I see with EMS sedation of excited delirium – not enough of the wrong drugs. Even if we give enough, without ketamine or droperidol, we are using the wrong drugs. The extreme of this is to not have any standing orders for sedation of excited delirium – how much more not enough of the wrong drug can we get than when we Just say No.

Go listen to the podcast and read the comments.

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See also –

Excited Delirium: Episode 72 EMS EduCast

Capnography Use Saves Lives AND Money – Part V

Droperidol, QT prolongation, and sudden death – what is the evidence – Part I

Or just click on the Excited Delirium category.

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Footnotes:

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[1] Podcast 060 – On Human Bondage and the Art of the Chemical Takedown
by EMCRIT
November 13, 2011
Podcast and page with research links

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Filed Under: EMCrit, Excited Delirium, Heresy, Ketamine, Pharmacology
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