Random pt care related questions

[sanchito45]

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Hey guys - a couple random questions for you guys:

1 - Do you ever call a code when the rhythm is vfib or pea or do you HAVE to wait for it to become asystole?

2 - If you've just intubated a patient and they're hypotensive obviously you want to be careful with starting propofol or fentanyl/versed. What do you use for post intubation sedation in that case? Big dose of pavulon?

3 - When, if ever, do you give roc/vecuronium instead of succinylcholine?

 

[Apollyon]

Hey guys - a couple random questions for you guys:

1 - Do you ever call a code when the rhythm is vfib or pea or do you HAVE to wait for it to become asystole?

2 - If you've just intubated a patient and they're hypotensive obviously you want to be careful with starting propofol or fentanyl/versed. What do you use for post intubation sedation in that case? Big dose of pavulon?

3 - When, if ever, do you give roc/vecuronium instead of succinylcholine?

Hmm...Sanchito, you ask some good questions, but, at the same time, the questions you ask should be ones to which you know the answer, too.

Anyways, I'll bite on 2 and 3. If you give a paralytic only, without a sedative, you are sadistically torturing that patient, and are committing malpractice, and might get sued, and WILL lose.

3. People with head bleeds and dialysis patients, and anyone else that is hyper K+ or has a tendency to bleed. Also, if (like I would know) the patient is one of those slow metabolizers of sux.

 

[sanchito45]

I know that you can't just give a dose of pavulon and call it a day. What I'm asking is do you ever give a big dose (ie like 10mg of pavulon) to hold them over until their pressure recovers. Tintinalli claims pavulon can cause hypotension but in my albeit limited experience has not.

Also, I know the contraindications for succ. What I'm asking is if one of those conditions don't exist (ie hyperk, burn/crush injuries) would you ever pick roc/vec over succ?

And why not bite on number 1? It's a legit question.

 

[annie5644]

#1 - if the patient is pulseless, call a code. i don't care what the monitor is doing. pulseless = coding. period.

 

[leviathan]

Hey guys - a couple random questions for you guys:

1 - Do you ever call a code when the rhythm is vfib or pea or do you HAVE to wait for it to become asystole?

I've seen lots of codes ended with an organized rhythm on the monitor. Kinda shocked me at first, but when they've been in arrest for 30 minutes, does it matter what's on the monitor at that point?

 

[deleted109597]

#1 - if the patient is pulseless, call a code. i don't care what the monitor is doing. pulseless = coding. period.

He's asking if you can end the code, not if you're going to hit the code button.

 

[deleted65604]

There is good evidence to support stopping code immediately if no cardiac activity on US, rather than flagging them with epi for 3 rounds. PEA is just as bad as asystole.

 

[DoctorMedic]

a lot of docs turn the monitor off after calling codes so if they do pop a PEA or something it doesnt make for a fun night of writing the chart...hehe

 

[Apollyon]

I know that you can't just give a dose of pavulon and call it a day. What I'm asking is do you ever give a big dose (ie like 10mg of pavulon) to hold them over until their pressure recovers. Tintinalli claims pavulon can cause hypotension but in my albeit limited experience has not.

Also, I know the contraindications for succ. What I'm asking is if one of those conditions don't exist (ie hyperk, burn/crush injuries) would you ever pick roc/vec over succ?

And why not bite on number 1? It's a legit question.

You said use pancuronium for sedation - look at your post.

And you asked when you use a nondepolarizer instead of sux.

In other words, you need to be MUCH clearer. I answered the questions you asked.

 

[NateintheED]

Agree that the original post needed to be clearer, however....

#2: If you want a SEDATIVE (versus a muscle relaxer/paralytic) to use when you're concerned about worsening hypotension, don't count out Ketamine. Yes, you can actually put someone on a ketamine drip. That being said, you still better be going after the cause of the hypotension.

#3: Roc/Vec instead of succ WITHOUT succ contraindications? Well, if its the first paralytic the nurse/pharmacist/whoever pushes meds can grab, and they need a tube NOW, then that's what I'll use.

 

[WilcoWorld]

1 - Yes, I will end a code on a patient who has persisting electrical activity without cardiac output. I'm likely to try a few more things first, but I will still call it - and then I make sure to turn off the monitor.

2- If the patient was totally obtunded prior to intubation, then I'm in less of a hurry to sedate, but it should always be at the front of your mind for a paralyzed patient, and as soon as you can sedate, you should. Start with low dose and/or short acting meds if you're worried. In the absence of contraindications ketamine is a good thought.

3- In residency it was sux, sux, sux - where I work now it's almost always roc. The reason for change is threefold: a) It's the "culture" where I'm working, and I like to keep my staff in their comfort zone during codes. b) Roc's onset is plenty fast, and I don't worry much about the longer duration of action*. Let's say we can't get the tube right away - once it wears off I'm still left with a patient who requires emergent intubation, so I think it's far more important to enter into RSI with back-ups for your back-up airways rather than to count on the patient being able to breathe on his own again a few minutes sooner. c) Sux has more contraindications than roc, so you don't have to think as much about giving roc, and I like to minimize the number of things I have to think about during codes. I prefer to save my pondering for back-porch epistemology.

*It's not like sux works like adenosine in that even if it has untoward effects they're only momentary. Being unable to ventilate a patient for sux's 5-10 min duration of action is a big deal, and not much different then roc's 15 min. It's not like we give the sux, fail the tube and think, "Oh well, he'll only be unventilated for 10 minutes".

 

[BADMD]

... Big dose of pavulon?

What others have said.

Also, keep in mind that pancuronium is steroid based and may have some of the same problems as etomidate. It is also has a greater association with prolonged muscle weakness.

Cis-atricurium, although more expensive, is probably a better choice. There is no need to give a big or a small dose. You give the right dose to get the effect. A small, therapeutic dose, will induce paralysis as well as a big dose.

As for actual sedation, you can certainly use benzo/opiate combos. You just have to be judicious and titrate to effect.

 

[Arch Guillotti]

Being unable to ventilate a patient for sux's 5-10 min duration of action is a big deal, and not much different then roc's 15 min. It's not like we give the sux, fail the tube and think, "Oh well, he'll only be unventilated for 10 minutes".

What dose of roc are you giving that wears off in 15 minutes?

 

[WilcoWorld]

You may have caught me with my emperical pants down. According to what I've read 0.45 mg/kg lasts 15-20 minutes, 1mg/kg lasts about 30 minutes - but this is only according to what I've read. To be completely honest, I've never sat there with a nerve stimulator to test this - given that you usually post in the Anesthesia forum, I suspect you may have.

However my main point is that I don't think waiting around for sux to wear off is an acceptable back-up plan. Because a) it's still too long of a time to go without ventilation b) at the end of either paralytics' duration of action I'm still left with a patient who needs an airway.

 

[ERNerd]

#1: I would not wait for the patient to become asystolic to end the code. Many things factor into the decision such as how long the patient has been down, what's been tried so far, US findings, likely etiology of arrest, etc. In general, I think we tend to code patients longer than is necessary.

#2: Paralysis without sedation is cruel. Most patients do not require paralysis post-intubation, but some sedation is a good thing regardless. As noted above, ketamine and treating underlying causes of hypotension are both good ideas for hypotensive patients. Consider adjusting your vent settings, too.

#3: I use sux unless absolutely contraindicated. Contrary to popular opinion, hyperkalemia and renal failure are NOT absolute contraindications. Neither is head injury (but pre-treatment with lidocaine and fentanyl is a good idea). I hold sux for burns > 5 days old, crush injury > 5 days ago, spinal cord injury > 5 days ago, or neuromuscular disease.

 

[Arch Guillotti]

You may have caught me with my emperical pants down. According to what I've read 0.45 mg/kg lasts 15-20 minutes, 1mg/kg lasts about 30 minutes - but this is only according to what I've read. To be completely honest, I've never sat there with a nerve stimulator to test this - given that you usually post in the Anesthesia forum, I suspect you may have.

However my main point is that I don't think waiting around for sux to wear off is an acceptable back-up plan. Because a) it's still too long of a time to go without ventilation b) at the end of either paralytics' duration of action I'm still left with a patient who needs an airway.

Our "normal" dose of roc for intubating in the OR is .6 mg/kg. RSI dose is 1.2 mg/kg. The reality for me is that unless it is going to be a short procedure I squirt the whole 50 in immediately after I give the induction agent because that is what is in the syringe I have in my hand. With some of the lower doses (20-30 mg), you may not lose your twitches at all. Our interpretation of twitches is notoriously unreliable so they aren't the end all be all.

We have had some pretty good debates in the anesthesiology forum about sux and when to give it (and when not to) usually in the context of an emergent tube on the floor or ICU when your help is limited. Some give it all the time, some give it rarely.

One idea is just to give a touch (20-40 mg) that will wear off quickly. Waiting around for a normal induction dose to wear off in the case of a can't ventilate/intubate scenario is a recipe for a dead pt - although one time I have gone to sleep once with prop/sux and been unable to intubate and had extreme difficulty ventilating. We woke up and went to plan B but I guess this isn't really an option in the ED.

Also, I am unclear on the risk with sux in someone with a tendency to bleed.

 

[bigtuna]

1 - Yes, I will end a code on a patient who has persisting electrical activity without cardiac output. I'm likely to try a few more things first, but I will still call it - and then I make sure to turn off the monitor.

2- If the patient was totally obtunded prior to intubation, then I'm in less of a hurry to sedate, but it should always be at the front of your mind for a paralyzed patient, and as soon as you can sedate, you should. Start with low dose and/or short acting meds if you're worried. In the absence of contraindications ketamine is a good thought.

3- In residency it was sux, sux, sux - where I work now it's almost always roc. The reason for change is threefold: a) It's the "culture" where I'm working, and I like to keep my staff in their comfort zone during codes. b) Roc's onset is plenty fast, and I don't worry much about the longer duration of action*. Let's say we can't get the tube right away - once it wears off I'm still left with a patient who requires emergent intubation, so I think it's far more important to enter into RSI with back-ups for your back-up airways rather than to count on the patient being able to breathe on his own again a few minutes sooner. c) Sux has more contraindications than roc, so you don't have to think as much about giving roc, and I like to minimize the number of things I have to think about during codes. I prefer to save my pondering for back-porch epistemology.

*It's not like sux works like adenosine in that even if it has untoward effects they're only momentary. Being unable to ventilate a patient for sux's 5-10 min duration of action is a big deal, and not much different then roc's 15 min. It's not like we give the sux, fail the tube and think, "Oh well, he'll only be unventilated for 10 minutes".

I think you probably were referring to emergent intubations but just to clarify...no paralytics needed during a true "code"

 

[Dimoak]

Also, I am unclear on the risk with sux in someone with a tendency to bleed.

I am far from an expert, but I believe it's because bleeders have a much higher likelihood of getting hyperkalemic.

 

[njac]

3- In residency it was sux, sux, sux - where I work now it's almost always roc. The reason for change is threefold: a) It's the "culture" where I'm working, and I like to keep my staff in their comfort zone during codes. b)

I didn't realize how much this is true until I started my (pharmacy) residency.

I worked for 3 years at the place where WW is, as well as did rotations in the ED and MICU. Going across the country as been eye opening as far as having to learn a completely different set of drugs as preferred agents. I haven't seen much here yet, but Vec is their #1 here, and with the Vec shortage they're using Pancuronium. I believe the RSI kits where WW are have all 3 succ, roc, and vec in them, so it does come down to physician preference.

 

[crewmaster1]

Of course you can call codes with patient's in PEA or even VF. You're just wasting your time, energy, resources, and all if you continue to flog a code that is not responsive to the appropriate interventions. No I'm not saying to do CPR for 2 minutes, shock them, give them and epi and walk away! But really, you can have shock resistant and medication resistant VF. If you've been coding for 20-30 minutes with multiple attempts at defibrillation, after good CPR and ventilations, and have given the appropriate meds and then patient doesn't resuscitate, there is no benefit to working the thing until they are asystolic. Consider the Hs and Ts and treat accordingly before you stop. I don't think you will often see a patient in VF last that long in VF, but I've seen PEA go on for a long, long time and not deteriorate into asystole.

 

[docB]

I rarely see VF persist through Amio 300 bolus then gtt then addl 150 bolus. At that point they usually either resolve or go asystolic.

Some of the most interesting codes I've had recently are the ones where the patient has VT that is pulsatile but then keeps degenerating to non-pulsatile. So you shock them and they go to asystole followed by CPR for 2 minutes then they're back in pulsatile VT. The interesting part is that pulsatile VT is better than nothing but since it keeps degenerating you feel obligated to treat it with amio even though you know that if you quiet down the VT you're probably going to be left with nothing.

 

[Jeff698]

As with others, I'll call a code while still in VF but I have to have worked them for much longer vs asystole where it doesn't take much for me to call it.

I think everyone has pretty well covered the paralysis w/o sedation aspect of this question. I'll add that I will use fentanyl & versed in pt's with borderline BPs. I also echo the suggestion of ketamine.

Finally, a big question is where they hypotensive before intubation? If not, step one is to take them off the blower and confirm tube placement. If it's in place, ask yourself if you've increased your inter-thoracic pressure with your ventilations and dropped your preload unknowingly. This is not at all uncommon with patients who have COPD/Asthma/ARDS.

Finally, as for never needing paralytics to intubate during a code, not quite. While I'll grand you it doesn't happen often, it did to me a couple of months ago. We had a guy who arrested as EMS was bringing him in the door with a STEMI. CPR started immediately. We went with just compressions for a bit while we moved him over, confirmed rhythm, shocked, etc. My resident was unable to get his mouth open w/o paralytics. Once they were push, he got the tube easily. Apparently, the compressions were working well enough. It was odd.

Take care,
Jeff