versed

[pmdc222]

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Does anyone else here think Versed is basically useless on the truck in most cases? My system does not have RSI or Etomidate. In our narc box: Morphine, Versed, Valium.

For cardioversion: If I'm cardioverting someone, the patient is usually too unstable for the Versed in the first place. Or it kicks in afterwards.

For intubation: Versed on its own...doesn't really do anything. It just doesn't really knock people down enough to make a difference.

I know some people give both morphine and versed and that it tends to work a little better for intubation.

Thoughts?

 

[146233]

I'd have to agree. At work, we have rigs in two different EMS systems. One doesn't let us sedate anyone at all, and, until recently, the other let us use conscious sedation with versed. (4mg initial IVP, then 2mg increments until adequate sedation achieved.) I found that with most patients, the 4mg (and even 6-8mg) didn't really do a whole lot in terms of sedation/loss of gag reflex.

I think the system must have recognized as much, since the 2007 SMO revision added etomidate (0.3mg/kg with a repeat dose if necessary) as the first-line drug for sedation. I feel etomidate as an induction agent works must better/faster than versed. I've read elsewhere that 10mg dose is sometimes used as premedication for cardioversion; at the moment, we're stuck with versed. (And we seldom have time to give it and let it kick in before having to zap.)

 

[TerraMedicX]

I would have to disagree. I think versed is a very useful medication. First, you must remember that versed has RETROGRADE amnesiac properties. This means that if you cardiovert someone and administer the versed within 10-20 min afterward, you can generally make them forget that they were ever cardioverted. Ofcourse, different people always seem to react to medications differently, but I have had very good success with this! I also use versed as my prefered sedative after preforming RSI (since you should not be rebolusing etomidate more than once due to its side effects on the endocrine system). My favorite use for versed, however, is as a general use chemical restraint. I'm lucky enough that our protocols allow us to use versed on standing order as a chemical restraint in violent patients. This means no waiting 15-30 minutes for haldol to kick in!! Plus there is no gray-area about giving versed IV (technically, haldol is only approved for IM administration). Finally, I have found one or two occasions where I could not get a Sz to break with valium, but for some reason versed worked great. I'm also looking forward to having nasal-atomized versed as an option for seizures in the future.


Nate.

 

[jwk]

First, you must remember that versed has RETROGRADE amnesiac properties. This means that if you cardiovert someone and administer the versed within 10-20 min afterward, you can generally make them forget that they were ever cardioverted.

Versed is used as a sedative. Using it 20 minutes later simply for it's amnestic properties is not a valid indication.

My favorite use for versed, however, is as a general use chemical restraint. I'm lucky enough that our protocols allow us to use versed on standing order as a chemical restraint in violent patients. This means no waiting 15-30 minutes for haldol to kick in!!
Nate.

I hope your use in this area is fairly limited. Compounding your problems with a respiratory arrest doesn't help the situation.

 

[viostorm]

Versed is great because you can give it IM if you can't get a line in a seizure patient.

I second TerraMedic's vote for use as amnestic. Regardless of the science, anecdotally I can say it has worked that way for me in the past with cardioversion.

 

[viostorm]

I also use versed as my prefered sedative after preforming RSI (since you should not be rebolusing etomidate more than once due to its side effects on the endocrine system).

I think there are better benzodiazepines for long term sedation, but we do the same thing here with the versed after RSI

 

[fiznat]

As others have said, Versed is good for IM administration with active seizures. Both Versed and Ativan can be given IM, but I understand that Versed has a faster uptake/onset IM compared to Ativan.

We also use it post-intubation to keep patients from bucking tubes. My experience is that the drug works very well for this purpose.

 

[pmdc222]

interesting responses...I guess I can't comment on using Versed for seizures because that is not in our protocol. We just use Valium, which I've always had success with.

We are also not doing chemical restraint. What state do you live in where you are allowed to do this - as well as push versed for it?

While I commented that I have not had success using it to facilitate intubation, I will agree that it is adequate to keep patients from bucking the tube after other sedation. No RSI here but we use versed for this case on interfacility transfers. Works ok. Haven't had a lot of luck just using versed to ease an intubation in the field. Thats our only option.

I guess its usefulness comes down to the system you work in and how you are allowed to use the drug.

Now -
Using Versed 10-20 minutes AFTER a procedure for retrograde effects? I would question this usage. I doubt this is written into the protocols in any state.

 

[146233]

We are also not doing chemical restraint. What state do you live in where you are allowed to do this - as well as push versed for it?

We (Chicago) also use it as a chemical restraint. Our SMO's call for 10mg IM to calm an "unruly or inconsolable combative or violent patient". I haven't used it yet, but it's interesting...

 

[McPoyle]

we use it for all of the indications stated above, save for the retrograde amnesia... I use it frequently after RSI, with our shorter transport times I prefer not to use additional parlytics if I don't have to.
As far as seizures, we recently added the intra-nasal aerosolizers so that we can use that route now as well. I haven't had a chance to use this yet however.
We also use it in regards to agitation for various reasons. I've used to calm pt's prior to moving them in cases where adequate immobilization is for some reason not possible.
For agitation in regards to mental health problems, we use versed along with haldol.

 

[gotmeds?]

We (Chicago) also use it as a chemical restraint. Our SMO's call for 10mg IM to calm an "unruly or inconsolable combative or violent patient". I haven't used it yet, but it's interesting...

Trust me, it works like a charm. 10mg is a little heavy, though. I've had a lot of success with 5mg IM. Do you guys carry Romazicon?

 

[viostorm]

interesting responses...I guess I can't comment on using Versed for seizures because that is not in our protocol. We just use Valium, which I've always had success with.

Valium IS good for seizures, but no IM route which is why versed is good.

I've pretty much gone to giving ativan on the ambulance for all seizures that I can get an IV on. It seems to work better but maybe it is just my imagination.

 

[viostorm]

Trust me, it works like a charm. 10mg is a little heavy, though. I've had a lot of success with 5mg IM. Do you guys carry Romazicon?

I'm with gotmeds, 5mg is usually PLENTY to make people snore.

No romazicon here, just an ETT if oversedated. 😀

 

[pmdc222]

Valium IS good for seizures, but no IM route which is why versed is good.

I've pretty much gone to giving ativan on the ambulance for all seizures that I can get an IV on. It seems to work better but maybe it is just my imagination.

Yeah, I believe we are getting Ativan soon for seizures. I'd be interested to see the difference.

The nasal atomizer is an interesting addition for seizures and I had never heard of that. I'd love to hear if people have success with it. We have the nasal atomizer already for Narcan and it works pretty well. My partner spend the entire shift the other day shooting saline up his nose...easily amused I suppose.

 

[146233]

As far as seizures, we recently added the intra-nasal aerosolizers so that we can use that route now as well. I haven't had a chance to use this yet however.

I hate the atomizer. For us, it's about as useful as a turd in the punch bowl. 😎

Trust me, it works like a charm. 10mg is a little heavy, though. I've had a lot of success with 5mg IM. Do you guys carry Romazicon?

I always thought 10 was going to be a bit of an excessive blow. No Romazicon here; how does that work for you?

Valium IS good for seizures, but no IM route which is why versed is good.

Chicago EMS has an IM route for Valium -- adults get 5-12mg in the absence of an IV.

 

[docB]

Romazicon (flumazinil) is bad news. It's like narcan for benzos but unlike narcan which goes away quick and you can overpower with big doses of narcotics it bumps the benzos off the GABA receptor and then stays there. If you give it to someone who is an alcoholic or uses benzos chronically you will precipitate withdrawals and seizures. These can not be treated with benzos because you already blocked the GABA receptor.

 

[viostorm]

Romazicon (flumazinil) is bad news. It's like narcan for benzos but unlike narcan which goes away quick and you can overpower with big doses of narcotics it bumps the benzos off the GABA receptor and then stays there. If you give it to someone who is an alcoholic or uses benzos chronically you will precipitate withdrawals and seizures. These can not be treated with benzos because you already blocked the GABA receptor.

I've heard that about Romazicon, but I've never met anyone who actually precipitated a withdrawal.

Wiki says onset of IM valium is 15-30 minutes.

----------

Found this here which seems to compare the two (midazolam vs diazepam):

http://www.wolfetory.com/education/Intranasal_Midazolam_for_Seizures_050102_unlinked.htm



Diazepam (Valium) is the most widely used drug for the emergent management of seizures in both adults and children.[7] Diazepam must be given intravenously or rectally since absorption is slow and erratic if given via the intramuscular route.[8-11] Though intravenous diazepam is fairly effective, it is not as effective as midazolam (Versed), thiopental, or pentobarbital.[2]. In addition, due to the difficulties of establishing an IV in a seizing patient administration of medications intravenous may result in delayed seizure control, especially in children.[12-14] Rectal diazepam offers an alternate method of delivery,[6, 15, 16] but has a much lower peak concentration, a slower onset of action, and due to patent protection the commercially available rectal diazepam product is considerably more expensive than generic intravenous diazepam or midazolam.[17, 18] In addition, rectal drug administration is less socially acceptable than other routes.[3] Intramuscular therapy with midazolam is a reasonable alternative and is as effective as IV diazepam[12] though not quite as effective as IV midazolam.[19]

 

[proman]

I would have to disagree. I think versed is a very useful medication. First, you must remember that versed has RETROGRADE amnesiac properties. This means that if you cardiovert someone and administer the versed within 10-20 min afterward, you can generally make them forget that they were ever cardioverted. .


Nate.

I agree with what JWK said. This is not supported by the literature. Midazolam only has reliable amnesia once nystagmus is present, and then for only about 20-30 minutes. There are rare case reports of transient retrograde amnesia but the reason the patients don't remember is likely due to cerebral hypoperfusion.

Midazolam is unique among the benzos in that its lipophilicity changes based on pH. At the packaged pH it is highly water soluble and rapidly absorbed from an IM injection. At physiologic pH a structural change occurs and midazolam becomes lipophilic, crossing the blood brain barrier. I think it's an ideal antiepileptic in the absence of an IV, and there's some evidence to support it. I don't think lorazepam nor diazepam belong in the field. Instead of trashing midazolam, toss the diazepam. For what it's worth, haloperidol is a more appropriate and safe pharmacologic restraint.

 

[McPoyle]

haha a turd in a punch bowl... I like that, I haven't had a chance to use it and judge for myself, i have heard good things about the atomizer though, what problems have you seen with it?
As far as dosage, we use 5mg for sedation of agitated pt's. However there is flexability there... our MD has now been telling us to use it in order to facilitate CPAP if the pt. is having trouble tolerating it (increasing anxiety) I don't personally feel very comfortable with this use yet, just seems that the risk of respiratory depression is too high..

 

[jwk]

As far as dosage, we use 5mg for sedation of agitated pt's. However there is flexability there... our MD has now been telling us to use it in order to facilitate CPAP if the pt. is having trouble tolerating it (increasing anxiety) I don't personally feel very comfortable with this use yet, just seems that the risk of respiratory depression is too high..

Hypoxic patients tend to get higher anxiety levels and even become combative as they start gasping for air. Even a couple minutes of high FiO2 with CPAP should help a lot. I'd be extremely cautious about sedating a patient that's already in respiratory distress.

 

[McPoyle]

Hypoxic patients tend to get higher anxiety levels and even become combative as they start gasping for air. Even a couple minutes of high FiO2 with CPAP should help a lot. I'd be extremely cautious about sedating a patient that's already in respiratory distress.

Thats exactly my thinking, I've personally never used it in this case and really don't feel comfortable doing so. The guidelines actually direct us to distinguish between general anxiety and hypoxia induced anxiety.... however in this population I don't see myself being able to do so with adequate confidence.

 

[greytmedic]

I miss the good ole' days of rectal valium. Nothing like shoving some meds up the butt and then getting a green EMT-B to hold the cheeks together

 

[146233]

We still use revyal valium if the pt has a script for diastat... I once got on the phone with med control to give a report and told them I'd given 4mg "by ass". They never did stop laughing long enough for me to finish the report. 🙂

 

[MavsFan08]

Does anyone else here think Versed is basically useless on the truck in most cases? My system does not have RSI or Etomidate. In our narc box: Morphine, Versed, Valium.

For cardioversion: If I'm cardioverting someone, the patient is usually too unstable for the Versed in the first place. Or it kicks in afterwards.

For intubation: Versed on its own...doesn't really do anything. It just doesn't really knock people down enough to make a difference.

I know some people give both morphine and versed and that it tends to work a little better for intubation.

Thoughts?

Versed can be used for RSI if enough is given. Valium does not cause amnesia like Valium does.

Versed can be used for any invasive or traumatic procedures so the patient will not remember, if the patient qualifies.

 

[canjosh]

Versed can be used for RSI if enough is given. Valium does not cause amnesia like Valium does.

Versed should be use for any invasive or traumatic procedures so the patient will not remember.

Valium does not cause amnesia like Valium? Are you ON Valium!? 😀

Versed should NOT be used for 'any invasive or traumatic procedures'! It should only be used when NECESSARY. A PIV is an invasive procedure; so is an i/o cath. Should these patients get Versed? Hell no. Benzos should be carried by EMS, but should only be used when the benefits decidedly outweigh the risks. The benefit/risk question is especially important when you are giving a drug which can depress respirations.

 

[MavsFan08]

Valium does not cause amnesia like Valium? Are you ON Valium!? 😀

Versed should NOT be used for 'any invasive or traumatic procedures'! It should only be used when NECESSARY. A PIV is an invasive procedure; so is an i/o cath. Should these patients get Versed? Hell no. Benzos should be carried by EMS, but should only be used when the benefits decidedly outweigh the risks. The benefit/risk question is especially important when you are giving a drug which can depress respirations.

Versed is more anmestic than Valium. This is why it is exclusively used by all anesthesiologists for pre-op.

-main advantage: WATER SOLUBILITY
--diazepam (Valium) is not--burns on injection, frequently precipitates in IV fluids
--midazolam (Versed) can be mixed with other preop medications and can be administered through IV fluids
-amnesia possible through and after procedure

http://www.animatingapothecary.com/dh5.htm

 

[jwk]

Versed is more anmestic than Valium. This is why it is exclusively used by all anesthesiologists for pre-op.

-main advantage: WATER SOLUBILITY
--diazepam (Valium) is not--burns on injection, frequently precipitates in IV fluids
--midazolam (Versed) can be mixed with other preop medications and can be administered through IV fluids
-amnesia possible through and after procedure

http://www.animatingapothecary.com/dh5.htm

Versed is used for it's sedating effects preoperatively, NOT because of it's amnestic properties. Is it used exclusively? No - some still use valium, but not many.

Intra-op some will use it for it's amnestic properties - some use valium for the same reason. Some will also give valium rather than versed for sedation during C-Sections with the idea that you don't get a retrograde amnesia with valium like you do with versed. Let mom see the baby, then sedate with valium. There is significant debate on whether versed truly has a retrograde amnestic effect - some believe it, some don't.

Valium is fine to give IV - used to do it all the time - until I switched to versed. 😉

 

[pmdc222]

Versed can be used for RSI if enough is given. Valium does not cause amnesia like Valium does.

Versed should be use for any invasive or traumatic procedures so the patient will not remember.

Yes, if you use enough versed it can act like RSI or you can use it as part of RSI, but we have restrictions on the ambulance. I have only a certain dosage range I can use and it is certainly not enough to "RSI" someone. I meant RSI in the sense of the full procedure with paralytics etc.

I understand the purpose of giving Versed. I disagree that versed should be used for ANY invasive or traumatic procedure. In theory should it be used for cardioversion because it is painful and traumatic? Of course. Is it always possible? Absolutely not. My last cardioversion was on a 45 year old male in SVT 10 out of 10 crushing chest pain, diaphoretic, in and out of consciousness, no radial pulses, and no audible blood pressure. Versed is not appropriate here. He didn't have the time or the blood pressure to get it. We just cardioverted him and he thanked us profusely later even after the pain. He understood that he would have died otherwise.

You always hope that you can give someone something to make them more comfortable, but it is just not always feasible. If that patient was stable, I could definitely have given it to him...but then again, I probably wouldn't have cardioverted him.

 

[MavsFan08]

Versed is used for it's sedating effects preoperatively, NOT because of it's amnestic properties. Is it used exclusively? No - some still use valium, but not many.

Intra-op some will use it for it's amnestic properties - some use valium for the same reason. Some will also give valium rather than versed for sedation during C-Sections with the idea that you don't get a retrograde amnesia with valium like you do with versed. Let mom see the baby, then sedate with valium. There is significant debate on whether versed truly has a retrograde amnestic effect - some believe it, some don't.

Valium is fine to give IV - used to do it all the time - until I switched to versed. 😉

I've never seen valium used on any of my rotations in anesthesia and surgery.

 

[MavsFan08]

Yes, if you use enough versed it can act like RSI or you can use it as part of RSI, but we have restrictions on the ambulance. I have only a certain dosage range I can use and it is certainly not enough to "RSI" someone. I meant RSI in the sense of the full procedure with paralytics etc.

I understand the purpose of giving Versed. I disagree that versed should be used for ANY invasive or traumatic procedure. In theory should it be used for cardioversion because it is painful and traumatic? Of course. Is it always possible? Absolutely not. My last cardioversion was on a 45 year old male in SVT 10 out of 10 crushing chest pain, diaphoretic, in and out of consciousness, no radial pulses, and no audible blood pressure. Versed is not appropriate here. He didn't have the time or the blood pressure to get it. We just cardioverted him and he thanked us profusely later even after the pain. He understood that he would have died otherwise.

You always hope that you can give someone something to make them more comfortable, but it is just not always feasible. If that patient was stable, I could definitely have given it to him...but then again, I probably wouldn't have cardioverted him.

You are arguing semantics here. I obviously didn't mean 100% of patients.

 

[pmdc222]

Ok, it just seemed that since you were quoting my statement about cardioversion, that's what you were referring to. I don't follow how it was a response then. Perhaps it was just a statement I guess.

 

[MavsFan08]

Ok, it just seemed that since you were quoting my statement about cardioversion, that's what you were referring to. I don't follow how it was a response then. Perhaps it was just a statement I guess.

We actually would use high-dose Versed for RSI in a crunch. I worked for a rural service with long transport times. We carried Valium, but used that typically for seizures.....

 

[fiznat]

I chemically restrained a 20 year old today. Fought with him for 15 minutes trying to do the whole "least invasive method" stuff first, but after he got free and lunged for my face I'd had enough. Our protocol is 5mg Haldol with 2mg Ativan, which we can combine in the same syringe and give IM. The freakin kid fought his restraints all the way to the hospital and then, as we're backing up into the bay, finally settled down and had a nice little nap. The triage nurses were making fun of us - looking all ragged and sweaty, and all for this peaceful little 20 year old, taking a cat-nap on the stretcher.

I wish the onset was faster. We still have to fight with these people all the way to the damn hospital. 👎


The nasal atomizers are great. I've never used it for Versed but I have with Narcan, and I gotta say it was pretty nice. No needles, no fuss. It worked pretty quick too.

 

[docB]

The nasal atomizers are great. I've never used it for Versed but I have with Narcan, and I gotta say it was pretty nice. No needles, no fuss. It worked pretty quick too.

Didn't the Russians use aerosolized benzo (Valium specifically) when they gassed everyone in a hostage crisis and accidentally killed everyone?
http://en.wikipedia.org/wiki/Moscow_theater_hostage_crisis

 

[psychbender]

Didn't the Russians use aerosolized benzo (Valium specifically) when they gassed everyone in a hostage crisis and accidentally killed everyone?
http://en.wikipedia.org/wiki/Moscow_theater_hostage_crisis

That was carfentanyl.

 

[canjosh]

That was carfentanyl.

Yes, I heard that the Russians had stockpiled some narcan to give to hostages...apparently they didn't have enough.

 

[12R34Y]

You should NOT be scared to give somebody 2-4mg of versed if they are hypotensive and needing cardioversion. Benzo's don't generally have any hemodynamic effects. they don't lower BP generally, they're very stable drugs. They do decrease your respiratory drive especially when given in conjuction with opiates.

You can give unstable vitals signs folks versed (2mg) for sure and not have any concern for their BP.

Fentanyl should also be given like candy in trauma and in medical situations even if your BP is low. Fentanyl at the doses we give generally doens't cause a decrease BP as well.

cArdiac anesthesia guys routinely give 1-3mg of fentanyl within minutes to induce general anesthesia and they never drop their BP's.

later

 

[jwk]

Fentanyl should also be given like candy in trauma and in medical situations even if your BP is low. Fentanyl at the doses we give generally doens't cause a decrease BP as well.

cArdiac anesthesia guys routinely give 1-3mg of fentanyl within minutes to induce general anesthesia and they never drop their BP's.

Don't give any drug like candy to anyone.

There's a big difference between experienced anesthesia providers or even EM residents giving drugs in a controlled situation and paramedics giving these same drugs in the field under less than ideal conditions.

 

[12R34Y]

Don't give any drug like candy to anyone.

There's a big difference between experienced anesthesia providers or even EM residents giving drugs in a controlled situation and paramedics giving these same drugs in the field under less than ideal conditions.

thanks dad.

I think my point was made. Of course you need a healthy respect for any drug you are giving to a patient, but i just heard some one on this board say they would not give versed or fentanyl to a patient they were going to cardiovert.

I understand that if they are so unstable that you don't have time to get a line on them then fine, but if you HAD a line you should give drugs....that's just mean.

 

[pmdc222]

thanks dad.

I think my point was made. Of course you need a healthy respect for any drug you are giving to a patient, but i just heard some one on this board say they would not give versed or fentanyl to a patient they were going to cardiovert.

I understand that if they are so unstable that you don't have time to get a line on them then fine, but if you HAD a line you should give drugs....that's just mean.

My story WAS about someone who was too unstable as you stated above. No time. I'm not cruel...if I can give Versed, I'm going to do it and I have. I was using the blood pressure as part of the picture not the whole picture. The versed/blood pressure debate is something I am happy to hear opinions about (because I'm not a doctor). But my point was about general instability and how sometimes its just not possible to give the drug. My first priority is my patient's well-being - I would never skip pain management if I didn't have to. But sometimes you have to weigh what is best for the patient, and in this particular instance it was to cardiovert immediately. I never said that I wouldn't give versed to a patient I was going to cardiovert if possible...this was merely an example of when it might not be possible. It was a response to another comment (someone used an absolute "all procedures" and I interpreted it as all instances -- later corrected that this is not how the person intended it).

My story was not intended to be interpreted as a general treatment method...

 

[jwk]

thanks dad.

I think my point was made. Of course you need a healthy respect for any drug you are giving to a patient, but i just heard some one on this board say they would not give versed or fentanyl to a patient they were going to cardiovert.

I understand that if they are so unstable that you don't have time to get a line on them then fine, but if you HAD a line you should give drugs....that's just mean.

No problem son.

My point was, and remains, that fentanyl (or any other drug for that matter)should not "be given like candy" to anyone. You imply that it's so safe that you can just give whatever amount you desire and not get in trouble, which is far from the truth.

 

[12R34Y]

No problem son.

My point was, and remains, that fentanyl (or any other drug for that matter)should not "be given like candy" to anyone. You imply that it's so safe that you can just give whatever amount you desire and not get in trouble, which is far from the truth.

thanks again dad.

I'm glad you were gracious enough to include physicians (ie EM residents) to give medication along with experienced anesthesisa providers.

what is it you do again?

later