Drug-assisted airway management

[Underwhelmed]

I stumbled on this while doing research for an updated TCCC presentation:

“The setting of the casualty care was at night in a non-permissive environment.The medic had sustained a sacral injury and damaged his NVG's during a hard landing on infil.The casualty had sustained a gunshot wound to the jaw.The medic was not called to the scene for ten minutes due to an ongoing firefight.The jaw was shattered and he had heavy maxillofacial bleeding.

The recovery position was attempted repeatedly, but the casualty refused to remain like that. Anxiolysis was attempted with Versed to facilitate maintaining the airway with position alone, but did not work.

The casualty became increasingly combative and the decision was made to perform the cric out of fear of completely losing the airway during evacuation.Due to the fact that the medic's NVGs were damaged, an operator (former 18D with two successful prior combat cric's) attempted the procedure with assistance by the medic.By then all landmarks had disappeared due to soft tissue swelling of the neck.Although complications resulted from the procedure, a definitive airway was established under extremely difficult conditions and the casualty lived...." http://www.medicalsci.com/files/03f_direct_from_the_battlefield.pdf

This got me curious as to what is available in the SOF medic's loadout, in addition to Versed. I don't imagine there is a whole lot more, given the prohibitively extensive equipment that you would (read: should) also have to confirm and monitor an intubation, but some juicy tidbits from an active 18D would shed a little more light on what is being used out there.

Any info would be appreciated.

John

[Surgicalcric]

...This got me curious as to what is available in the SOF medic's loadout, in addition to Versed. I don't imagine there is a whole lot more, given the prohibitively extensive equipment that you would (read: should) also have to confirm and monitor an intubation, but some juicy tidbits from an active 18D would shed a little more light on what is being used out there.

Any info would be appreciated.

John

If you are referring to paralytics the answer is no we don't generally carry them.

NPA's, safety pins, cric kits, and laryngoscope with tubes are carried in various configurations given the bag, the missions and the support available. How they are utilized and when in the continuum of care depends on the situation at hand.

HTH,

Crip

[swatsurgeon]

Remember, analgesics have sedating properties, sedatives have no analgesic properties...All of the cric's I have performed were with either no medications or just an opioid. In a perfect world and what I carry now, is ketamine. It serves all purposes for an emergency airway.

The last one a friend of mine did on a cop, no meds were used and a successful cric was performed in the field.

Crip, are you issued ketamine or just fentanyl or morphine with your versed?

ss

[Surgicalcric]

Crip, are you issued ketamine or just fentanyl or morphine with your versed?

ss

Depends on where we are/what we are doing whether we have Ketamine on hand. We do have Morphine (at a minimum) and Fentanyl though.

That said I have yet to perform a cric with a pre-medicated patient at all (I have zero as an 18D but 7 as a paramedic.)

Somehow I had a brain fart earlier and failed to mention the above meds. Sadly I had just finished this exact conversation with another 18D. I seem to be developing an advanced case of CRS.

Crip

[Underwhelmed]

Interesting, I've always been a fan of ketamine for a variety of reasons-- reasons I'm sure you both are well-aware of. And unlike Etomidate or Versed, Ketamine can actually be antagonized by Narcan at certian levels.

I've never used it though, the only medications I've had experience with are opiates and Versed. (RSI being the exception) And through a a few needles (and even less surgicals) my patients condition never seemed to warrant sedative/hypnotics, because they were pretty out of it to begin with. Guess I've been lucky.

[swatsurgeon]

Interesting, I've always been a fan of ketamine for a variety of reasons-- reasons I'm sure you both are well-aware of. And unlike Etomidate or Versed, Ketamine can actually be antagonized by Narcan at certian levels.


Underwhelmed,
Where did you validate the use of narcan for reversal of ketamine....I have been using the medication for over 25 years and have never read this, seen this or heard of this by toxicologist, anesthesiologists, pharmD's, etc. There must have been opioids involved for narcan to work??
As far as I am aware, there is no and has never been a reversal/antagonist for ketamine......do you have other information? Please educate us.


ss

[Underwhelmed]

I'll get the study now, Ketamine has been shown to bind to opiate receptors at high-levels.

[Underwhelmed]

http://journals.lww.com/anesthesiology/Abstract/1982/04000/Opiate_Receptor_Mediation_of_Ketamine_Analgesia.11 .aspx

Not the original source I read this from, I think it was in Tintinalli, but I found this almost instantly.

[A few mins later...]

Whew, good thing I have a copy of Tintinalli in my home. It wasn't in there, but I WILL find where I got that information.

I remember it as being particularly shocking, a few months ago I overheard a vet talking to one of her techs about using narcan for ketamine, and I thought to myself "Hah! She clearly dosen't know how ketamine works." Later out of curiosity, I did some research on it, and sure enough they found that Ketamine had some action on optiate receptors at hypnotic doses. This seems counterintuitive, being that one of the strong points of ketamine is that it ISN'T an opiate and thus does not carry the same undesirable side-effects... but anyway, I'll keep working on it because I know the type of fire I'll be under if you don't see more proof. :p

[swatsurgeon]

http://journals.lww.com/anesthesiology/Abstract/1982/04000/Opiate_Receptor_Mediation_of_Ketamine_Analgesia.11 .aspx

Not the original source I read this from, I think it was in Tintinalli, but I found this almost instantly.

[A few mins later...]

Whew, good thing I have a copy of Tintinalli in my home. It wasn't in there, but I WILL find where I got that information.

I remember it as being particularly shocking, a few months ago I overheard a vet talking to one of her techs about using narcan for ketamine, and I thought to myself "Hah! She clearly dosen't know how ketamine works." Later out of curiosity, I did some research on it, and sure enough they found that Ketamine had some action on optiate receptors at hypnotic doses. This seems counterintuitive, being that one of the strong points of ketamine is that it ISN'T an opiate and thus does not carry the same undesirable side-effects... but anyway, I'll keep working on it because I know the type of fire I'll be under if you don't see more proof. :p


The sign of a competent learner and educator...have a basis of supportive evidence. Thanks for the abstract, I had no idea it was that mechanism (in the non-human brain!!!!) . Hopefully you can dig up the reference...we are all here to learn.

ss

[farcefiasco]

*

[Underwhelmed]

Wow, nice. There goes the abstract. :p

[Red Flag 1]

Remember, analgesics have sedating properties, sedatives have no analgesic properties...All of the cric's I have performed were with either no medications or just an opioid. In a perfect world and what I carry now, is ketamine. It serves all purposes for an emergency airway.

The last one a friend of mine did on a cop, no meds were used and a successful cric was performed in the field.

Crip, are you issued ketamine or just fentanyl or morphine with your versed?

ss

Not only is there no analgesic effect from Benzos, given in the face of inadequately controlled pain, the brakes just come off and you will have a combative patient. Don't try to chase pain with anything but analgesics, tranqulizers will help, and may reduce the total amount of narcotics in some cases.

Ketamine in small doses has analgesic ability. In large doses, Ketamine can function as an induction agent IM/IV for general anesthesia. Ketamine has the advantage of sympathomimetics and supports blood pressure where other agents depress BP and such. I expect Ketamine in higher concentrations ie 100mg/ml would be of value in the field.

Have no experience trying to "reverse" Ketamine with anything but tincture of time. If Ketamine is used in conjunction with opioids, Naloxone may well show clinical effects of "reversal".

RF 1

[Underwhelmed]

While we're on the subject of airway drugs, did you guys hear about the new study that dispeled the intraocular pressure contraindication of succinylcholine?

Increased intraocular pressure was one of the like... 13 contraindications of succinylcholine; one of my buddies [a flight surgeon] found a study that equated the increase in pressure to blinking your eyes 80 times.

I mean, It dosen't really change much, I'm not gonna ask the head trauma patient with a clenched jaw if he has narrow-angle glacouma before we RSI his ass. They used to make us put temp strips on their forehead for malignant hyperthermia, too--- I mean I can see why, and I understand the dangers... but there's no way we can tell most of the time. It's not like they make 'medic alert' bracelets that say "Malignant Hyperthermia".

I guess that's why prehospital medicine makes some providers stroke out, if we followed some of the "relative" contraindications in a good number of life-saving medications we would never get our jobs done. :p

[Red Flag 1]

While we're on the subject of airway drugs, did you guys hear about the new study that dispeled the intraocular pressure contraindication of succinylcholine?

Increased intraocular pressure was one of the like... 13 contraindications of succinylcholine; one of my buddies [a flight surgeon] found a study that equated the increase in pressure to blinking your eyes 80 times.

I mean, It dosen't really change much, I'm not gonna ask the head trauma patient with a clenched jaw if he has narrow-angle glacouma before we RSI his ass. They used to make us put temp strips on their forehead for malignant hyperthermia, too--- I mean I can see why, and I understand the dangers... but there's no way we can tell most of the time. It's not like they make 'medic alert' bracelets that say "Malignant Hyperthermia".

I guess that's why prehospital medicine makes some providers stroke out, if we followed some of the "relative" contraindications in a good number of life-saving medications we would never get our jobs done. :p

I'd like to see the study if you can get it. Many of the unwanted effects of succinylcholine (Sux), a depolarizing neuro-muscular blocker, can be obtunded with a small dose of non-depolarizer in pre-treatment; 3mg of Currare (DTC) was what I used. Other notable effects include increased intragastric pressure, and generalized muscle pain being the most noted. While there are now rapid acting non-depolarizers on the market, Sux is the most rapidly acting neuro-muscular blocker, for rapid endotracheal intubation. Open globe injuries would probably have me looking at Zemuron, but probably would heavy pretreat and go with sux. The choice is really a huge risk/benefit decision. You say, "it dosen't really change much"; not so if you are leaking vitrious from an eye. The choice is bilndness or death from aspiration pneumonitis.

Malignant Hyprethermia is another issue that is well off topic here. If I had it, or someone in my family had it, I WOULD get a bracelet. I'd also do the same for all genetically linked family members. A temp rise is a late indicator in this dangerous event. I would be glad to begin a thread on Malignant Hyperthermia if SS and other mods think it would be of value.

RF 1

[Underwhelmed]

I'll get ahold of him for it, the latest study I can personally produce is from 1993, and I know this study was later than that.

I know you want hard evidence to claims that sux actually does not increase intraocular pressure as significantly as we once thought, and therefore quells the concern about extruding eye contents into your own head... please bear with me, I'll get it as soon as I can.

Didn't mean to open a new can of worms over MH, because that's a HUGE can of worms. :p

[wook]

One recent article discussing Ketamine and IOP...


Am J Ophthalmol. 2007 Mar;143(3):494-9. Epub 2007 Jan 2.

The effects of sevoflurane and ketamine on intraocular pressure in children during examination under anesthesia.
Blumberg D, Congdon N, Jampel H, Gilbert D, Elliott R, Rivers R, Munoz B, Quigley H.

Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. dana.blumberg@duke.edu

Abstract
PURPOSE: We studied the effects on intraocular pressure (IOP) of anesthesia administered during examination under anesthesia (EUA) in children.

DESIGN: Randomized clinical trial.

METHODS: This randomized trial compared IOP after inhaled sevoflurane gas to that after intramuscular ketamine hydrochloride in children undergoing EUA. IOP was measured in 30 eyes with TonoPen XL (Mentor, Inc, Norwell, Massachusetts, USA) as soon as possible after anesthesia induction (T1) and two, four, six, and eight minutes thereafter. At the same times, we recorded systolic and diastolic blood pressure (SBP, DBP) and heart rate (HR).

RESULTS: Compared with the mean IOP at T1, IOP in the sevoflurane group was significantly lower for all measurements from two to eight minutes thereafter (mean decrease in IOP: two minutes = 12%, four minutes = 19%; six minutes = 19%; eight minutes = 17%, all P < or = .01). In the ketamine group, mean IOP was not significantly changed from T1 through six minutes, whereas at eight minutes, it was 7% lower (P = .03). SBP and DBP were significantly lower for sevoflurane than for ketamine at all measurements from two minutes onward, and HR was lower for sevoflurane than for ketamine at two, four, and six minutes.

CONCLUSIONS: IOP measured after ketamine sedation is more likely to represent the awake IOP than that after sevoflurane anesthesia. Changes in SBP, DBP, and HR caused by sevoflurane suggest that hemodynamic alterations may underlie its effects on IOP.

[wook]

I think ketamine has been underutilized in the USA and has alot of dogma surrounding its usage. There has been recent discussion about ketamine decreasing Intracranial Pressure (ICP), not raising it.



J Neurosurg Pediatr. 2009 Jul;4(1):40-6.

Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension.
Bar-Joseph G, Guilburd Y, Tamir A, Guilburd JN.

Paediatric Critical Care, Meyer Children's Hospital, Rambam Medical Center, Haifa, Israel. g_barjoseph@rambam.health.gov.il

Comment in:

J Neurosurg Pediatr. 2009 Jul;4(1):37-8; discussion 38-9.

Abstract
OBJECT: Deepening sedation is often needed in patients with intracranial hypertension. All widely used sedative and anesthetic agents (opioids, benzodiazepines, propofol, and barbiturates) decrease blood pressure and may therefore decrease cerebral perfusion pressure (CPP). Ketamine is a potent, safe, rapid-onset anesthetic agent that does not decrease blood pressure. However, ketamine's use in patients with traumatic brain injury and intracranial hypertension is precluded because it is widely stated that it increases intracranial pressure (ICP). Based on anecdotal clinical experience, the authors hypothesized that ketamine does not increase-but may rather decrease-ICP.

METHODS: The authors conducted a prospective, controlled, clinical trial of data obtained in a pediatric intensive care unit of a regional trauma center. All patients were sedated and mechanically ventilated prior to inclusion in the study. Children with sustained, elevated ICP (> 18 mm Hg) resistant to first-tier therapies received a single ketamine dose (1-1.5 mg/kg) either to prevent further ICP increase during a potentially distressing intervention (Group 1) or as an additional measure to lower ICP (Group 2). Hemodynamic, ICP, and CPP values were recorded before ketamine administration, and repeated-measures analysis of variance was used to compare these values with those recorded every minute for 10 minutes following ketamine administration.

RESULTS: The results of 82 ketamine administrations in 30 patients were analyzed. Overall, following ketamine administration, ICP decreased by 30% (from 25.8 +/- 8.4 to 18.0 +/- 8.5 mm Hg) (p < 0.001) and CPP increased from 54.4 +/- 11.7 to 58.3 +/- 13.4 mm Hg (p < 0.005). In Group 1, ICP decreased significantly following ketamine administration and increased by > 2 mm Hg during the distressing intervention in only 1 of 17 events. In Group 2, when ketamine was administered to lower persistent intracranial hypertension, ICP decreased by 33% (from 26.0 +/- 9.1 to 17.5 +/- 9.1 mm Hg) (p < 0.0001) following ketamine administration.

CONCLUSIONS: In ventilation-treated patients with intracranial hypertension, ketamine effectively decreased ICP and prevented untoward ICP elevations during potentially distressing interventions, without lowering blood pressure and CPP. These results refute the notion that ketamine increases ICP. Ketamine is a safe and effective drug for patients with traumatic brain injury and intracranial hypertension, and it can possibly be used safely in trauma emergency situations.

[Retiredfire]

My servive would use a non depolarizing.(vec) folowed by a depolarizing(suc). both of these were preceded by an benzo(versed). so you got ver-vec-succed. If you are looking for reversibility try roc, but imho once you commit you need to be prepared for a diffucult airway and poss of a cric