Pain and Terror as Effective Pressors

An anonymous EM Intensivist writes:


I am writing to comment on a trend that I’m noticing among my residents, and I wonder if others are noticing a similar trend.  I am an emergency physician and an intensivist at the University of XXXXXXX, and I have a number of EM residents who avidly listen to your podcasts.


Over the course of the last year, most of our residents have made the transition to using rocuronium for RSI (mostly based on recommendations from your podcast, I think).  I use rocuronium preferentially as well, for many of the same reasons that you cite.


What has not accompanied the use of rocuronium, though, is an accompanying willingness to provide adequate sedation and pain control.  I find that this is especially true with trauma intubations.  I would say that the usual course of events goes something like this: etomidate and rocuronium for RSI, tube goes in, patient is hypotensive (trauma patient), so patient gets crystalloid or blood during emergent evaluation.  After 5-10 minutes, blood pressure and HR start to trend back up, and most everyone in the trauma bay is patting themselves on the back because they have resuscitated a hypotensive trauma patient.  They are going to CT.


In the old world order (the etomidate and sux days) — which I do NOT think was better — the clinical course would be the same … except.  After 10-15 minutes, that hypotensive trauma patient would start coughing (with better vitals), then would sit up and give someone the finger while he was preparing to pull his endotracheal tube out.  The janitor would peer into the trauma bay and would recognize a trauma patient who needs sedation, and sedation would be provided.


Now, everyone is hesitant to give long-acting sedative medications to our patients immediately post-intubation, because pts are “sedated” and we’re worried about hypotension.


I think that this is an unintended consequence to the transition of moving to rocuronium as a paralytic agent for RSI.  I think it’s a great drug, but I think that when the tube goes through the cords, the intubator needs to announce to everyone in the room “I’ve given a paralytic drug that lasts for an hour, the sedative agent that I gave does not, so we are going to give ___ right now so that this guy does not wake up paralyzed.”  Propofol infusion +/- fentanyl, bolus of midazolam and dilaudid — I don’t really care what people use, but I think that the way that people are starting to practice is to unintentionally use pain and awareness as a pressor, and I hate to see this happen.  I also think that people need to think to watch the vitals and respond with sedation as necessary.  I had one case of a SAH that started with intubation and ended with a resident using labetalol IVP for HTN that started about 20 minutes after intubation.  In many of these patients, propofol can be a very effective antihypertensive.


I have not done in depth analyses to see what our patients remember (perhaps we should), but I’m a little worried that someone out there is aware of their resuscitation while they are paralyzed because we are not rigorously applying the pharmacokinetics we know about the agents we are using.  I think that in some cases, their physiology would suggest that they might.


Thanks for all the good work you do for our community,



This wee is my audio response. But to sum it up:

  • If you are going to use roc, you better be starting sedation the second you are done securing the tube
  • There is no patient so unstable that they do not deserve analgesia and sedation.
  • For more see this previous post on post-intubation sedation/analgesia

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  1. Shelley says

    This is NOT just a problem at your hospital….. I am a ER and Trauma ICU nurse and changed jobs/locations 8mo ago and have been extremely frustrated with the same issue. I feel like I have to fight to get anyone to order sedation and pain medicine and have never seen this many self-extubations in my life. I even had a patient on a Nimbex gtt and proned (d/t penetrating trauma to the chest, high vent support, fulminating ARDS) and I literally had to BEG for sedation and pain medicine. It’s unreal… especially for a supposed Level 1 Trauma Center.

    • says

      that is horrible for the patients and the nurses that have to watch the patients suffer round-the-clock as opposed to the docs who are checking in intermittently.

  2. Craig B RN says

    And were is the nursing staff with these patients.? Why aren’t they up on the residents face to sedate better.

    • says

      I think everyone is prone to the, “if the patient is not complaining then I don’t need to worry.” Except it is tough to complain when paralyzed. Roc should only be sued if you made a pre-intubation decision as to post-intubation strategy–then the nurses are empowered.

  3. Joseph says

    Scott – I liked your comment that at the very least, some analgesic is required. I’ve encountered some patients who remain agitated on high doses of midazolam – and with a little fentanyl they settle very quickly. Now I make sure theres some analgesic on board and then titrate my sedative hypnotics.

    • says

      Probably about 5 minutes for that combo. Etomidate will come close to matching sux, so if you had to concentrate on only one thing with this combo, i would get some pain meds on board within that timeframe.

      • says

        We’ve got comparatively many to choose from–morphine, fentanyl, dilaudid–but fentanyl boluses is what I’m most comfortable with. Would it be better to use a longer acting narc instead, or even versed? I struggle with how hypotensive a patient realistically could be for a useful dose of versed (considering EMS pressor choices aren’t quite friendly).

        • says

          if you keep pushing fentanyl alone till comfort, the patients will love you. If you wanted to add midaz, it would only be 2 mg or so for anxiolysis and amnesia.

  4. says

    This is in response to Christopher’s question on the time frame. I did catch that he said he was using Etomidate and Succinycholine and this comment is really for the Etomidate and Rocuronium folks. I personally believe you should handle your post intubation analgesia and sedation prior to the intubation taking place. If we are committing to paralysis the certainly we should commit to analgesia and sedation. Why not administer not try this combo. Option A: Fent, Etom, Roc, and Versed while the tube is being passed. Option B: Ketamine & Roc my personal favorite. Its the nectar of the gods for that sick trauma patient. Of course don’t forget that many patients need to be prepared for intubation with a bit of fluid and perhaps a touch of an alpha agent as well. Listen to Scotts podcast on push dose pressers. I have available Phenylephrine at the patients side in an RSI med kit.

        • Minh Le Cong says

          Special K, its not just for horses~!

          Seriously, kudos to Scott and his email commenter on raising this important and oft neglected issue in critical care medicine.
          Awareness and pain peri and post intubation is a real issue. Read this.

          Research from London HEMS shows that increases in BP and HR can occur, independent of RSI drug use, when prehospital intubation is performed. I interview Dr Brian Burns on a research paper about that here

          AND the title of Psychic Terror is very apt. I am aware of at least two retrieval cases where a psychiatric patient was intubated as chemical restraint and sedated with morphine and midazolam infusions for the flight..and these patients complained of recall and awareness during the intubation and transport.
          Both times the patients have specifically requested NEVER to be intubated again for chemical restraint. As Scott points out, our patients deserve high level standard of sedation care before they get to the ICU. Does anyone use standardised sedation scoring systems? I introduced this to our service as result of my ketamine sedation research but its also being used for intubated patients as that is standard of care in ICU. Upstairs care, downstairs and outside!

          Its not cookbook recipe critical care medicine. Every patient needs individualised packaging and sedation . You put the tube in, your work gets harder not easier because that patient is now relying upon you to totally care for them. Medical ethics call it ” removing the necessities of life” as the patient is rendered unable to care for themselves.

  5. David Anderson says

    Having practiced in Australia and NZ, every time I read anything about patients being paralysed and not sedated I cringe. I just don’t think this happens here. It’s cruel and it’s bad medicine.

    Having said that, you sometimes see inexperienced practitioners (myself included when I was starting out) overdo the sedation and have to quickly reach for the metaraminol (not sure if you have that in the US as I never hear it mentioned. It’s an alpha agonist similar to phenylephrine that can be given as a bolus). The pharmacology of anaesthetic induction agents can be made very simple in the shocked patient – the response you get is proportional to the plasma concentration, not the dose. Shocked patients have a lower effective plasma volume, so you can achieve the same plasma concentration with a much lower dose.

    For inducing shocked patients in ICU I typically use ketamine and roc or, increasingly, a cocktail that I have picked up from a consultant (attending) who I respect a great deal; a large dose (up to 500mcg) of fentanyl, a small dose (2-5mg) of midazolam and a proper rapid-sequence dose of roc (1.2mg/kg). Those with some anaesthetic experience may recognise this as being similar to the “cardiac anaesthetic.” If it works for someone having a STEMI why shouldn’t it work for everyone else!?

    I’ve been using this cocktail for a few months now and haven’t got into serious trouble yet. Although I still have a syringe of metaraminol drawn up at all times when I’m playing with these drugs (actually, our fabulous nurses have it drawn up in advance…)

    • says

      Always said the Australasians are more enlightened folks (just kissing up to the LITFL crew.) For us on the opposite side of the world, push-dose phenyl will do all the same things David mentioned for metaraminol.

  6. Andreas says

    Easy to forget appropiate sedation in all urgent inductions of anaesthesia. Not only trauma, but also eg ruptured aortic aneurisms. Why not iv infusion ketamine 3-4 mg/kg/t? Then cognitive capacity and hands free for other stuff.

  7. Shannon says

    Pain and terror as a treatment plan–scary. As an ICU nurse I ‘m pretty insistent on what are we mixing right now for after. Our unit just closed and with this came standard admit forms that include sedation and goals for the sedation. We’re pretty excited because it lays out all the choices clearly. Ketamine is something we ‘re just beginning to talk about and I’m really interested in hearing about what you have to say about it. Your podcast rocks!

  8. Eric says

    I have been fortunate to have worked in flight and progressive critical care as a Paramedic in Texas. Now I am working towards my BSN but work providing NON card class education to experienced field medics in 911 and Transfer. It amazes me daily how many do not understand the difference between Paralytics, sedation and analgesia. I do not blame the clinicians as I do the industry for not being dedicated to what becomes sometimes a inhumane experience for the patient. I have also run into a huge amount of EMS services that are very knowledgeable about procedures and QA/QI these calls with a fine tooth comb.
    In all fairness we have Rescued patients from outlying hospitals. Once arrived to find a intubated patient tied to the bed thrashing around. The patient was so tachycardic and hypertensive the doctor was considering *denosine for this potential SVT. Report stated the patient was RSI and then sedated with vecuronium. The Vecuronium sedation had obviously worn off…..complete sarcasm. An appropriate amount of Versed and 6entanyl was administered and could only hope the benzo s would at the least give some amnesia and relief of the clinical induced psychotic episode over the last hour and a half.

    • says

      standard ED practice in the States a decade ago and prob. still the care in some hospitals post-ed sedation was 2-4 mg ativan, no analgesics; if the patient was still “bucking” the vent, they got paralyzed. Horrible stuff.

  9. says

    Hi Scott
    As my fellow Aussies have mentioned – the idea of paralysis without sedation/analgesia is just not something that one would even consider in this country – I would be calling my lawyer if this happened in error!

    Sounds like the US EDs might need to undergo some cultural shift to achieve what you describe as humane sedation. I a sure your Anaesthetists would spend a considerable amount of energy trying to avoid “awareness” in the OT – and yet it seems allowable in the ED?

    Great podcast Scott – maybe this will create a rethink?

    Just for the record – the standard practice here in Broome (Aust):
    we have infusions of sedative / analgesic and relaxants all ready to go before you intubate if there is time. I delegate this job to a pair of nurses as soon as the decision to tube is taken
    Push doses of alpha-agonists are routinely at arms reach for the old, unwell or weak-hearted patients.
    Generally I start my sedative / analgesic infusions as soon as the tube is in place and then titrate it up to get the BP and HR where I want it.
    There are some folk using BIS monitoring in some scenarios to ensure adequate sedation.

  10. Ben Hoffman says

    Here in New Zealand Intensive Care Paramedics are utilising fentanyl and midazolam for post-intubation analgesia/sedation. I can’t speak for in the hospital but I imagine something similar, I’ll ask around.

    I am a huge proponent that people need to be adequately sedated and pain free and that you can not have too frequent-a drugging! (well you can if you do something muppeted like destroy their blood pressure)

    That midazolam is good stuff, mmm num nums …

  11. says

    I’m with David re: the cardiac anaesthetic regimen… Fent/ roc or if really clapped out ketamine/roc.

    Good tip from Casey, having staff delegated to drawing up the sedation infusion whilst setting up for the RSI

    I trust you are using the same infusion regimens as your retrieval service? Big fan of low volume infusions, minimising dead space with 1ml extension lines and the Niki T34L pump (even an idiot like me can figure it out without having to ask a nurse)

    • says

      cardiac-anesthesia induction is great stuff; any who use it, be wary: it will drop the BP like a stone if the patient is reliant on endogenous catecholamine surge.

      • Angel says

        Completely agree with Scott. The “cardiac anesthesia induction” works for the stable patient with current or previous isquemic heart but not for a Killip or Forrester IV patient or with another source of haemodinamic impairment (that is, shock near death patients). In my oppinion in this condition I use to offer a “smell dose” of midazolam (I think called Ativan in USA) just for amnesia and low dose fenta or even better remifentanilo titrated according to BP and BIS (Bispectral Index) for the cardiac patients in which the use of ketamine remains controversial.
        Intubation can kill patients by others ways besides jeopardizes oxygentation. Blunted when you can but don´t be Blind for the haemodinamic response you can get.

        • says

          midaz is still midaz in the States. Great advice. Before it went on shortage, I was using scopolamine for the same purpose. An old but good drug that covers for potentially inadequate induction in the profoundly shocked pt.

          • Duncan says

            Dear Scott,
            Most of the ED in Hong kong still stocks scopolamine injection (called Buscopan), however it’s mainly for treatment of bowel colic/nonspecific abdominal pain. Not sure if ICUs in Hong Kong are stocking it.
            What is the dose of scopolamine you used for induction for intubation? Also how is it speed of onset of action from your experience (relative to other IV induction agent commonly used)?

            -I can see for tachycardiac patient It might not be a good idea to use scopolamine so that there heart rate might shoot up to sky.
            -Probably droperidol can serve the same purpose. I remember you have mentioned it as altenative to ketamine in DSI podcast right?

  12. N. Diamond says

    This is a topic that needs to be brought to all critical care practitioners attention.
    We see this frequently when patients arrive in the ICU from the OR or ED. The sedation and pain meds wear off and they are left paralyzed. There is nothing worse than to see a patient in that condition especially when it can be easily fixed with some analgesia and sedation. My preference is a fentanyl drip for pain control and propofol or versed depending on blood pressure and presence of neurotrauma.
    Thanks for sharing this important point.

  13. says

    Duncan (see above)

    scop dose I use is 0.4 mg, but this is not induction, purely amnestic. I’ll then add small doses of ketamine.

    not much tachycardia with this dose of scop

  14. minh le cong says

    DUncan, Scott, I think there is confusion about scopolamine and scopolamine butylbromide (tradename Buscopan). Buscopan as we know it in Australia is used for bowel cramps and as an antispasmodic. The attachment of a butylbromide moiety prevents scopolamine from effectively crossing into the CNS so it mainly acts peripherally. the dosages of Buscopan therefore are different and 10-20mg PO or IV doses are common. I would check your drug info before giving Buscopan for amnesia effect, Duncan!

  15. Gazi says

    Hi Scott, thank you for the wonderful lecture. I am new in the blog. You mentioned the sedation drip , the option and doses was going to be in the show note but I don’t see it . Please can you send me a link to that.
    PS: love emcrit, learning a lot.


  1. […] Although Roc -Rocks it sucks when you don’t provide effective post intubation care with adequate sedation and analgesia. Scott has a good rant about this in Pain and Terror as Effective Pressors. […]

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