Cite this post as:
Scott Weingart, MD FCCM. Pain and Terror as Effective Pressors. EMCrit Blog. Published on May 16, 2012. Accessed on April 24th 2024. Available at [https://emcrit.org/emcrit/pain-terror-pressor/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: May 16, 2012
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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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.
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.
This actually happened to me. I was intubated when vocal fold swollen/inflamed from severe thrush and inflammation. Nobody told me I would be paralyzed. There was some kind of window or lag between the rocuronium going in IV and the Fentanyl and whatever sedative it was combined with. It was easily the worst experience of my life. After the tube vented I was propped back ip on pillow and I was suddenly aware i was paralyzed but fully awake. I didnt know if the doctors KNEW I was awake though and feared they may have to do procedures on me… Read more »
And were is the nursing staff with these patients.? Why aren’t they up on the residents face to sedate better.
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.
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.
A1 sedation
What’s the timeframe on adding an analgesic/sedative post RSI? We’re currently using etomidate+succ.
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.
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).
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.
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… Read more »
I really hope we get ketamine added, as many of these problems start to be less problematic 🙂
I think Minh would agree
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. http://escholarship.org/uc/item/3wg7h4rg#page-1 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 http://prehospitalmed.com/2012/05/12/pharm-podcast-009-prehospital-airway-literature-updates-with-dr-brian-burns/ AND the title of Psychic Terror is very apt. I am aware of at least two retrieval cases where a psychiatric patient was… Read more »
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… Read more »
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.
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.
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!
thanks, my friend
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… Read more »
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.
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… Read more »
Fantastic Casey
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 …
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)
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.
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… Read more »
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.
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)? P.S. -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… Read more »
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.
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
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!
Oops, thanks for your reminder, Minh!
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.
check out this prior post
Hi! So regarding the topic of awareness during intubation, do you think that etomidate may be the problem? Or inapropiate coordination between drug 1 and drug 2? Because I have seen many reports with etomidate but not so many with propofol for example. Thanks