In this episode the guys are joined by Don Spaner, MD the CMO of the University Hospitals EMS Institute. The discuss all aspects of ketamine use, protocols, pitfalls, and public opinion. Part 3 of the series finds the guys discussing TXA, Push Dose Epinephrine, and Certadose Pediatric medication tool. 

Ketamine

UH Mindset

• Ketamine getting bad press recently

• Poor outcomes in other areas of the country

• Drug is safe, decisions surrounding were unsafe

• Has led to anti-ketamine legislature in other states

• Identify and treat underlying causes

• UH aggressively reviews all ketamine case – trying to prevent such legislation in Ohio

• Every 2 weeks all UH EMS Medical Directors and EMS coordinators get all ketamine uses for review and discussion as a group

• Each reviewed on its own merits

• Individual Medical Directors take the feed back to their departments

• Most common feedback / critique missing post administration capnography or glucose checks

The Medication

• Derivative of PCP – opposite hemodynamic and respiratory effects of our “usual” hypnotic sedatives

• Bronchodilator effects – good for intubation of asthma patients

• Wide dosing range – effects vary

Indications – Protocol

• Violence

• Airway – RSI and DAI

• Pain

Pain use

Good for patients who are working a narcotics recovery program – ketamine non-narcotic but has significant opiate caliber analgesia. These patients still deserve Pain management, while not risking their recovery

Good for patient well acclimated to narcotics and now desensitized.  Stimulates NMDA receptors rather than MU like narcotics. Works by different mechanism,  may give relief when narcotics may have failed.  Sickle cell cases are a good example of this.

Good for shocked trauma patients. Ketamine has stimulant properties that increases HR and BP. Its likely safer in these cases as the HR is compensatory in the shock state. Blunting Pain in this case may unintentionally dump BP by reducing the HR which is due to the pain. Giving ketamine (after other resuscitation measures are underway) may prevent this unintended BP drop by directly increasing the BP and HR while simultaneously addressing pain.

Routes

• IV, IO. IM. IN

• Mathematical dosing – 0.1 - 0.3 mg/kg

• Functional (protocol) dosing 10mg doses up to 30 mg max

• Can be smarter than protocol and start lower if especially small patient

• Derivative of PCP – opposite hemodynamic and respiratory effects of our “usual” hypnotic sedatives

• Beonchodilatory effects – good for intubation of asthma patients

• Wide dosing range – effects vary

Airway

• Used in both drug assisted airway and RSI as induction agent

• Benefit that it simultaneously provides analgesia, sedation, dissociation, and amnesia.

• Because is PCP like, stimulates sympathetic nervous system, thus bronchodilation

• Versed only sedates and produces amnesia can and can produce hypotension

• Dangerous to let head injured patient BP drop. Ketamine better induction option

Dissociative dose > 1-2 mg/kg

Want to “come heavy” with this dose to assure appropriately disassociated, larger boluses than when compared to pain dosing.

Usually 100 mg, attempt procedure, repeat 100 mg in 2-3 mins if needed. If patient unresponsive to 200, add benzo and or analgesic (fentanyl) these patients may have a tolerance to PCP-like substances and may need combination therapy to induce.

Be prepared to suction, these larger doses often create excessive salivation

Patient will still be breathing (unless some untoward polypharmacy reaction, or other unanticipated situation)

Will have to time tube delivery of ETT with vocal cords.

Drug assisted airway protocol not limited to just delivery of ETT, can be used with extraglottic airways also

Major tranquilization dose - Violence

• Protocol use is for violence – differentiated from “combative”

• Dr Spaner helps frame who is violent vs combative by “if you had a taser, would you use it to protect yourself”

• Scott’s mindset is “if I backed up, would the threat follow me”

• Combative patients are “reacting” to our treatment or attempted treatment

Dosing

• May be 4.5 mg / kg in some protocols

• UH has chosen simpler, lighter dosing in this protocol in the name of safety

• Protocol dose flat 250 mg IM only – may repeat in 5 mins if patient is still violent

• General thought processes is; If there is time to start an IV and / or the patient lets you the are not a candidate for ketamine already

• Lighter initial dose seems to work well, only few cases require second 250 IM injection.

• Goal is to make scene safe, not make patient unresponsive

• If patient is not violent after first dose but still awake, that is ok – add benzos for any additional agitation.

• After scene safe within about 10 mins consider IM benzo to prevent emergence reaction

• Patients that are violent when medicated, may resume violence when waking up in an altered state after metabolizing the ketamine – “crazy down, crazy up”

• A prophylactic benzodiazepine may help mitigate this

Operational Pharmacology / Equipment Use

Carpuject Use

• Proper way

• Take carpuject medication out of “cigarette” tube

• Put in carpuject carrier tail end first – does not fit and risk of breaking if put in nose first

• Push rod threads onto stopper inside carpuject – allows stopper to be pushed or pulled

• “Activate” the carpuject before use by half turning blue tail piece – cam action pushes small internal needle through stopper to allow drug to administer. This is also a tamper evident safety.

• Express any air in carpuject – leaving only medication

• Note: There is 2 ½ ml graduations on a standard small volume carpuject, despite most medications being only 1 – 2 ml. The internal stopper will be back at the 2 ½ ml mark regardless of fill

• Attach choice of administration device on the luer lock end – administer

• Or attach to luer lock needless port on IV tubing

Alternately the luer lock end can be removed from the carpuject cartridge and the medication drawn with another needle and syringe from the rubber stopper. DO NOT inject any air, this will blow the stopper out of the rear of the carpuject. Drawing medication will pull the stopper down as you withdraw medication.

IV sets

Different ports on IV tubing require different ways of adapting syringes or other IV lines to them

3 Basic types:

• Tradition injection port – requires a needle to access – poor for piggyback lines

• Split septum injection ports – will accept a needle or a blunt cannula – identified by raised white rim around the injection port -

• Luer lock, or “screw on” port – has luer threads on the external and a self-sealing internal valve. This can only be used with luer lock threaded devices (tubing / syringes). Blunt cannulas or needles inserted into the internal valve causes it to stick open and leak.

Push Dose Epinephrine (PDE)

• Replaces drip pressors in protocol as treatment for shock

• Gives small aliquots, or doses of a very dilute epinephrine concentration to manage HR / BP

• Given in mcg (micrograms)

• IM concentration is 1000mcg / ml (1 mg / ml) – higher concentration needed for IM injections, the muscle is the dilution

• IV Concentration for cardiac arrest is 100mcg / ml (0.1mg / ml) (1mg / 10ml) are all the same thing. Need mid concentration for not beating hearts with minimal blood flow (CPR flow). Given directly into bloodstream, IV / IO

• IV concentration for beating hearts (shock) is 10mcg / ml – push dose epinephrine (PDE). This is made note carried. It is made from existing concentration by dilution. Mathematically this can be done many ways. One was is officially suggested in this area – below.

Making PDE the locally sanctioned way

Place 1 mg (1000 mcg) of 1mg / ml (1:1000) concentration – epi vial – into a 100 ml bag of D5W. Agitate. Withdraw from same injection port on D5W bag and administer – below.

Why this way is sanctioned locally;

• You have extra immediately available if more than 10 ml is needed to stabilize your patient – 100ml’s

• It requires gross motor function to get the med out of the vial and into the bag. It doesn’t matter if air gets in the syringe while injecting the bag – there is already air in the bag

• The bag can be spiked and used for a epi drip if the provider chooses after the PDE has yielded results

• It does not use up pre-filled syringes of epi which are more costly and the most common concentration of epi on shortage

D5W is the most often supplied mixing base as all medications that EMS needs to mix are “happy” in D5W. Some other medications are less properly mixed in saline. So D5W is supplied as the “standard” mixing base in our boxes. Epi is perfectly happy in epinephrine if that is all you have.

Administration – for hypotension and / or bradycardia

Push 1ml of the 10 mcg / ml concentration and reassess

Epinephrine is metabolized fast. In the time the machine re-assesses if the resultant values are low, administer more PDE. If the BP does not “move” much ex. You start with a BP of 60/40 (Map 47) and the first 10 mcg of epi move the BP only to 66/43 (Map 51) then you can increase subsequent doses to push it further along. Subsequent doses are not entirely additive to the preceding dose, because its metabolized quickly, in some regards you are basically starting over every push. You might consider 20 or 30 mcg push on the next administration given the case presented. You may give up to 50 mcg / dose as needed to stabilize your patient.  

 Whereas the introduction of PDE to protocol was to encourage pressor use in lieu of pressor drips, drips are not disallowed. In fact, the concentration mixed for PDE is actually very functional for converting to a drip once stabilized with PDE. If a bag of PDE is mixed as discussed above (10 mcg / ml) and spiked with a 10 drop set that means that every 10 drops that fall out of the chamber = 1 ml. 1 ml = 10 mcg’s. Or said another way, each drop = 1mcg. This makes figuring out how many drips / min are needed really easy if you started with PDE. Lets say you gave the patient 70 mcg over about 5 mins to stabilize them, the patient averaged about 14 mcg (70 / 5) per min. Once your bag is spiked, you know the patent “likes” about 14 mcg / min, all you need to do is count out 14 drops (14 mcg) every min with a 10 drop set. This only works this smoothly with a 10 drop set.

Pediatrics

In pediatrics PDE is given for shock at 1 mcg / kg up to 10 kg. This means that every 22 pound (10 kg) or greater kiddo can have full adult doses. This is red boxed (online medical control required) in UH and surrounding systems. Most peds will respond to fluid boluses thus negating these medications.

Tranexamic Acid (TXA)

Indications

Tranexamic acid (TXA) indicated in hypotensive and tachycardic (systolic less than 90 heart rate greater than 120) after uncontrolled hemorrhage. In other words this is for shocked trauma patients. This must be given within 60 mins of the injury to be effective.

There has also been added an epistaxis indication in the 2023 protocol. For nose bleeds that are refractory to standard BLS care a TXA soaked gauze product can be used for packing. In this case, the provider chooses which gauze product to use, and soaks it in TXA. Once soaked, the affected nare(s) are cleaned out by blowing or suction of the nose then packed with the soaked TXA gauze.

Physiology

TXA is a reversable antifibrinolytic that inhibits the conversion of plasminogen to plasmin, thus keeping clots intact. TXA does not “MAKE” clots. Giving such a drug to a person would yield an immediate death from a concurrent MI, PE, and Stroke. This only preserves existing clots to prevent additional or rebleeding and allow more time and better survival for surgical intervention.

Dosing

TXA is supplied as a 1000mg (1 gram) vial. The current protocol calls for 2 grams ( 2 vials) of TXA mixed in a 100 ml bag of D5W and given over 10 mins or hand pushed over 10 mins. Kids are given 15 mg / kg mixed into a 100 ml bag and given over 10 mins. This is red boxed (online medical control required) in UH and surrounding systems.

Naloxone (Narcan)

Narcan is given to restore respirations in known or suspected opiate overdoses. This should be the only indication. There have been cases of patients who are altered, but breathing, or have just admitted to use of opiates but are awake that have received Narcan. These patients may be dosed with an opiate, but are not overdosed as suggested by the fact that they are breathing.

The overarching rule with these cases is the “resuscitate then antidote” mindset. If a BVM is not required, then neither is Narcan. Begin BLS ventilation, support circulation as necessary, then add the antidote.

The overdosed patient is both hypercarbic and hypoxic from not breathing adequately or at all. Breathing for this patient, with supplemental oxygen will often result in the them waking simply by correcting the hypoventilation. These patients need Narcan to combat the opiates and maintain their breathing.

It is not appropriate to get on scene, administer the Narcan, and hope it restores their breathing without ventilatory intervention from EMS. Understand intranasal (IN) Narcan requires time to work, and absorption rates vary with each patient. Likewise IN or IV use of Narcan requires perfusion to work quickly. Someone in hemodynamic collapse may not “pick up” the drug quickly. IV is preferred when available.

Olanzapine (Zyprexa)

Zyprexa is an newer generation anti-psychotic medication. It could in some respects be thought of as a oral haloperidol (Haldol) with fewer side effects. They have similar indications and effects. Zyprexa in EMS is supplied as a ODT (orally disintegrating tablet) 10 mg tablet. Being a orally delivered medication, the patient has to be somewhat cooperative and willing to use the medication.

Indications – Protocol

Zyprexa is indicated for acute agitation in a patient with psychosis. This is not for all episodes of agitation. So, this would not be indicated in panic or anxiety attacks, or undifferentiated agitation cases. This is for bipolar or schizophrenic cases that are agitated and may be hearing voices or seeing things.

Dosing

In the patient who is amenable to the use of the medication, a single 10 mg tablet is given orally. This, like most other ODT tablets should be allowed to melt in the mouth then swallowed down. In practice most providers give this SL, as most patient seem to understand “let this melt under your tongue”. Onset is usually within 10 mins. This is not given with concurrent benzodiazepines by EMS.

Caution

Zyprexa is supplied in ODT blister pack that looks very similar to our more frequently used ODT medication, ondansetron (Zofran). The trade name of both of these drugs start with “Z” and both generic names also start with “O”. The combination of look alike and sound alike make these medications a prime situation for a medication administration error. Be sure to double or triple check when using either of these agents. UH packages and labels the Zyprexa to assure that it stands out as different from the Zofran.

UH EMS Drug Box Program

The University Hospital drug box exchange program supplies pharmacy stocked and maintained drug boxes for the EMS system. The drug box and its contents are tracked by an RFID tag system called Kitcheck. These are the little tags added to each medication in the drug box. This allows the boxes to be quickly scanned for content and expiration by the pharmacy.

Drug boxes are exchanged at your medical control hospital when the are expired or exhausted. This may be done in the ED or in the Pharmacy depending on the hospital. The box is exchanged for another fresh box when needed.

The boxes are sealed with green seals from the pharmacy. Inside there are red and yellow seals. The yellow seals are used when something is used from the box, but the box is still serviceable. These would be cases where there are still enough medication of a particular class or category to fulfill all protocols relevant to that medication. Red seals are used to flag a box is not serviceable by the previously noted cases or any controlled substance has been used.

There is a medication tracking form that is included in each box and is required to be filled out and sent back with the box. It is good practice to fill out the form and take a picture for attachment to your ePCR with the call.