Alright, buckle up, everybody. Let’s talk sedation.
Specifically, we’re diving into prehospital sedation for procedures, namely intubation and cardioversion/pacing. Sedation options for the patient with excited delirium will be covered in a future email.
There have been LOTS of questions surrounding sedation strategies for intubation, and there seems to be a LOT of confusion with how to deal with these calls based on various OLMC recordings. So let’s clarify some points:
1. EMS crews in NYC do NOT carry paralytics, and so intubations are technically not RSI, but rather medication-assisted intubation (MAI).
a. There is one exception to this with FDNY’s specially trained rescue paramedics, who receive training in Rocuronium and Succinylcholine for very specific circumstances, but these cases will never come to our OLMC phone, so you’re better off ignoring it.
2. Paramedics do not require OLMC approval to intubate, but they DO require OLMC approval for sedation medications in the pre/post-sedation period. For example, they do not need to call us to intubate an unresponsive patient in respiratory failure, but if that patient becomes agitated to the extent that they need sedation for the intubation, OLMC is required.
a. This allows crews to intubate patients without calling first if the patient is truly in such extremis that they can’t resist the intubation procedure.
b. If the patient DOES require sedation for intubation and the crew calls to request orders, I personally use this as an opportunity to (quickly) discuss the case with the crew. Does the patient really need intubation at all? Is NC/NRB sufficient? Would they tolerate CPAP? Is an NPA with BVM ventilation all they need until they get to the ED, or would they just get intubated on arrival anyway? Also recognize that quality bagging is extraordinarily difficult with a 2-person crew that is simultaneously carrying a patient down 6 flights of stairs and into the back of a soon-to-be-moving ambulance, which may be another reason to justify a more definitive airway. Often, if the patient is awake enough to need sedation, you can take a minute or two to ask some of these questions.
3. EMS crews in NYC do NOT carry paralytics. Don’t ask them to give them.
4. When discussing the medications used by paramedics for sedation, there are specific combinations of meds permitted as Medical Control Options. Please look closely at the attached pdf to see what meds and dosages are explicitly written, and begin to familiarize yourself with the options. Briefly, for intubation, they are:
a. Diazepam, dosed before and after intubation, OR
b. Midazolam, dosed before and after intubation, OR
c. Etomidate before intubation, followed by a SINGLE dose of a benzodiazepine after intubation.
d. That’s it. Try to keep those three options separate, as sometimes even crews will get wrapped up in the confusion and blend the choices together (eg, a call asking for Etomidate before intubation, Diazepam after intubation, and a SECOND dose of Diazepam “just in case” is a common OLMC request that inappropriately combines options A and C, but recognize that that’s a lot of sedation!).
e. If needed, other medications such as Ketamine or Fentanyl can be used as Discretionary Orders (crews carry and are trained in those medications for EDP and Pain Management protocols, respectively; you are requesting an “off-label” use). I will often use this strategy for the hypotensive patient requiring intubation, as I personally don’t like benzos or Etomidate in those scenarios.
5. EMS crews in NYC do NOT carry paralytics.
6. MCOs for sedation for synchronized cardioversion or transcutaneous pacing are similar to those for intubation but utilize half-dose Etomidate. Check the pdf for specifics.
7. Like discussed in the last email, be sure to practice good closed-loop communication when authorizing these medications, which means giving the name of the medication, the dose, and the route (these should all be IV/IO; if a crew wants to intubate, cardiovert, or pace, but they don’t have some sort of vascular access, you may want to discuss priorities with them). Have the crew repeat the order back to you! This prevents errors and should be standard patient care!
8. EMS crews in NYC do NOT carry paralytics.
9. Seriously.
10. EMS crews
11. in NYC
12. do NOT carry paralytics.
And finally, don’t forget that these orders for controlled substances will ultimately need a tracking number (MMC-####)! You can offer it to the crew at the time of the order, but often they will just want to call back for it after they secure the tube. That’s fine since you’ll have more time to get patient info and find out how well your medication choices worked!
Hopefully this clears some things up for you all the next time a crew calls for “orders to intubate.” Keep this email and pdf for reference, but also remember that you can use www.nycremsco.org for the latest iterations of the protocols, as well as the hard copy in the protocol binder! It has that fresh book smell!
David Eng
P.S., EMS crews in NYC do NOT carry paralytics.
