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2

Protocol Update2015-2016 Version

3Outline

• Review major changes• Rocuronium Bromide In-service• Ketamine In-service

4The Changes

Changes this revision: Numerous editing, spelling and formatting corrections “Celox” deleted and a hemostatic agent /dressing protocol created King Airways added as an agency optional” “combitube” language removed in treatment algorithms and “Supraglottic airway” added due to

the addition of King Airways Ketamine updated to include analgesia Morphine changed; initial dose is now 2-5mg instead of 2-4mg. Helicopter use updated with newest air ambulance protocol language STEMI has saline lock added as preferred IV access in the non-hemodynamically compromised

patient. Added V4R requirement to 12-lead suspicion of RVI Fixed AEMT protocols to reflect full scope of practice Rocuronium Bromide added Adrenal Crisis added

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ROCURONIUM BROMIDE(Zemuron) A Non-depolarizing paralytic

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Mechanism of Action

• Rocuronium is a non-depolarizing neuromuscular blocking agent with a rapid to intermediate onset of action, depending on dose, and with an intermediate duration of action. Rocuronium produces neuromuscular blockade by competing with acetylcholine for cholinergic receptors at the motor end plate.

7Indications

• Rapid Sequence Induction where Succinylcholine is unavailable or contraindicated (hyperkalemia).

• As a post-induction maintenance paralytic.

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Precautions / Side Effects

• Respiratory paralysis; insure secondary airway is available.• Pre-medicate and maintain sedation with Benzodiazepines.• Use with caution in patients with known significant Hepatic

disease, pulmonary hypertension and valvular heart disease.• Hypersensitivity /anaphylaxis• Transient hypotension and Arrhythmia• Tachycardia• Hypertension

Less than 1% of the studied population.

9Dosing

• INDUCTION DOSAGE• Adult: 1.0 mg/kg slow administration (30-60 seconds)• Pediatric: 0.6mg/Kg

• MAINTENANCE DOSE• Adult: 0.15-0.2 mg/Kg IV prn or 10-12 mcg/kg/min via

IMED pump only for transports > 1 hour.• Pediatric: 0.15mg/Kg IV prn or 7-10 mcg/kg/min IV via

IMED pump only for transports > 1 hour.

10Onset of Action

• Median time of onset for 1mg/Kg is 1.1-1.4 minutes (slightly slower than Sux)

• Duration is approx. 50-60 minutes

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Ketamine(Ketalar) A rapid-acting, general anesthetic agent

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Mechanism of Action

• Ketamine acts primarily as an antagonist of the NMDA receptor, and this action accounts for most of its effects.

• Works similarly to serotonin re-uptake inhibitors and can have an additive effect for those taking anti-depressants

• Onset of Action is 30 seconds to 3 minutes• Duration is 45-60 minutes.

13Indications

• It is the drug of choice for people in traumatic shock who are at risk of hypotension.

• Sedation to facilitate intubation in the combative patient and those who are candidates for RSI.

• Sedation in Agitated Delirium.• Sedation / analgesia in the high acuity burn or trauma patient

requiring prolonged extrication for traumatic pain management.

• Sedation / analgesia in association with opioid administration to treat those patients suffering from traumatic pain.

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Precautions / Side Effects

• Transient increases in blood pressure and pulse rate. Usually self-resolved.

• Oral secretions have suction available.• Nausea (consider pretreating in the immobilized patient).• Transient, self-resolving, arrhythmias.

15Contraindications

• Glaucoma • Schizophrenia • Pregnancy • Stroke / Increased ICP

16Dosing

• RSI and Agitated Delirium • Adult: Administer 2mg/Kg IV/IO over 1 minute. 3mg/Kg IM. • Pediatric >3months Administer 1.5mg/Kg IV/IO over 1 minute. 3mg/Kg IM

• Sedation for Severe Burns/ Sedation for Painful Procedures • 0.5-1 mg/kg IV/IO or 2mg/Kg IM. Repeat every 5 minutes as needed to assist

in maintaining sedation.

• Pain Management (Only used in conjunction with an opiate or known allergies to opiates are documented).

• Adult/Pediatric: • Administer 0.2mg-0.5/Kg IV/IO over 1 minute (slow push), repeat every 5

minutes as needed. 0.5-1mg/Kg IM may be given if no IV /IO available. • Max single dose is not to exceed 50 mg. • Additional dose(s) require opiate dose to be reduced by half of the original

dose • If nystagmus is noted, hold further administration.

17Notes

• Ketamine must be used with a Benzodiazepine to minimize hallucinations / emergence reactions associated with emergence from the medication.

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2016 AND BEYONDEMS in Josephine County

19In Process

• New Medical Director process• County CQI /QA programs and implementation• MCI Drill• Protocol Review and Development• PHCC