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NOV
06

Do The White Right (propofol isn't the devil)

Early in my paramedic career I remember being told that propofol was the “white assassin” and had no role in the back of an ambulance or helicopter. The common quotes bounced around the web like a beach ball at a NickelBack concert.

“You can either have a patient properly sedated or a patient with an adequate blood pressure.”

“Propofol is meant for dark and quiet ICU rooms.”

I would pick up patients who were on a propofol infusion and switch it out for ketamine in transport. It made sense to use a sedative that not only was sold as being hemodynamically stable, but also included analgesic coverage. This was the ultimate BOGO!

I started to realize that almost every facility would discontinue the ketamine and put the patient back on propofol upon arrival. It is not common to see patients in an ICU on a ketamine infusion. This meant the patient now had to come off the ketamine, receive a new loading dose of propofol, and then be started on the infusion. Was this really worth it?

Additionally, I found ketamines "analgesia" over-rated when given as a mono therapy for intubation. My patients still ended up needing slugs of fentanyl during transport.

When I fast forward to the way I conceptualize sedation strategies now, there’s a stark contrast. The beginning stages of my knowledge were not formed by anything but input from others. I hated propofol and dopamine before I even knew why..

Here’s why I am saying all this..

I recently came across a tweet from a medical conference stating: “propofol doesn’t work in helicopters.” I feel this is less of a problem with the surrounding ambience as it is with our understanding of pharmacodynamics. I figured I would do a quick blog on some thoughts I have regarding propofol in the transport environment. I started off my rant with a tweet.

Dosing

Propofol is dosed with an initial loading dose of 0.5 to 2 mg/kg. This loading dose will depend on your patients hemodynamics. I generally find 0.5mg/kg over 5-10 minutes is the goldilocks number.

Here is a quick graph I made to illustrate how long it would take to reach a loading dose of 0.5 mg/kg.

After the loading dose, I typically drop to 30 mcg/kg/min. This is obviously patient specific. 

It's important to note that in order to avoid hypotension, your loading dose SHOULD NOT be a rapid push. Our friend @ChillaPharmD who works as a PharmD (go figure) had some great insight on this.

 

"What if I already used a sedative agent that works on the GABA receptors?"

Within the GABA receptor are subtype receptors that all circle around a chloride channel. Imagine a rose petal, and in the center of the petal is the chloride channel. Midazolam, etomidate, and propofol all work on different sites within the GABA receptor. Not to mention Ketamine works on the NMDA receptor which blocks excitatory stimulus from glutamate. When activated, chloride will pass through the channel and further drive down the action potential. This makes it harder for a messenger coming across the synaptic gap to trigger a stimulus. Here's an illustraton I created for a segment we did discussing this in the FOAMfrat refresher.

If other sedatives or analgesics are onboard, you may consider reducing your dose of propofol. This is where liberal dosing of analgesia allows conservative doses of sedative. The insert for propofol recommends the following:

"So I load with Propofol, start an infusion, and then I’m good — right?"

Propofol doesn’t do crap for analgesic coverage. The goal should be to optimize analgesic therapy to make the patient comfortable and then use a pinch of sedation to relax anxiety from noxious stimuli (I also highly recommend ear muffs as a non pharmaceutical means).

Propofol and Fentanyl

In my opinion these two agents should always be given together. If the patient has a long term paralytic onboard or shows any signs of discomfort I typically do something like this.

1. Show up at bedside - 100mcg fentanyl 

2. Make sure the ventilator is not set on some torcherous setting and that the foley bag is draining properly (two things that have bit me in the @$$ when it comes to patient comfort).

3. The Propofol tends to stay anywhere between 30mcg/kg/min (if no loading dose was provided, I may bump to 50mcg/kg/min per the chart above.

4.Minutes from short final - 100mcg fentanyl 

 

Summary

Propofol can be very effective in transport medicine if properly dosed and coupled with an "analgesic 1st" approach. As mentioned above, there is always risk of hypotension with ANY central nervous system depressant. The dosing and understandings of how each of your tools work will be your best guide to adequate and safe sedation stewardship.

When you think propofol... think fentanyl.

-Tyler Christifulli

References:

Diprivan Insert 

Propofols Role In The ICU

Propofol In Sick Cardiac Patients (Dose low and slow)

EMCrit on Propofol and Post Intubation Sedation

0
NOV
03

Intubate with your glutes.

 

“Did you just, uh... Did you just grunt? You really shouldn’t be, you know, grunting while intubating.” 

The paramedic in the back of the ambulance with me is a tired, sweaty mess. We are going through DSI training and working on intubation. 

“My shoulder is burning,” he says. “I need to take a break.”

I tell him, “Listen, you have to use your glutes when you intubate.” 

He looks at me like I have gone insane, and without further explanation, I guess I can’t blame him. For all the much-needed focus on improving intubation techniques out there—ramping the patient up, align axes, getting “the view,” SALAD and more—most training misses something huge; how we position our bodies before intubating and how proper biomechanics can be used to our advantage when intubating.

Properly positioning the patient before intubating is important, but how you position yourself before intubating is even more important.

After 16 years in EMS, I can make a fairly good assessment of how well an intubation is going to go just based on the body positioning of the person doing the intubation. Seeing nothing more than where and how they stand in relation to a patient I can get a pretty good sense if this will be an easy intubation for them or if it is going to be a struggle. 

Many people attempt to intubate patients using the forearm smash to the face approach (FSTTFA). It usually does not go well. They might get the endotracheal tube in there, but it is an ugly ride on the struggle-bus.

The FSTTFA (see figure 1, below) is bad for everyone involved—both you and the patient. People adopt this technique because they learned to intubate this way and it sort of works, at least just well enough so that people just keep doing it. Every patient they intubate with this technique ends up being “a really hard tube.” Using the FSTTFA approach is an inefficient way to intubate patients. 

Most people learned to intubate on manikins that had lightweight heads and they needed to use a forearm smash to the face to keep the lightweight manikin from lifting off the ground when they were intubating it. Using manikins with unrealistically light heads formed bad habits that for many people carried over into the real world. In addition to making viewing the glottic opening harder and causing your shoulder to burn, using the FSTTFA makes fitting the endotracheal tube in a patient’s mouth difficult as your wrist is covering half of their mouth. 

 

Figure 2 below shows another example of the FSTTFA. Note the elbow being several inches below the wrist. 

Using your whole body to intubate allows you to progressively adjust how much power you put into the laryngoscope and allows you to use much more efficient from a biomechanical perspective. Figure 3 points out some of the issues you’ll encounter if bad biomechanics are used when intubating.

 

So how do you intubate with your glutes?
To be honest, it really isn’t about using just your glutes as much as it is about using your whole body to intubate. Thinking about using your glutes is a good prompt to get you to use your entire body when intubating a patient and made for a catchy headline. 

Start by standing behind and to the side of the patient at about a 30 - 45-degree angle to them, not parallel to them. Standing at an angle to the patient gives you options. Angles equal options.  Extend your left hand with the laryngoscope in it like you were going to shake someone’s hand but you decided to ignore social norms and are doing it with your left hand, bringing it across your body to about your midline, (figure 4 below).

Stand up tall. Resist the urge to crouch down and get near the patient. You are going to be bringing the patients airway into your line of sight and avoiding putting your face in the splash zone. Put the laryngoscope in the patient’s mouth. You will not be able to see much at this point but that is okay, keep the faith and it will all work out. 

Many people say to follow the tongue down but this advice needs to be clarified; trying to glide the blade down the tongue often results in shoving the tongue down and into your way. Instead of sliding down the tongue think about "hopping" the blade down the tongue in small increments. Lift the tongue and advance just a little bit and then repeat as needed—lift and advance, lift and advance, tiny little hops down the tongue until you see something else you can identify. 

The epiglottis should start to come into view at some point. Nextyou need to displace the jaw up and forward a little bit. Just a little bit. Depending on your laryngoscope blade choice now is the time to either sweep and lift the epiglottis or put upward pressure on the hyoepiglottic ligament causing the epiglottis to rise out of your way and giving you a view of the glottis. Remember, you don't want a view of their carina, you just want a so-so view of the glottic opening. If you go for the view that lets you see their alveoli, you'll have a great view, but you will struggle to get the tube to go where you want it to go. 

A patient that is easy to intubate may not require much power to lift the jaw and tissues to get a view of the glottic opening but a patient with an extremely anterior airway and stiff jaw may require you to generate some significant power to displace the tissues to get a view or to pass the tube. If you need more power drive your left elbow rest into your iliac crest and step or rock forward using your entire body to move the patient’s tissues. You should not feel your shoulder burning at this point, (figure 5 below). This is the beauty of using your whole body here. 

There should be several inches of space between your forearm and the patients face if you do this right, your left arm should come diagonally across the patients face, if you are in the wrong position your arm will be parallel to the patient’s face, (see figure 6 below). A good test to see if you are using your whole body is to see if you can maintain this visualization for sixty seconds without burning out your shoulder.

Use your whole body.
When you use your whole body to intubate you have numerous options in how you can move the laryngoscope to adjust your view; you can move your wrist in all four planes, raise or lower your forearm, pronate or supinate the radius and ulna, internally or externally rotate your arm at the shoulder,  abduct or adduct the arm, and use your lower body to drive your torso forward or backward and up and down. When you try to intubate like you are Salt Bae sprinkling some salt, you can use your shoulder and some muscles in your wrist and not much else. Using your whole body to intubate gives you options, doing the Salt Bae face-smash gives you no options and other than you can skip shoulder day for one arm.  

What about if they are on the floor? 
Many of the same principles apply when intubating a patient on the ground. If at all possible, elevate the patient's head with whatever you can find. Our video laryngoscope Pelican case is about the right size to put under a patient's head to ramp them up a bit. When intubating on the ground EMS providers often go with either the head-in-the-lap move (yuck) or the cover-me-I'm-under-fire-prone maneuver. Neither of the aforementioned techniques let you use your whole body. The head in the lap relies on shoulder strength and the prone intubation puts you in the Salt-Bae face-smashing position. Unless then you are actually under fire and then there is some merit to keeping a lower profile, then again I have never been under fire but I tend to think there are no ET tubes in a gunfight. 

To use your whole body to intubate a patient on the ground there are two options. Option one is for you to get on both knees and be at around a 45-degree angle to the patient, option two is a to get in a lunge like position with one knee on the ground at a 45-degree angle to the patient. 

 

What about if they are trapped in a car / strapped to a table upside down in the dark and it is raining / they're trapped under a collapsed building and I have to crawl in there and I can't use my whole body to intubate? 
Just use a friggin i-gel. Seriously. 

 

 

 

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