2008 EAGLES PRESENTATION. Intranasal Versed Usage in an Urban Fire Based EMS System: PARAMEDIC PERCEPTION OF UTILITY

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1 2008 EAGLES PRESENTATION Intranasal Versed Usage in an Urban Fire Based EMS System: PARAMEDIC PERCEPTION OF UTILITY

2 CFD EMS OVERVIEW

3 CFD EMS OVERVIEW

4 CFD EMS OVERVIEW All ALS EMS System Two EMT-Ps on each Medic Vehicle (32) At least one EMT-P on each engine (34) Engine/medic stations Seven EMS Supervisors (Lieutenants)

5 Intranasal Versed effects in the field Why intranasal Versed for seizures in the EMS setting? No needles No need for an IV in a seizing patient. Rapid delivery No delays in IV attempts. Socially acceptable No need for rectal drug administration.

6 Intranasal Versed Research Studies Rectal diazepam fails to abort about 40 percent of seizures in randomized controlled trials. (Lancet 1999;353:623; J Pediatr 1999;135:398; J Child Neurol 2002;17:123.) Several randomized trials now demonstrate that transmucosal intranasal midazolam is as effective as intravenous diazepam and more effective than rectal diazepam in aborting prolonged seizures. (J Child Neurol 2002;17:123; Brit Med J 2000;321:83; Epilepsy Behav 2004;5:253.) In addition, its preference over rectal diazepam by caregivers and its safety as home therapy have been established in multiple small studies. (Arch Dis Child 2004;89:50; J Paediatr Child Health 2004;40:556; Eur J Paediatr Neurol 1999;3:73; Seizure 2000;9:417.)

7 Intranasal Versed Research Studies Seizures. Lahat et al, BMJ, Prospective study: IN midazolam versus IV diazepam for prolonged seizures (>10 minutes) in children. Similar efficacy in stopping seizures (app. 90%). Time to seizure cessation: IV Valium: 8.0 minutes. IN Versed: 6.1 minutes.

8 Intranasal Versed Research Studies Seizures. Lahat et al, BMJ, Conclusions: IV diazepam and IN midazolam have similar efficacy at controlling prolonged seizures in children. IN midazolam controls seizures more rapidly because there is no delay in establishing an IV.

9 Intranasal Versed Research Studies Sedation Henry et al, Pediatr Dent, 1998 IV vs. IN drop vs. IN atomized midazolam in dogs Conclusions: Both nasal routes produced higher CSF concentrations; atomized higher than IN drops Malinovsky et al, Anaesthesia, 1995 Oral vs. IN vs. rectal midazolam in kids Conclusions: Sedation occurred sooner with IN meds (7.7min vs. 12.5min rectal)

10 CFD Protocol for IN Versed For treatment of persistent seizure activity Procedure: Assess ABC s Airway, Breathing, Circulation For pulseless patients, proceed to ACLS guidelines Apply 100% oxygen NRB mask to seizing patient Use age based table to determine proper volume of Versed for atomization:

11 Patient age (years) IN Versed Dosing Table Weight (kg) IN Versed volume in ml* 5mg/ml concentration IN volume (ml) Dose (mg) 5 mg / ml Neonate 3 kg 0.3 ml 0.6 mg <1 yr 6 kg 0.4 ml 1.2 mg 1 yr 10 kg 0.5ml 2.0 mg 2 yr 14 kg 0.7 ml 2.8 mg 3 yr 16 kg 0.8 ml 3.2 mg 4 yr 18 kg 0.9 ml 3.6 mg 5 yr 20 kg 1.0 ml 4.0 mg 6 yr 22 kg 1.0 ml 4.4 mg 7 yr 24 kg 1.1 ml 4.8 mg 8 yr 26 kg 1.2 ml 5.2 mg 9 yr 28 kg 1.3 ml 5.6 mg 10 yr 30 kg 1.4 ml 6.0 mg 11 yr 32 kg 1.4 ml 6.4 mg 12 yr 34 kg 1.5 ml 6.8 mg Small teenager 40 kg 1.8 ml 8.0 mg Adult or full-grown teenager 50 kg 2.0 ml 10.0 mg

12 CFD Protocol for IN Versed Load syringe with appropriate milliliter volume of Versed (use only 5mg/ml concentration) and attach MAD nasal atomizer Place atomizer within the nostril Briskly compress syringe to administer 1/2 of the volume as atomized spray. Remove and repeat in other nostril, so all the medication is administered Continue ventilating patient as needed If seizures persist 5 minutes after treating, consider repeating ½ dose of Versed either intranasally, intramuscularly or intravenously. Secure airway if necessary.

13 Intranasal Versed for TASER patients A. Secure scene and use Universal Precautions B. Remove from volatile environment C. ABC (airway, breathing, circulation) D. Vital signs, pulse oximetry and temperature if possible E. May sedate patient using intranasal Versed or if possible IV Versed. Dose according to protocol. F. IV Access with NS G. If patient has been TASERED or has extensive muscle activity, consider IV fluid bolus of 500cc over 20 minutes with half ampule of Sodium Bicarb in IV bag.

14 Analysis and Implementation of IN Versed Analysis of product: Jan-May 2003 Recommendations made: June 2003 MAD device arrives: September 2003 Training/Protocol development: Oct 2003 Training completed: December 2003 Devices deployed: Feb 2004

15 Survey specifics on IN Versed use Distributed to all EMS personnel on medics 2 EMT-Ps/32 medics x 3 units = 192 total medics received survey Two month response time given Oct-Dec 2007 Responses returned to EMS education 149 responses back: 77% return rate

16 Results of IN Versed Survey for CFD EMS I most often use Intra-Nasal Versed for the following chief complaint(s): Excited Delirium Seizures Induction for Intubation Sedation for Cardioversion Pain Control Other (please specify) Other Pain Sed ETT Series2 Series1 Sz ED

17 Results of IN Versed Survey for CFD EMS Approximate number of times I use Intra-Nasal Versed each month: [ 0 5 ] [ 6 10 ] [ ] [ > 15 ] [>15] [11-15] [6-10] Series1 [0-5]

18 Results of IN Versed Survey for CFD EMS On a scale of 1-10, I feel that I have received enough education to use Intra-Nasal Versed effectively on patients who need it: Not comfortable Somewhat comfortable Very comfortable nine seven five Series1 three one

19 Results of IN Versed Survey for CFD EMS On a scale of 1-10, I feel comfortable assembling and using Intra-Nasal Versed on patients who need it: Not comfortable Somewhat comfortable Very comfortable nine seven five Series1 three one

20 Results of IN Versed Survey for CFD EMS On a scale of 1-10, I feel that as a result of Intra-Nasal Versed administration, the patient generally: Gets worse Remains unchanged Improves nine seven five Series1 three one

21 Results of IN Versed Survey for CFD EMS I feel that having IN Versed available to me has enhanced my practice as a paramedic: Did not enhance Somewhat enhanced Greatly enhanced nine seven five Series1 three one

22 Conclusions from survey on IN Versed IN Versed used most often for seizures (81%) IN Versed used 0-5 times per month (97%) 96% felt comfortable with education on IN Versed 3% felt uncomfortable utilizing IN Versed Patient remains unchanged or improves 99% of time 93% felt it somewhat or somewhat or greatly enhanced their practice

23 Things we wish we had done better Tighter control of who got survey form Better application of statistical analysis Ask what unit day and medic vehicle worked Post survey on intranet Better questions: How many times did IN Versed not: Abort seizure Adequately sedate patient Do you feel IN Versed is NOT helpful in your practice? I feel that I need more education using IN Versed Other we are not smart enough to ask right

24 Questions??????????

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