Re: RSI Drugs

March 25, 2005

If he rode a Yamaha his ICP WOULD be high.

Larry

>

> Barry,

>

> I thought you rode a Yamaha. Sorry.

>

> GG

> In a message dated 3/24/05 23:04:28, ultrahog2001@a... writes:

>

> >

> > Rather judgmental statement don't you think Gene?

> >

> > Barry Meffert

> >

> > In a message dated 3/24/2005 2:24:25 PM Central Standard Time,

> > wegandy1938@a... writes:

> > I've intubated a few swine in my day also. Most were riding

Harleys as I

> > recall, so I naturally assumed low ICP to begin with.

> >

> > Gene

> >

> > In a message dated 3/23/05 21:40:35, bbledsoe@e... writes:

> >

> > >

> > > Emerg Med J. 2001 Nov;18(6):453-7.

> > >

> > > In patients with head injury undergoing rapid sequence

intubation, does

> > > pretreatment with intravenous lignocaine/lidocaine lead to an

improved

> > > neurological outcome? A review of the literature.

> > >

> > > N, Clancy M.

> > >

> > > Emergency Department, Southampton General Hospital, Tremona

Road,

> > > Southampton SO16 6YD, UK. poppabear66@h...

> > >

> > > It is well known that laryngeal instrumentation and

endotracheal

> > intubation

> > > is associated with a marked, transient rise in intracranial

pressure

> > (ICP).

> > > Patients with head injury requiring endotracheal intubation

are considered

> > > particularly at risk from this transient rise in ICP as it

reduces

> > cerebral

> > > perfusion and thus may increase secondary brain injury. The

favoured

> > method

> > > for securing a definitive airway in this patient group is by

rapid

> > sequence

> > > intubation (RSI). In the United States the Emergency Airway

Course teaches

> > > emergency physicians to routinely administer intravenous

lidocaine as a

> > pre

> > > treatment for RSI in this patient group in an attempt to

attenuate this

> > rise

> > > in ICP. A literature search was carried out to identify

studies in which

> > > intravenous lidocaine was used as a pretreatment for RSI in

major head

> > > injury. Any link to an improved neurological outcome was also

sought.

> > Papers

> > > identified were appraised in the manner recommended by the

evidence based

> > > medicine group to ensure validity. There were no studies

identified that

> > > answered our question directly and, furthermore, it is our

belief that no

> > > such study, at present, exists in the literature. Six valid

papers were

> > > found, which individually contained elements of the question

posed and

> > these

> > > are presented in a narrative and graphic form. There is

currently no

> > > evidence to support the use of intravenous lidocaine as a

pretreatment for

> > > RSI in patients with head injury and its use should only occur

in clinical

> > > trials.

> > >

> > > Publication Types:

> > > Review

> > > Review, Tutorial

> > >

> > > ______________________________

> > ______________________________________________

> > > __-

> > > J Trauma. 2005 Feb;58(2):278-83.

> > >

> > > Intracranial pressure changes during rapid sequence

intubation: a swine

> > > model.

> > >

> > > Bozeman WP, Idris AH.

> > >

> > > Department of Emergency Medicine, Wake Forest University

School of

> > Medicine,

> > > Winston-Salem, NC 27157, USA. wbozeman@w...

> > >

> > > BACKGROUND: Controversy and speculation exist regarding

intracranial

> > > pressure (ICP) changes produced by various combinations of

rapid sequence

> > > intubation (RSI) agents. In this pilot study, we sought to

develop a swine

> > > model to investigate these changes in classic RSI. METHODS:

Eight adult

> > > swine were instrumented with arterial and intracranial

pressure monitors.

> > > Four different versions of rapid sequence intubation were then

performed

> > > sequentially in each animal in a crossover trial design:

regimen 1,

> > > thiopental; regimen 2, thiopental and succinylcholine; regimen

3,

> > lidocaine,

> > > thiopental, and succinylcholine; and regimen 4, pancuronium,

lidocaine,

> > > thiopental, and succinylcholine. ICP and hemodynamic

parameters were

> > > recorded and compared. Trials were excluded from analysis if

baseline ICP

> > > measurements were unstable or if intubation was difficult.

RESULTS: Peak

> > > changes in ICP were noted at 2 to 3 minutes after

administration of

> > > induction agents. Mean values for peak changes in ICP were as

follows:

> > > regimen 1 (n = 5), 3.6 mm Hg (95% confidence interval [CI],

1.0-6.2 mm

> > Hg);

> > > regimen 2 (n = 9), 13.6 mm Hg (95% CI, 9.6-17.6 mm Hg);

regimen 3 (n = 2),

> > > 16.0 mm Hg (95% CI, -34.8-66.8 mm Hg); and regimen 4 (n = 3),

12.0 mm Hg

> > > (95% CI, -8.3-32.3 mm Hg). CONCLUSION: The model is effective.

It enables

> > > investigators to examine the aggregate ICP effects of

combinations of RSI

> > > medications. RSI regimens with paralysis produced threefold

increases in

> > > peak ICP change compared with the sedation-only regimen.

Pretreatment

> > agents

> > > did not affect ICP changes. Future investigations can examine

other agents

> > > and add experimental manipulation of ICP to simulate head

injury

> > physiology.

> > > Additional parameters including cerebral metabolism and/or

oxygenation may

> > > also be explored.

> > >

> >

_____________________________________________________________________

_______

> > > _______________________________

> > > Lidocaine toxicity.

> > >

> > > Mehra P, Caiazzo A, Maloney P.

> > >

> > > Department of Oral and Maxillofacial Surgery, Boston

University School of

> > > Dental Medicine, Massachusetts 02118, USA.

> > >

> > > Local anesthetics are the most commonly used drugs in

dentistry. The

> > number

> > > of adverse reactions reported, particularly toxic reactions,

are

> > > extraordinarily negligible. This article reports a case of

lidocaine

> > > toxicity with its typical manifestation in a 37-yr-old healthy

male. The

> > > toxic reaction followed transoral/transpharyngeal topical

spraying of

> > > lidocaine preoperatively during preparation for general

anesthesia. A

> > review

> > > of dosages of the most commonly used local anesthetic drugs in

dentistry

> > and

> > > the management of a toxic reaction is presented. Clinicians

need to be in

> > a

> > > position to recognize and successfully manage this potential

adverse

> > > reaction.

> > >

> > > Publication Types:

> > > Case Reports

> > >

March 25, 2005

If he rode a Yamaha his ICP WOULD be high.

Larry

>

> Barry,

>

> I thought you rode a Yamaha. Sorry.

>

> GG

> In a message dated 3/24/05 23:04:28, ultrahog2001@a... writes:

>

> >

> > Rather judgmental statement don't you think Gene?

> >

> > Barry Meffert

> >

> > In a message dated 3/24/2005 2:24:25 PM Central Standard Time,

> > wegandy1938@a... writes:

> > I've intubated a few swine in my day also. Most were riding

Harleys as I

> > recall, so I naturally assumed low ICP to begin with.

> >

> > Gene

> >

> > In a message dated 3/23/05 21:40:35, bbledsoe@e... writes:

> >

> > >

> > > Emerg Med J. 2001 Nov;18(6):453-7.

> > >

> > > In patients with head injury undergoing rapid sequence

intubation, does

> > > pretreatment with intravenous lignocaine/lidocaine lead to an

improved

> > > neurological outcome? A review of the literature.

> > >

> > > N, Clancy M.

> > >

> > > Emergency Department, Southampton General Hospital, Tremona

Road,

> > > Southampton SO16 6YD, UK. poppabear66@h...

> > >

> > > It is well known that laryngeal instrumentation and

endotracheal

> > intubation

> > > is associated with a marked, transient rise in intracranial

pressure

> > (ICP).

> > > Patients with head injury requiring endotracheal intubation

are considered

> > > particularly at risk from this transient rise in ICP as it

reduces

> > cerebral

> > > perfusion and thus may increase secondary brain injury. The

favoured

> > method

> > > for securing a definitive airway in this patient group is by

rapid

> > sequence

> > > intubation (RSI). In the United States the Emergency Airway

Course teaches

> > > emergency physicians to routinely administer intravenous

lidocaine as a

> > pre

> > > treatment for RSI in this patient group in an attempt to

attenuate this

> > rise

> > > in ICP. A literature search was carried out to identify

studies in which

> > > intravenous lidocaine was used as a pretreatment for RSI in

major head

> > > injury. Any link to an improved neurological outcome was also

sought.

> > Papers

> > > identified were appraised in the manner recommended by the

evidence based

> > > medicine group to ensure validity. There were no studies

identified that

> > > answered our question directly and, furthermore, it is our

belief that no

> > > such study, at present, exists in the literature. Six valid

papers were

> > > found, which individually contained elements of the question

posed and

> > these

> > > are presented in a narrative and graphic form. There is

currently no

> > > evidence to support the use of intravenous lidocaine as a

pretreatment for

> > > RSI in patients with head injury and its use should only occur

in clinical

> > > trials.

> > >

> > > Publication Types:

> > > Review

> > > Review, Tutorial

> > >

> > > ______________________________

> > ______________________________________________

> > > __-

> > > J Trauma. 2005 Feb;58(2):278-83.

> > >

> > > Intracranial pressure changes during rapid sequence

intubation: a swine

> > > model.

> > >

> > > Bozeman WP, Idris AH.

> > >

> > > Department of Emergency Medicine, Wake Forest University

School of

> > Medicine,

> > > Winston-Salem, NC 27157, USA. wbozeman@w...

> > >

> > > BACKGROUND: Controversy and speculation exist regarding

intracranial

> > > pressure (ICP) changes produced by various combinations of

rapid sequence

> > > intubation (RSI) agents. In this pilot study, we sought to

develop a swine

> > > model to investigate these changes in classic RSI. METHODS:

Eight adult

> > > swine were instrumented with arterial and intracranial

pressure monitors.

> > > Four different versions of rapid sequence intubation were then

performed

> > > sequentially in each animal in a crossover trial design:

regimen 1,

> > > thiopental; regimen 2, thiopental and succinylcholine; regimen

3,

> > lidocaine,

> > > thiopental, and succinylcholine; and regimen 4, pancuronium,

lidocaine,

> > > thiopental, and succinylcholine. ICP and hemodynamic

parameters were

> > > recorded and compared. Trials were excluded from analysis if

baseline ICP

> > > measurements were unstable or if intubation was difficult.

RESULTS: Peak

> > > changes in ICP were noted at 2 to 3 minutes after

administration of

> > > induction agents. Mean values for peak changes in ICP were as

follows:

> > > regimen 1 (n = 5), 3.6 mm Hg (95% confidence interval [CI],

1.0-6.2 mm

> > Hg);

> > > regimen 2 (n = 9), 13.6 mm Hg (95% CI, 9.6-17.6 mm Hg);

regimen 3 (n = 2),

> > > 16.0 mm Hg (95% CI, -34.8-66.8 mm Hg); and regimen 4 (n = 3),

12.0 mm Hg

> > > (95% CI, -8.3-32.3 mm Hg). CONCLUSION: The model is effective.

It enables

> > > investigators to examine the aggregate ICP effects of

combinations of RSI

> > > medications. RSI regimens with paralysis produced threefold

increases in

> > > peak ICP change compared with the sedation-only regimen.

Pretreatment

> > agents

> > > did not affect ICP changes. Future investigations can examine

other agents

> > > and add experimental manipulation of ICP to simulate head

injury

> > physiology.

> > > Additional parameters including cerebral metabolism and/or

oxygenation may

> > > also be explored.

> > >

> >

_____________________________________________________________________

_______

> > > _______________________________

> > > Lidocaine toxicity.

> > >

> > > Mehra P, Caiazzo A, Maloney P.

> > >

> > > Department of Oral and Maxillofacial Surgery, Boston

University School of

> > > Dental Medicine, Massachusetts 02118, USA.

> > >

> > > Local anesthetics are the most commonly used drugs in

dentistry. The

> > number

> > > of adverse reactions reported, particularly toxic reactions,

are

> > > extraordinarily negligible. This article reports a case of

lidocaine

> > > toxicity with its typical manifestation in a 37-yr-old healthy

male. The

> > > toxic reaction followed transoral/transpharyngeal topical

spraying of

> > > lidocaine preoperatively during preparation for general

anesthesia. A

> > review

> > > of dosages of the most commonly used local anesthetic drugs in

dentistry

> > and

> > > the management of a toxic reaction is presented. Clinicians

need to be in

> > a

> > > position to recognize and successfully manage this potential

adverse

> > > reaction.

> > >

> > > Publication Types:

> > > Case Reports

> > >

March 25, 2005

What's the fuss?

I thought Gene was referring obliquely to his pig trachea airway presentations.

>I've intubated a few swine in my day also. Most were riding Harleys as I

>recall, so I naturally assumed low ICP to begin with.

>

>Gene

Conley Harmon

----------

No virus found in this outgoing message.

Checked by AVG Anti-Virus.

Version: 7.0.308 / Virus Database: 266.8.1 - Release Date: 3/23/2005

March 25, 2005

Do you have any literature on keeping the Succinylcholine at room temp for 90

days? If so, I would love to have it. Our pharmacist make us change every

14 days. Cost for us is not a big deal, I think we pay something like 33 cents

per vial, but there is a hassle factor of keeping it changed out.

In a message dated 3/22/05 1:39:55 PM Central Standard Time,

acilis1@... writes:

> Succinylcholine is kept on the units for 90

> days at room temperature and then discarded. Zemuron

> is discarded after 60 days. Being a smaller service

> the cost factor for discarding the meds annually is

> fairly low.

>

> Jimmy Hoskins, EMS Director

> Lake Whitney Medical Center EMS

>

March 25, 2005

Do you have any literature on keeping the Succinylcholine at room temp for 90

days? If so, I would love to have it. Our pharmacist make us change every

14 days. Cost for us is not a big deal, I think we pay something like 33 cents

per vial, but there is a hassle factor of keeping it changed out.

In a message dated 3/22/05 1:39:55 PM Central Standard Time,

acilis1@... writes:

> Succinylcholine is kept on the units for 90

> days at room temperature and then discarded. Zemuron

> is discarded after 60 days. Being a smaller service

> the cost factor for discarding the meds annually is

> fairly low.

>

> Jimmy Hoskins, EMS Director

> Lake Whitney Medical Center EMS

>

March 25, 2005

Do you have any literature on keeping the Succinylcholine at room temp for 90

days? If so, I would love to have it. Our pharmacist make us change every

14 days. Cost for us is not a big deal, I think we pay something like 33 cents

per vial, but there is a hassle factor of keeping it changed out.

In a message dated 3/22/05 1:39:55 PM Central Standard Time,

acilis1@... writes:

> Succinylcholine is kept on the units for 90

> days at room temperature and then discarded. Zemuron

> is discarded after 60 days. Being a smaller service

> the cost factor for discarding the meds annually is

> fairly low.

>

> Jimmy Hoskins, EMS Director

> Lake Whitney Medical Center EMS

>

March 25, 2005

Our morphine has to be kept above 59F. You might want to check this before

storing in the fridge.

However, with that in mind, if you check the " ranges " on all the meds we

carry, we have a 6 degree window of allowable temperature. IMPOSSIBLE, even

with

on board ACs, heaters and refrigerators. It would be incredibly difficult to

maintain that strict a level in the pharmacy itself.

In a message dated 3/22/05 12:05:31 PM Central Standard Time,

ftstems@... writes:

> These meds are kept in refrig along with

> narcs and treated just like narcs, just due to the way they work and

> potential risk of them falling into the wrong hands. Hope this helps.

> Shanna Worthington EMT-P

> EMS Director

> Fort Stockton EMS

>

March 25, 2005

Our morphine has to be kept above 59F. You might want to check this before

storing in the fridge.

However, with that in mind, if you check the " ranges " on all the meds we

carry, we have a 6 degree window of allowable temperature. IMPOSSIBLE, even

with

on board ACs, heaters and refrigerators. It would be incredibly difficult to

maintain that strict a level in the pharmacy itself.

In a message dated 3/22/05 12:05:31 PM Central Standard Time,

ftstems@... writes:

> These meds are kept in refrig along with

> narcs and treated just like narcs, just due to the way they work and

> potential risk of them falling into the wrong hands. Hope this helps.

> Shanna Worthington EMT-P

> EMS Director

> Fort Stockton EMS

>

March 25, 2005

,

In the 2001 PDR, it states that the multi-dose vials are stable up to

14 days at room temperature without significant loss of potency. I

found a product information sheet that states the same as the PDR at

http://us.gsk.com/products/assets/us_anectine.pdf Here is a related

article:

Am J Hosp Pharm. 1984 Feb;41(2):300-2.

Shelf life of unrefrigerated succinylcholine chloride injection.

Boehm JJ, Dutton DM, Poust RI.

The shelf life of succinylcholine chloride injection at several pH

values when stored at room temperature was evaluated. Solutions

containing 20 mg/ml of succinylcholine chloride were stored at 25 and

40 degrees C. The reaction was studied at pH values ranging from 3.0

to 4.5. At two-week intervals, the solutions were assayed by high-

pressure liquid chromatography. The initial amount of succinylcholine

chloride in all samples was 100.1 +/- 2.37% of label claim.

Hydrolysis of succinylcholine chloride in unbuffered solutions

followed apparent zero-order kinetics. The pH range of maximum

stability was found to be from 3.75 to 4.50. Succinylcholine chloride

decomposed at a considerably higher rate at 40 degrees C. Allowing

for the effects of pH adjustment during manufacture and degradation

during shipping, losses of 7.0% and 9.0% potency can be expected

after storage at 25 degrees C for four and six weeks, respectively.

Succinylcholine Chloride Injection, USP, should be stored in the

refrigerator; if unbuffered succinylcholine chloride injection

complying with USP pH limits must be stored at room temperature, it

should not be kept for longer than four weeks

D. Stone

> Do you have any literature on keeping the Succinylcholine at room

temp for 90

> days? If so, I would love to have it. Our pharmacist make us

change every

> 14 days. Cost for us is not a big deal, I think we pay something

like 33 cents

> per vial, but there is a hassle factor of keeping it changed out.

>

> In a message dated 3/22/05 1:39:55 PM Central Standard Time,

> acilis1@y... writes:

>

> > Succinylcholine is kept on the units for 90

> > days at room temperature and then discarded. Zemuron

> > is discarded after 60 days. Being a smaller service

> > the cost factor for discarding the meds annually is

> > fairly low.

> >

> > Jimmy Hoskins, EMS Director

> > Lake Whitney Medical Center EMS

> >

>

March 25, 2005