1. Welcome! Webinar participants Please be sure your mic is on mute You can send messages in the chat pane Mute Cellphones 1

2. Protocol Update 2015-2016 Version 2

3. Outline Review major changes Rocuronium Bromide In-service Ketamine In-service 3

4. The Changes 4

5. ROCURONIUM BROMIDE (Zemuron) A Non-depolarizing paralytic 5

6. 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. 6

7. Indications Rapid Sequence Induction where Succinylcholine is unavailable or contraindicated (hyperkalemia). As a post-induction maintenance paralytic. 7

8. 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 8 Less than 1% of the studied population.

9. Dosing 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. 9

10. Onset 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 10

11. Ketamine (Ketalar) A rapid-acting, general anesthetic agent 11

12. 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. 12

13. Indications 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. 13

14. 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. 14

15. Contraindications Glaucoma Schizophrenia Pregnancy Stroke / Increased ICP 15

16. Dosing 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. 16

17. Notes Ketamine must be used with a Benzodiazepine to minimize hallucinations / emergence reactions associated with emergence from the medication. 17

18. 2016 AND BEYOND EMS in Josephine County 18

19. In Process New Medical Director process County CQI /QA programs and implementation MCI Drill Protocol Review and Development PHCC 19