I would like to know from as many flight nurses & flight paramedics
1) What meds ( and the dose) are you currently using for your patients in flight when they become nauseated or are vomiting?
2) Do you use them often & do they usually work?
3) If you use phenergan, do you dilute it? And do you see many side effects from it & what kind? Also, if you use phenergan, what dose do you start with?
4) Why did your program choose the specific anti emetic that you are currently using?
5) If you use compazine, do you have trouble keeping it in stock & why that drug over other anti emetics?
Please tell me what program you fly with. I am researching anti emetics used in R/W programs because we are trying to get our protocols changed & in order to do that, I need feedback from other programs. ( I fly for a R/W program in Missouri).Thankyou in advance for your input.

We use Phenergan, star with 12.5mg SIVP, repeat as needed in 10-15 min. We normally dont dilute it and we rarely need the repeat dose. It works very well. My program has used it long before I came around, so I dont know their rationale behind this specific drug, but it is cheap , effective, and easy to keep in stock.

We carry Phenergan and Zofran. We use phenergan 12.5-25 mg as needed, if we need to potentiate the effect of narcotics for pain control. I personally like Zofran, dose is 4mg, as needed. It does not have the side effects like Pherergan does. We fly a BK117 and since that AC is nicknamed the vomit comet, we use it quite a bit for prophylaxis for someone in full spinal restrictions, etc at the crews discretion! I hope this helps.

We have the options of reglan 5-10mg (may mix with benadryl) and Zofran 4mg. These are not supposed to be given until the pt c/o nausea. Prior to flight I ask patients if they get air/car sick. If they do, I believe that they just complained of some nauea . Most of my immobilized pt's also c/o of nausea prior to lifting off . I personally believe that we should have a protocol for all immobilized patient's to get some sort of anti-emetic. A clean/patent airway is still/always will be #1 on the list. I am very liberal with zofran.

LOL @ the "vomit comet" for the BK117. I love a BK117, and never had that much of a problem. Anyway, the two programs I've worked for (one fixed wing, one rotor wing) both used Phenergan 12.5mg and of course either 1/2 that or going w/ wt based for peds. Althought it wasn't standard to mix it w/ NS, most of us did, 9mL NS to 25mg Phenergan (25mg/1mL). That decreased the burning sensation that a lot of patients get. I've used Zofram, and found it to be a good drug, but if you don't give it before the patient vomits then its worthless and I kinda like the sedative effect of Phenergan anyway. If they sleep through the flight, all the better.

As for when to give it, it was left up to the crew. If was going to be extrememly hot/bumpy then I gave it. Or if I knew I was going to be giving narcotics the patient got it. I'm a sympathetic yacker, the patient yacks and my body thinks it should do the same. So if they even remotely needed it, they got Phenergan or Zofram.

Just my $0.32.

Jerry

The air service that I currently work for uses Reglan 5-10 mg IV (don't really know why, no one seems to know the reasoning behind it). A previous service that I worked for used phenergan 6.25-25 mg IV diluted in 10-20 cc of NS to reduce the burning sensation and the sedative effect.

We use phenergan, 6.25 to 25mg slow IVP, depending on pt size, how bad the nausea seems to be, and how much sedation we want. I think the reasons we use it over other meds is because its cheap, easy to give, and most of the EMS services and hospitals in our area also use it. We're pretty liberal with it and give it to pretty much everyone who gets opiates, and lots who don't.

I saw a pretty profound dystonic reaction one time that must have been from the phenergan, but I've never seen any other side effects from it. Most where I work dont really consider the mild sedation a "side" effect; it's one of the reasons we like to give it. Works GREAT with morphine or dilauded...

Interesting, this is the first time I've ever heard of diluting Phenergan. I've given lots of it on flights and in the ED, and I dont think I've ever heard someone complain of a burning sensation from it.

We stopped using Pheneragan related to the side effects and recent disfavor w/ this drug. We replaced it w/ Anzimet used mostly in treating cancer pt's ie.. the chemotherapy areana. Great drug w/o the side effects. There is alot of negative associated w/ Pheneragan and some institutions will not use it. Dosing is very simple and usually the same as Phenergan. Because of minimal side effects and rapid onset you can use it leberally.

Our program as a whole uses Zofran 4 mg as needed. We also carry Phenergan. We give Zofran on all immobilized patients that remotely c/o nausea. We have found the elderly population as a whole does a lot better on Zofran than Phenergan. Hope this helps!

Robbie Tester, BS, NREMT-P, FP-C
LIFE FORCE, Chattanooga TN

We also use phenergan 12.5-25 for most medical pts, however we also use Zofran on a somewhat regular basis as well. More times than not we admin prior to loading the pt. with or without C/O of nausea.

Our current practice is to use Phenergan in those patients who have a patent airway, are hemdynamically stable, have not ingested alcohol, and have not sustained multiple trauma.
We use Anzimet in patients where Phenergan is contrainidicated. The majority of our patients recieve Anzimet including our pedi population.

yes some people still use inapsine....(see recent 'black box' literature) we also use phenergan. should always dilute as extremely caustic to the tissues. (also one of the most common successful lawsuits levied against nurses) ? about medics...i've worked somewhere that the latter had to be administered concomitantly with benadryl to decrease the risk of a phenothiazine reaction. still do that to this day. that's one of the last things i wish to see in a helicopter during flight. during initial interview with the pt, if they have a hx of nausea or appear anxious...out come the meds

1) What meds ( and the dose) are you currently using for your patients in flight when they become nauseated or are vomiting?

Phenergan 12.5 up to 25
Zoferan 4 up to 8 (new addition)
Inapsine .625 up to 1.25

2) Do you use them often & do they usually work?

I am big fan of zoferan in the hospital and I think it will be great in the A/C. I also have had excellent results with inapsine (yes i know about the warnings)

3) If you use phenergan, do you dilute it? And do you see many side effects from it & what kind? Also, if you use phenergan, what dose do you start with?

I always give phenergan through a running IV line and start with 12.5 then ramp to another 12.5. I have seen the dystonic reactions enough that I tend not to use it at all if possible.


4) Why did your program choose the specific anti emetic that you are currently using?

CQI committe research and efficacy

Hope this is helpful and fly safe.

We use Zofran for every patient that we fly, just a a precaution. Most of our patients are hoisted into the airframe with a SKED or Stokes on a wench. The Zofran works ok I guess. We used to used Inapsine prior to the "black box" warning and I liked that alot better for not only the nausea factor, but for the anxiety of being hoisted as well. Now we have to use a little IV valium in addition to the Zofran to achieve the same end. (ugghh)
As a side discussion here, does anyone have any first hand (anecdotal) experience with the 'bad juju' that goes along with droperidol ?

-josh

We use Phenergan on our patients starting with the 12.5mg and as some others said, that usually does the trick. I wish we carried Zofran, but it's a bit more expensive and doesn't make our pt's sleep away the trip and since we fly VERY long range trips on our lears, we like the sleepy bye affect. Just a little FYI, Zofran can drop your B/P, so be careful on your patients that are already a bit hypotensive. Hope this will be helpful like the other responses you have received..

I have used droperidol both in ICU/ER setting as well as flight for years and have never seen a bad outcome. The research shows that in a small sect of the population is at risk for prolonged QT. Based on that I choose not to give it to people with pre existing heart conditions.

The problem with black box drugs such as inapsine and demerol is that it often occurs due to one successful litigation. All of the drugs we give have inherent risks. From my perspective its a matter of risk v benefit. I have also noted the cases of fatality associated with inapsine were at a dose range of 2.5 or greater . I give it in doses of .625 to a maximum of 1.25.

Here is a quote from a peer review of the evidence in regards to inapsine:

For more than 30 years, droperidol (Inapsine), a butyrophenone, has been used as an antiemetic and antipsychotic agent. In 2001, the FDA placed a black box warning on droperidol to alert practitioners to a new perceived hazard, and set new recommendations for safe use. The warning was precipitated by reports of cases of QT-interval prolongation that were associated with droperidol use, which led to torsades de pointes and death. Since the warning, use of droperidol has declined dramatically, and many hospitals have restricted its use or have removed it from their formularies. In this review article, the authors assessed the evidence for an association between droperidol use and QT-interval prolongation.

A literature search identified 3 clinical studies (2 nonrandomized prospective trials and 1 observational cross-sectional survey), 1 abstract, and 7 case reports. The authors also reviewed FDA postmarketing surveillance data. After applying principles of evidence-based medicine, the authors concluded that droperidol administration does cause QT-interval prolongation. The crux of the issue, however, is whether droperidol use, at recommended doses, is a risk factor for life-threatening dysrhythmias. Using Hill's criteria for establishing cause and effect (which are based on the premises that cause precedes effect, response is dose dependent, and the same effect occurs under similar circumstances), the authors concluded that the scant and incomplete data do not provide convincing evidence of a causal relation between droperidol administration and life-threatening cardiac events. In an accompanying editorial, an FDA representative states that the black box warning is appropriate even if causality is not established fully.

Comment: Given our litigious world, many clinicians have changed their practices with respect to this highly useful drug, despite the paucity of evidence to support the black box warning. Unfortunately, fear of the legal system, rather than scientific evidence, has had a profound effect on the practice of medicine.

If your looking for more information on inapsine and research here are some links:

http://www.asahq.org/Newsletters/2002/4_02/mccormick.htm
http://emergency-medicine.jwatch.org/cgi/content/full/2003/610/1