Anybody ever seen this?

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Specializes in Emergency/Critical Care Transport.

We've seen pt's that can take a ton of narcotics and not even slow their resps or even get drowsy. I am always amazed at the people who I give 8-10mg of Dilaudid to over a few hours that are still c/o of pain. (This is NOT a pain/narcs/ seeking thread). My thought is always, "Pain? How are you still breathing?"

Yesterday the medics brought me a 57 yo lady with long hx of COPD/CHF who had developed dyspnea and called 911 on EMS arrival she asked the paramedic to intubate her. She had been tubed in the past. He complied. On arrival ED post 2mg Versed she was awake and able to answer questions by nodding. She was only gagging a little on the tube, She had no resp effort w/o bagging. Gave her 3more mgs of Versed which stopped the gag and she was still awake, soon her gag came back, but still no resp effort. Hung a propofol drip started @ 5mcg/kg/min. Lady is still awake! Her bp hanging in the 155/90 range, bump up the drip to 10mcg/kg/min, still awake! still good BP

IV line was patent, central line placed, propofol switched to central line, pt still awake and answering questions with a nod. Upped the drip to 15mcg's pt's bp began to slump down to 106/60 range but she was still wide awake. She went to

ICU that way. Even 5mg bolus's didn't snow her! Everyone else I have hung propofol on was out like a light with 5mcg's, rarely have I had to go beyond 10. This woman was amazing! So anyone ever seen this before?

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medic....on the narc thing...an opioid works by filling delta/kappa receptors...these receptors when full trigger the manufacture of more receptors ie: increased tolerance...so when some are on high dose narcs it will not effect them like it would someone who doesn't take them because they have more receptors to fill.

as far as the versed...i don't know if she was on any other meds that may have inhibited its effect..it also has a short 1/2 life...

the propofol doses were low (and i know she was a little old lady) - and technically those doses are effective...but again her body is in a state of stress...so she was eating up that stuff like candy...it also has an extremely short 1/2 life as well ....bolus wise 20-50 mg is more of the norm...and as for a drip - even 20mcg/kg/min is the lowest dose i would start w/ if i wanted someone out.....

just my 2 cents....but good discussion

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Specializes in Emergency/Critical Care Transport.

Yeah I know about the receptors thing. It still amazes me though.

With the propofol once I got to 15mcgs her BP was dropping, she was in failure so I didn't want to have to bolus her with fluids if it got too low, or do the old dopamine in one line, propofol in the other and titrate them back and forth till you hit a level spot. I've never seen pts with that do too terribly well.

Thanks for the input A-girl!

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Originally posted by athomas91

medic....on the narc thing...an opioid works by filling delta/kappa receptors...these receptors when full trigger the manufacture of more receptors ie: increased tolerance...so when some are on high dose narcs it will not effect them like it would someone who doesn't take them because they have more receptors to fill.

while this may be true, i think the real reason is that we probably don't cut our stuff as well as they do on the street! (only kidding guys!) lol

but seriously,

yes, i have seen this and have been utterly amazed. i also think some of it may be do to the patients perception of things. you know, sort of like that will to live thing. i truley believe that state of mind assists in guiding our body's reaction to things. sort of like the pain/seeker/abuse thread - but not touching on the subject, purely observation. some people come in in crisis and they perceive it to be the worst so thier minds may not allow them to feel effects as quick as we think they should. at least this is what i have observed.

ie: the man with the kidney stone. we know that for a man, this is natures way of letting him know what labor is like. yea, it hurts! so that initial 2 mg of dilaudid might not work as fast.

ie: sticking kids..... well, the anticipation hurts the most. how many times have you stuck a 6 year old and they acted all out and then you were finished and they said, "is that all?"

ie: your intubated lady. well, if she thought that she was going to die, maybe her mind would not let her go out. her will to live was stronger at that time than your drugs. sort of like that adreneline rush when the meek skinny guy lifts up the car to save the baby.

i think this and what athomas said may be an answer!:D

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Specializes in ER, ICU, L&D, OR.

Ive seen it before

and Im never amazed anymore

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