Zachary2011

Our hospital, insulin gtss goto the units only... ie ICU/CCU/CVICU..... however I think depending on the circumstances they should be able to goto the floors or at least to PCU of which is considered critical care, however they dont take care of any critical pts. ... I never understood that..... I do think q 1 hours accu checks is too much for the floor nurses they are busy enough...... it all depends if they are DKA, whats there anion gap, how symptomatic are they....... if I have time I prefer to watch them in the ER after their boluses, and k and get the suger down enough to start the D5 with the gtt, hopefully their anion gap is much more narrow or even normal and then they can be sent to somewhere other then the units. However at this time the units complain the pt. is too stable even if on insulin gtt for them to accept, and the other floors say they are too unstable or they wouldnt be on an insulin gtt........... but I believe for the most part our gtts goto the units.

Most the docs I know differ the versed dose for each individual pt., the usual things as in weight, age, extent and type of injury...... many times they will give 2-4mg, monitor the pt and if needed give more.........also I completey understand the diprivan being the big gun as compared to versed being a little 22. I was just curious as to which you would prefer to administer for reductions. As I mentioned on earlier posts, I have learned a lot from these posts and will never personally give diprivan to a pt. not intubated. Is there even a better drug of choice then versed........ at times if the docs think they can do the reduction with just valium and morphine or demerol they do that...... I prefer that for pt. safety also ,if at all possible. If this question is for a whole different post I apologize,,,, I just thought who better to ask then the people whoms post Ive been reading. All seem like they could give me some helpful info. on this subject. Thanx again

I agree w/ Tazzi, Some people just cant handle betablockers, just as some cant handle calcium channel blockers........... However I think you did the right thing regardless of what response the pt. had.......... Ive seen pt.s go into complete heart block after getting a beta blocker......

Hi again, I just want to say I have learned a lot from this discussion, and myself will no longer give diprivan personally, however I am sure it will remain the drug of choice for reductions in the ERs I work at.............. My only question is, we are all talking about aspiration, apnea, etc. other s/s , these same complications occur with versed, in fact just lucky Im sure but the only time I have had to bag a pt. post reduction was on versed.... we always consider last meal and fluids...... then the part about calling anesthesia........ oh my..... that wont happen..... at least where I work it takes an act of God to get them to do a blood patch........I understand they are busy........ but our ER docs in my opinion def. have the skills to manage these pts. , of course now I say if you want the diprivan pushed...... you push it.......... anyway I guess the real question was ,dont these same complications occur with versed......... are they just more likely with diprivan? How much more likely? If you worked in the ER what would you rather give for reductions and why? Thank you for all your help!!

I agree w/ CEN35, many times its actually a blessing I would think that some of the pts. that code do not make it.. Its all about quality of life........ The children on the other hand is horrible....... we just had a 10 day old die about 2 weeks ago and those are the ones that get to you......... also when a code comes in by the medics and you know them.......... as many of you know your friends and family just dont look like themselves when they come in intubated, coding , or critically ill. When that happens it tears your heart out. But you keep going ....... I strongly believe ER care sets the tone for the pts. future recovery and the fact is no one can do it better then we can (ER Team) given the situation and circumstances that we work in, so with that said most deaths I believe is God calling for them and no matter what we do we cant change that calling.

You can inject a small amount or air with all IM injections so that the air aids in pushing the med deeper into the muscle so less if any is lost when you remove the needle. As far as measuring whats in the needle, I hope one would change the needle from the one used to draw up to the one used for injection, and as someone posted the needles do hold meds..... ie; if you use a blunt to draw up morphine, say 2 mg which is 0.2 ccs then you pull back on the syringe after discarding the vial you will get about 1/2 cc or more of morphine that was in the blunt. making your dose almost 3 mg instead of 2 mg....... just change the needles from the one used to draw up the med to the one used for injection. Either way with the excpetion of pediatrics I wouldn't be to concerned.

i just want to thank everyone for all the information, i can say now i will no longer push diprivan on a non-intubated pt. except for rsi ( we rarely use diprivan for rsi except sometimes for burn pts) i will continue to hang the gtts post intubation and draw my line there. i had no idea legally i was on such thin ice, so much literature by lww and even ena supported the use of diprivan for cs. i have certain rules i go by as a nurse, 1) pt safety, 2) tx pts with the best care and with all my heart 3) being my pts. advocate,, i love my job and honestly feel nursing chose me, i treat all who come in through the door as i would want to be treated. i do think there is still a chance that diprivan may become the drug of choice for difficult reductions and for cs, but untill the laws clearly state and i am educated extensively with a certificate allowing me to administer it i will never do it again. also if i had to goto crna school to push it on a non-intubated pt. i think ill just keep asking the docs. for morpine, valium, versed, or whatever else................. thank you all rns, crnas(of whom i really appreciate you all sharing some of your knowledge with me). again. thank you

[ I don't understand why these RN feels like that need to be pushing the envelope with their licenses, it's not like they are getting paid more money for that service. It is all too risky for me. I would rather leave it up to the trained aesthesis. Just my opinion. In the ERs I work at, 1 in Fort Worth and one farther south, The ER Docs want Diprivan to be drug of choice for all CS, and this POST I have been really trying to pay close attention to and learn from. We give Diprivan fairly frequently for reductions., cardiac conversions ...etc......... I made it a point to ask the Medical Director if I should be worried about its administration. He said you have a far less monitoring time post drug dose then w/ versed and morphine of which is what we usedto use........ 8 mins as opposed to 2-6 hours of drug effect. He said all else is same, have ambu bag, intubation box, at bedside and monitor vitals just as you would w/ versed. Please , if anyone can tell me why I should be concerned............... now keep in mind I am not a CRNA, I am an RN and I am aware of dosing, side fx, poss. complications,and I am very comfortable with handling complications should the arise etc. however much of the CRNA knowledge, ie; chemical make-up, exact physiology etc. is over my head. I would just like to be able to tell our docs why I shouldnt give diprivan when they all seem okay with our nurses doing that. Thanx for any help

I am not an LVN anymore, graduated ADN and now working on BSN, Sorry I just never updated my profile. I was also unaware that this was strictly a CRNA post, my bad.

Wow, Ouch, Sorry for the post........ No I dont know of LPNs pushing Diprivan, only RNs, heres a few examples of where I am coming from........ A friend of mine is a Gastro Doc and they used to use Fentanyl and Versed for colonoscopy procedures. Now they use only diprivan...........versed's duration is anywhere from 2-6 hrs., and diprivan's duration is 3-5 mins. so if complications where to occur ie: hypotension, apnea, bradycardia, the time from of managing these complications would be much shorter, Granted you can give romazicon for versed reversal. For example when we would do a reduction we used to give morphine and versed and monitor and sent the pts. home hours later. Now that we use diprivan we can send the pt. home 30 mins. post reduction. Recovery time for diprivan is 8 mins., 20 mins if given with an opiod. They pt. should be monitored equally the same with SpO2, Heart, BP, RR, and resp. equip. at bedside. Sorry if I dont see the diferences in monitoring and actions, and that I see the pros of diprivan related to the shorter half life. Please educate me on this, I have no problem being told why I am wrong and the reasons behind it. But please dont be rude and condenscending. Sorry I even expressed my opinion or view.... but really please let me know why my view is wrong, I would appreciate it.

Do you give versed as an RN, well if so, diprivan is no different, Has pretty much same effects with a much shorter half life. And as with versed you need to have an Ambu bag, and Resp Box at hand for possible BVM and intubation if unable to BVM effectively. We give Diprivan all the time in our ER also for reductions and such and use the gtts for post intubation sedation. Just need your ER doc there for airway managment. I guess I dont understand the big deal w/ diprivan and some nurses not thinking it should be in there job description. Nothing to be too concerned about, so easily titrated even by IV push, onset is like 30 sec.s and pt. is back to baseline LOC in 15 min.s Its a wonderful med and so much safer then Versed .

I am so sorry you are discouraged and the support you needed was lacking. But......... I work in a very busy busy ER, and many times we work short...... Do I think a new Grad should start their career there... No I dont, By being as busy as we already are its near impossible to give a new nurse the time and attention they deserve.... I hate that its that way but it is. Now I also worked at other ERs in Texas not near as demanding, and in that case a new Grad would probably learn and have the support they needed. It just depends on so many factors, pt. rollover, managers, staffing, acuity, etc. I honestly think a new nurse should gain exp. at least for one year in another dept. other then ER, ER is fast paced, so the nurses themselves need to be fast. Hang in there, give yourself 1 year on a medical or tele, then go back down to the ER and I bet you will own that ED within 6 months. Take Care

As all have mentioned different hospitals have different ways of calling codes, ........ first thing is be sure and assess the pt. and not just the monitor before calling a code. Also be certain the pt. is not a DNR before calling a code. Every floor should have at least 1 crash cart and you should start CPR right away and bag the pt. right away. By thyis time their should be help for you and even before a Doc shows up he should be on a monitor and if V-Fib or V-Tach(pulseless) shock the pt. Give Epi right away and possibly Atropine (unless has had a heart transplant, then Atropine does no good), if pt is diabetic give 1 amp of D50. This is all ACLS protocol , and by protocol you can do any of these life saving measures without a Dr. at bedside. I work in an ER and many times we dont call the codes , we have all we need there...... now Pharmacy responds to all codes called overhead which is wonderful, no reason to even break open the crash cart. Just a hint, if you feel no radial pulse they still may have a pulse, on avg. you need a systolic of at least 90 for a radial, and 60 for a femoral. But please start cpr asap, there has been so many times I respond to a code on the floors and there 4 or 5 nurses standing around the pt. as if just waiting on someone to say okay boys and girls you can start CPR and ACLS now.

I apologize if I sounded harsh towards anyone. The point is I have great respect for most Medics and for most ER nurses.

Its a shame how some people are speaking about the other profession on here, "Try intubating on a hill with coyotes and bears chasing you on skateboards"...................... We as nurses speak to the pts. family when one passes, yes even the 10 day old babies, in fact I would say 90% of our pedi codes are brought in by mom and dad and not the Ambulance. If you want to work in the hospital and want more respons. goto school, get you liscence, hell the way some are talking get your MD cause evidently you are all that and more already , and I am speaking about a few posts on here........ sounds to me like your above all the rest but unlucky for you noone else knows that. I was an EMT for 8 yrs. before I got my RN I have been on both sides of the fence......... and the one thing I hear from most EMTs that get there liscence....... "I had no idea"..... and I am sure nurses would say much of the same with a few shifts on the truck......