Doczilla

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Doczilla last won the day on April 21

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About Doczilla

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  1. C-Collar only immobilization

    I've been heavily involved with this in our state and elsewhere. SSI has been around for a long time, but where we are changing the thinking is in not having the patient remain on the backboard once moved from point of injury to the stretcher. I've had emails from several states asking for our protocols, clinical justification, and training materials. NAEMSP came out with a position paper on it last year as well. The original position paper was pretty strongly worded about doing away with the LBB as much as possible, but a consensus document with ACS-COT was created, and it was softened to get buy-in from the surgeons. Some have gone on a system wide basis, while others are doing it at the state level. It's been very well accepted, and I'm getting emails on the ACEP EMS list indicating that more areas are doing it. It's widespread enough now that adopting the protocol is no longer "outside" the usual care, but an accepted practice. It's a tide, hopefully for good. 'zilla
  2. Drugs for agitated patients?

    Concern for overdosage in trauma. Too much ketamine will dick up our neuro exam in a trauma patient if the ketamine is given for pain when the intent is not to knock them out. For the RSI/STI/sedation, there is a wide therapeutic index for the dissociative doses, so we are not as concerned about an overdose. 'zilla
  3. Drugs for agitated patients?

    We are adding Ketamine this year to the regional protocol for agitated delirium/combative patient. 100mg IV/IN or 500mg IM. We are also allowing its use in the RSI and sedate to intubate protocols. 100mg IV/IN A couple of local services (mine) will be using it for pain control in trauma, 0.5mg/kg IV. 'zilla
  4. Backboarding policy change

    No, it was a copy of ours. We use selective spinal clearance with NEXUS like everyone else, and have for many years. This memo is specifically a back boarding/transport policy.
  5. Backboarding policy change

    Job: We've not addressed the n/v thing specifically. We are still log-rolling, but if adequate personnel are at hand, the lift-and-slide is encouraged. One of our FD LTs is at the NFA this week training. Someone from another state 2 time zones from here showed him a copy of our own spinal memo, and said they were adopting it. I think that is kind of cool, but I'm wondering where they got it from, since I haven't sent it out nationally until tonight. 'zilla
  6. Tardive dyskinesia treatment?

    A key thing here is to know the difference between a dystonic reaction and tardive dyskinesia. Both can occur with the "typical" antipsychotic medications such as Haldol, Thorazine, and others. Medications such as Reglan and Compazine can also do it. A dystonic reaction is similar to what you describe. It can happen with the first dose or any subsequent dose of a medication, particularly if combined with other similar medications or after a dose adjustment. The onset is fairly sudden, and they may not have had anything similar before. I have seen this effect also from "energy drinks". I also saw this after administration of a dose of Zofran in the ER, but failed to find any reference in the literature to such reactions being common. Treatment is supportive, and benztropine (Cogentin) or benadryl can be given for the effects and is usually pretty effective. A dystonic reaction is reversible with no lasting effect. Tardive dyskinesia is an insidious movement disorder that can be caused by long term use of antipsychotic medications. It more closely resembles Parkinson's disease, with movement difficulties, ataxia, and cogwheel rigidity. The onset is over weeks to months and is not reversible. It is typically permanent. 'zilla
  7. NSAID allergy and ASA

    It is in the same class because of similar actions on the cyclooxygenase pathway. Either medication can shunt processing of arachadonic acid through lipoxygenase to create leukotrienes, which cause bronchospasm. This is the reason that the NSAIDs have a precaution when using them in patients with a history of severe asthma. If the patient says they get short of breath with NSAIDs, I would give a different drug, like Plavix, for suspected acute coronary syndrome. If they said "it upsets my stomach" or "I get nauseated" or "it decreases the strength of the dilaudid", then I wouldn't have a problem giving aspirin for ACS. 'zilla
  8. Ketamine... PCA?

    Preach it, brother. Unbelievable how in one of the greatest nations on earth with outstanding health care, we can find ourselves wanting for morphine, which has been around for TWO CENTURIES and costs damn near nothing. All because of regulatory crap. Regarding ketamine as a PCA drug, Bernhard has it right. There are also pain specialists doing ketamine infusions (yes, it's legit) for complex chronic pain syndromes such as reflex sympathetic dystrophy. These infusions are at higher doses than the PCA I think, since you are trying to get the patient into a bit of a twilight and keep them there for about 4 hours. These are often done on an outpatient basis, and have some fairly good outcomes. 'zilla
  9. Backboarding policy change

    The "number needed to treat" reflects the number of patients that will receive a treatment in order to create one good outcome. Few treatments benefit every patient who receives them. For example, cholesterol lowering drugs are known to help prevent heart attacks, but not 100% of the time. You will have to give hundreds of people the drug before you can say you have prevented one heart attack. A NNT of 1 means that everyone who receives the treatment lives, and everyone who doesn't (the controls) dies. For the spinal study, you have to immobilize over 1000 patients before you could theoretically prevent one bad outcome (doubtful that backboarding would even do so). The "number needed to harm" is the same concept, only looking at bad outcomes. Say a treatment is very toxic, and there is a 5% mortality rate caused by the drug. For every 20 patients who receive the drug, one will die, therefore the NNH is 20. In the spinal immobilization study, you would only immobilize 66 people before you caused a bad outcome. Taking the above numbers into account, if you immobilized 1032 patients with penetrating trauma, you might prevent 1 bad outcome, but cause bad outcomes in 15 others. More on this calculation: http://en.wikipedia.org/wiki/Number_needed_to_treat A "distracting injury" is theoretical. The idea is that if you have a painful enough injury, such as a femur fracture or rib fracture, it may focus your mind so that you do not feel the pain in your neck from a spinal fracture, and you should therefore be immobilized until x-rays are performed. What the study showed was that of these patients with confirmed spinal injuries, 87% of them had other injuries that would meet their definition of potentially distracting. What they found was that even with these other injuries, all but 4 of the patients still had pain and tenderness in their neck. Of the 4 that did not, all 4 had tenderness and bruising of the anterior chest. It calls into question the theory of a distracting injury that would require x-rays of the neck on a patient who has no neck pain, or perhaps we should better define a distracting injury to include anterior chest tenderness. 'zilla
  10. Upper GI Bleeding and Octreotide

    Octreotide causes vasoconstriction of the splanchnic bed (mesenteric circulation), and in theory decreases rate of GI bleeding. Not sure it would do anything for nose cancer, but if there is bleeding further down in the GI tract, it might help. 'zilla
  11. Backboarding policy change

    UPDATE: We have implemented new policy on immobilizing patients, and I have copied the policy below. There is substantial room for EMT judgment. It went into effect about a month ago, so I thought I'd share the experience thus far. The director and AD of Trauma thought it looked good. Our trauma team is pretty good about getting patients off of the backboard during the secondary survey and before any CT scans. The medical director for our ER group liked it as well. We've had an internal ER policy in place for a year not where the medics and nurse get the patient off the board upon arrival at the hospital and before being seen by a physician. The competing hospital system has had such an ER policy for at least 2 years with very good success. Acceptance of this internal policy has been mixed. Some nurses are in favor, others nervous about it and unwilling to take the patient off the board, so they will just let the attending know that there is a patient on a board and to see them quickly so they can be removed from the board (easier at some times than others). The EMS response has been interesting. The 2 agencies where we implemented it seem to like it quite a bit, but they tend to be fairly progressive services. There are some who have been teaching in the area, and response has been all over the map. Some medics think it's great. One chief stormed out of the room and said it would never be implemented at his service as long as he was there. Over his dead body, or something to that effect. It seems to be the younger medics who like the policy more. A snide comment by one of the other local EMS medical directors: "The chance of endorsing this policy is inversely proportionate to the size of your prostate." One hospital, a level III trauma center, initially pushed back very hard. As one doc said to the crew, "dumbest f&%#ing thing he'd ever heard." They initially said they would purchase backboards and reimmobilize any of our patients until the scans were done, but subsequently reversed their stance on it and are supportive. Another doc, from the same hospital, said it was "long overdue". Another local agency (with which I have no involvement) has reviewed and adopted the policy. We've had to tweak the policy a couple of times: - The flight service has very strong feelings on immobilizing any patients they transport, and insist that it be done. I think this is not huge, partly because we hardly ever call them due to ground transport times of <30 min, and if we did, it would be for a critically ill trauma patient that is likely to remain on the board anyway. - We had to put stronger emphasis on the multi system blunt trauma patient who cannot follow commands that should remain on the board. - Initially the memo referred to use of the board for extrication, which to my mind meant "movement from point of injury", but was interpreted by some to mean only vehicle extrication. So this was clarified. The medics have been very understanding of it as we adjust the policy and training based on their feedback. Nothing new is perfect the first time out, and they have been very patient. 'zilla To: All Bigredtruck Fire Division Personnel From: Doczilla, MD Re: Change in spinal immobilization protocol The following policy combines policy memo from July 6, 2012 and subsequent clarification from July 14, 2012 memo. Substantial evidence now exists to show that long back boards may cause harm to patients, and no literature has yet shown a benefit of their use. Back boards do a horrible job of immobilizing the spine, and movement is worse on the backboard than on a soft surface that conforms to the patient. Patients who are alert enough to follow commands can typically maintain stabilization of their own spine without assistance. Backboarding increases mortality in certain trauma patients. Backboarding does nothing to prevent neurological complications from spinal injury. Backboarding restricts respiration, which some patients cannot tolerate. Backboarding rapidly leads to skin breakdown and pressure ulcers, even after a short period of time, and is particularly hard on the elderly. Effective immediately, the following changes are to take place in our practices of spinal immobilization: These patients may require immobilization with a cervical collar: High risk injury (high speed MVC, axial loading injury) Focal neurological deficits such as paralysis Intoxication or altered mental status Age >65 Presence of midline bony tenderness of the spine Midline spinal pain with movement of the neck Patients without any of the above findings may be transported without a cervical collar. Selectively immobilize (with a cervical collar) only those patients at high risk for spinal injury as above or with clinical indications of spinal injury. Use the long spine board, scoop stretcher, vacuum mattress, short board, or Kendrick Extrication Device (KED) to minimize movement of the patient when moving them from the point of injury to the stretcher. Once the patient is moved to the stretcher, using log roll or lift-and-slide technique, lay the patient flat on the stretcher and leave the c-collar in place. Elevate the back of the stretcher as needed for patient comfort. Do not transport a patient to the hospital on a backboard, short board, KED, or vacuum mattress unless it is necessary for patient safety. Patients who are markedly agitated and confused from head injury may not be able to follow commands with regard to minimizing spinal movement, and combativeness may also be a factor. Patients may remain on a backboard if the crew deems it safer for the patient, and this will be at the discretion of the crew. A multi system blunt trauma patient, such as from a high velocity crash or significant fall, who is unable to follow commands due to combativeness, intoxication, or decreased mental status, should remain on the backboard for their safety until handoff to the ED. Never immobilize a patient with penetrating trauma such as a gunshot wound or stab wound. Even with neurologic deficits caused by transection of the spinal cord, the damage is done; additional movement will not worsen an already catastrophic injury. Emphasis should be on airway and breathing management, treatment of shock, and rapid transport to a Level 1 or 2 trauma center. If manual cervical stabilization is hampering effort to intubate the patient, the neck should be moved to allow securing the airway. An unsecured airway is a far greater danger to the patient than a spinal fracture. Eliminate the "standing take-down" for backboarding patients who are ambulatory after an injury. Place a collar and allow the patient to sit on the cot, then lie flat. Patients who are ambulatory and able to follow commands do a better job of preventing movement of an injured spine than rescuers do. Remove cervical collars on conscious patients that tolerate them poorly due to anxiety or shortness of breath. Patients who are markedly agitated and confused from head injury may not be able to follow commands with regard to minimizing spinal movement, and combativeness may also be a factor. Patients should remain on a backboard if the crew deems it safer for the patient, and this will be at the discretion of the crew. [The Helicopter Service] has requested that we fully immobilize on a backboard all blunt trauma patients transported by them, regardless of complaint. This is so they may remain consistent with their own policies on spinal immobilization. The new protocol will: reduce pain and suffering reduce complications decrease on scene times reduce injuries to crews who are attempting to carry immobilized patients reduce unnecessary imaging costs and radiation exposure Any questions about protocols or medical treatment may be directed to myself or Capt. Awesome. Very respectfully, Doczilla, MD FACEP Medical Director Bigredtruck Fire Division Cc: Chief
  12. Backboarding policy change

    Feel free to share. It's a policy memo, so public record anyway.
  13. Backboarding policy change

    I sent the memo to two of the EMS agencies (fire based, as are most around here) where I work. We are attempting to effect a cultural shift for the benefit of our patients. I guess we will see if it takes hold. There is no question that spinal immobilization is painful and anxiety provoking for nearly everyone. Patients often have back pain induced solely by lying on the backboard, pain which resolves not long after removal of the board, but which may prompt imaging in the ED due to pain and tenderness caused not by the presenting injury but by the backboard. We have seen harm in other ways: the demented elderly patient with a ground level fall who becomes more agitated from the pain and restriction of the board, the patient from the MVC with anxiety disorder who panics in the straps, the monstrously obese patient who has the equivalent of another person sitting on their chest and has to fight gravity to breathe. I've summarized below some notes from a presentation I have given on myths in EMS. The bottom line up front is that spinal immobilization on a long backboard has no evidence to support its use, but substantial evidence of harm. It is predicated entirely upon theories of injury that have never been shown. It has been taught dogmatically to EMS providers, nurses, and physicians for 3 decades, though there is now a swell of thought that we should modify the practice. Using a long backboard makes sense when pulling an injured person out of the water, or moving them out of a smashed vehicle, but once on the ambulance stretcher, movement is minimal, even with jarring movements of the ambulance. Being on a hard, slippy surface of a backboard will worsen that movement rather than improve it. The National Association of EMS Physicians is working with the American College of Surgeons on a position paper regarding backboarding. The gist of it is that we should eliminate backboards for anything but extrication. There's a few things I've discovered in the literature: Backboards do a horrible job of immobilizing the spine, and movement is worse on the backboard than on a soft surface that conforms to the patient. Patients who can follow commands can typically maintain stabilization of their own spine without assistance. Backboarding increases mortality in certain trauma patients. Backboarding does nothing to prevent neurological sequelae from spinal injury. Backboarding restricts respiration, which some patients cannot tolerate. Backboarding rapidly leads to skin breakdown and pressure ulcers, even after a short period of time, and is particularly hard on the elderly. I think there are some steps we can take to eliminate some pain and suffering and reduce some unnecessary imaging. Stop transporting patients to the hospital on backboards. Utilize the long spine board only for extrication purposes. Once the patient is extricated, using log roll or lift-and-slide technique, lay the patient flat on the stretcher and leave the c-collar in place. Do not ever immobilize a patient with penetrating trauma such as a gunshot wound or stab wound. Immobilization DOUBLES the mortality rate of these patients. Even with neurologic deficits caused by transection of the spinal cord, the damage is done; additional movement will not worsen an already catastrophic injury. Emphasis should be on airway and breathing management and rapid transport to a trauma center. If patient is being intubated, and manual cervical stabilization is hampering this effort, the neck should be moved to allow securing the airway. An unsecured airway is a far greater danger to the patient than a spinal fracture. Eliminate the "standing take-down" for backboarding patients who are ambulatory after an injury. Place a collar and allow the patient to sit on the cot, then lie flat. Patients who are ambulatory and able to follow commands do a better job of preventing movement of an injured spine than rescuers do. Selectively immobilize (with a cervical collar) only those patients at high risk for spinal injury or with clinical indications of spinal injury. Remove cervical collars on conscious patients that tolerate them poorly due to dementia, anxiety, or shortness of breath. Leaving the collar on and fighting them will encourage more spinal movement rather than less. Clear patients from any spinal immobilization clinically utilizing the spinal clearance protocol. This protocol indicates those patients who may require immobilization: High risk injury (high speed MVC, axial loading injury), focal neurological deficits such as paralysis, intoxication, age <65, and presence of midline bony tenderness of the spine. Patients without these findings may be transported without spinal immobilization. Patients who are markedly agitated and confused from head injury may not be able to follow commands with regard to minimizing spinal movement, and combativeness may also be a factor. These patients should remain on a backboard if the crew deems it safer for the patient, and this will be at the discretion of the crew. The above measures will reduce pain and suffering, reduce complications, decrease on scene times, reduce injuries to crews who are attempting to carry immobilized patients, and reduce unnecessary imaging costs and radiation exposure. There is no doubt that our crews will get some push back from the staff at the hospitals. Nurses or physicians may rebuke them for having the patient off the backboard. FD crews should be reassured that hospital staff does not determine their treatment protocols or operational policy, and that any questions can be directed to command staff or to me or to the hospital EMS coordinators. 'zilla, MD Hauswald M,McNally T. Confusing extrication with immobilization: the inappropriate use of hard spine boards for interhospital transfers. Air Med J. 2000 Oct-Dec;19(4):126-7. This was a survey of inter facility transport services. 18/30 interfac transport services immobilized for transfer, even if cleared by sending ER MD Additional 4/30 immobilized unless cleared radiographically No services moved pts to softer surface if known to have injury McHugh TP,Taylor JP. Unnecessary out-of-hospital use of full spinal immobilization. Acad Emerg Med. 1998 Mar;5(3):278-80. 51% reported no neck or back pain at scene of accident before full spinal immobilization 13% not even asked about neck or back pain before full spinal immobilization Haut ER,Kalish BT,Efron DT,Haider AH,Stevens KA,Kieninger AN,Cornwell EE 3rd,Chang DC. Spine immobilization in penetrating trauma: more harm than good? J Trauma. 2010 Jan;68(1):115-20; discussion 120-1. Twice the mortality rate in penetrating trauma if immobilized (14.7 vs. 7.2%) 0.01% had incomplete neurological injury and underwent fixation Number Needed to Treat: 1032 Number Needed to Harm: 66 Davis, et al: retrospective study of 32,117 trauma patients 2.3% with c-spine injury 10 patients with delayed diagnosis of spinal injury AND permanent neurological sequelae Bottom line: "hidden" spinal injuries which lead to paralysis are extremely rare Gerrelts, et al: Review of 1331 trauma patients 5 patients with delayed diagnosis of cervical injury None with permanent deficit Bottom line: "hidden" spinal injuries which lead to paralysis are extremely rare Platzer et al: 347 with c-spine injuries Of the 18 with delayed diagnosis, 2 had permanent deficit Bottom line: "hidden" spinal injuries which lead to paralysis are extremely rare Hauswald: 5 year retrospective review New Mexico vs. Malaya Malayan medics do not use spinal immobilization The difference: Malayan patients had less frequent deterioration and less overall neuro disability Limitations: Small numbers, different mechanisms (more MVCs in the USA, more falls in Malaya) Neuro decompensation occurs in 5% anyway, despite ideal attention to spinal immobilization. Spinal immobilization raises intracranial pressure 4.5 mmHg Manual In Line Stabilization (MILS) led to failed intubation in 50% after 30 seconds of intubation attempt vs. 5.7% without MILS Gruen, et al: Trauma mortality in 44, 401 patients. 2594 deaths, errors in 64. Failure to secure an airway in 16% of those If spinal immobilization led to a failed airway, then it killed the patient. Santoni: MILS doubles force necessary for intubation Santoni BG, Hindman BJ, Puttlitz CM, Weeks JB, Johnson N, Maktabi MA, Todd MM. Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Anesthesiology. 2009 Jan;110(1):24-31. Totten, et al: LBB or vacuum mattress restricted respiration by 15% Bauer, et al: LBB limits respiratory function Respiratory failure is COD in 6% of trauma patients Hauswald: Substantial force required to injure spinal cord Post-injury movement probably not sufficient to injure the cord, even if already partially injured Chan D,Goldberg RM,Mason J,Chan L. Backboard versus mattress splint immobilization: a comparison of symptoms generated. J Emerg Med. 1996 May-Jun;14(3):293-8. Perry SD,McLellan B,McIlroy WE,Maki BE,Schwartz M,Fernie GR. The efficacy of head immobilization techniques during simulated vehicle motion. Spine (Phila Pa 1976). 1999 Sep 1;24(17):1839-44. 3 times more likely to develop pain with LBB than vacuum mattress Trunk movement still significant; no method with a LBB eliminates motion Konstantinidis A,Plurad D,Barmparas G,Inaba K,Lam L,Bukur M,Branco BC,Demetriades D. The presence of nonthoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study. J Trauma. 2011 Sep;71(3):528-32. 101 blunt trauma patients with c-spine injuries 87% had “distracting” injuries: rib fractures, lower and upper extremity fractures 4% had no tenderness on c-spine All 4% had bruising and tenderness of anterior chest Bottom line: "distracting injuries" are largely a myth. Horodyski M,Conrad BP,Del Rossi G,DiPaola CP,Rechtine GR 2nd. Removing a patient from the spine board: is the lift and slide safer than the log roll? J Trauma. 2011 May;70(5):1282-5; discussion 1285. Del Rossi G,Horodyski M,Heffernan TP,Powers ME,Siders R,Brunt D,Rechtine GR. Spine-board transfer techniques and the unstable cervical spine. Spine (Phila Pa 1976). 2004 Apr 1;29(7):E134-8. Del Rossi G,Rechtine GR,Conrad BP,Horodyski M. Are scoop stretchers suitable for use on spine-injured patients? Am J Emerg Med. 2010 Sep;28(7):751-6. Epub 2010 Feb 25. Log roll creates unacceptable motion Lift and slide technique creates less motion Scoop stretcher may be better as well J Trauma. 2009 Jul;67(1):61-6. Motion of a cadaver model of cervical injury during endotracheal intubation with a Bullard laryngoscope or a Macintosh blade with and without in-line stabilization. Turner CR, Block J, Shanks A, Morris M, Lodhia KR, Gujar SK. Source Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA. turchris@med.umich.edu Abstract BACKGROUND: Endotracheal intubation in patients with potential cervical injury is a common dilemma in trauma. Although direct laryngoscopy (DL) with manual in-line stabilization (MILS) is a standard technique there is little data on the effect of MILS on cervical motion. Likewise there is little data available regarding alternative airway techniques in this setting. This study compared intubations with and without MILS in a cadaver model ofcervical instability. We also used this model to compare intubations using DL with a Macintosh blade versus a Bullard laryngoscope (BL). METHODS: Complete C4-C5 disarticulations were surgically created in 10 fresh human cadavers. The cadavers were then intubated in a random order with either BL or DL with and without MILS. The motion at the unstable interspace was measured for subluxation, angulation, and distraction. RESULTS: MILS did not significantly affect maximal motion of this model in any of the three measures using either DL or BL. There were no clinically significant differences in maximal median motion in any of the three measures when comparing the two blades. However, there was significantly more variance in the subluxation caused by DL than by BL. CONCLUSIONS: We were unable to demonstrate any significant effect of MILS on the motion of an unstable cervical spine in this cadaver model. The BL appears to be a viable alternative to DL in the setting of an unstable lower cervical spine. Ann Emerg Med. 2007 Sep;50(3):236-45. Epub 2007 Mar 6. Manual in-line stabilization for acute airway management of suspected cervical spine injury: historical review and current questions. Manoach S, Paladino L. Source Department of Emergency Medicine, State University of New York-Downstate and Kings County Hospital Center, Brooklyn, NY 11203, USA. seth.manoach@downstate.edu Abstract Direct laryngoscopy with manual in-line stabilization is standard of care for acute trauma patients with suspected cervical spine injury. Ethical and methodologic constraints preclude controlled trials of manual in-line stabilization, and recent work questions its effectiveness. We searched MEDLINE, Index Medicus, Web of Knowledge, the Cochrane Database, and article reference lists. According to this search, we present an ancestral review tracing the origins of manual in-line stabilization and an analysis of subsequent studies evaluating the risks and benefits of the procedure. Allmanual in-line stabilization data came from trials of uninjured patients, cadaveric models, and case series. The procedure was adopted because of reasonable inference from the benefits of stabilization during general care of spine-injured patients, weak empirical data, and expert opinion. More recent data indicate that direct laryngoscopy and intubation are unlikely to cause clinically significant movement and that manual in-line stabilizationmay not immobilize injured segments. In addition, manual in-line stabilization degrades laryngoscopic view, which may cause hypoxia and worsen outcomes in traumatic brain injury. Patients intubated in the emergency department with suspected cervical spine injury often have traumatic brain injury, but the incidence of unstable cervical lesions in this group is low. The limited available evidence suggests that allowing some flexion or extension of the head is unlikely to cause secondary injury and may facilitate prompt intubation in difficult cases. Despite the presumed safety and efficacy of direct laryngoscopy with manual in-line stabilization, alternative techniques that do not require direct visualization warrant investigation. Promising techniques include intubation through supraglottic airways, along with video laryngoscopes, optical stylets, and other imaging devices.
  14. Drugs for agitated patients?

    Actually, Geodon is pretty good for agitation. Works quickly enough, and if dosed properly, brings them down but not out. The side effects aren't any worse than haldol.
  15. Ketamine

    Ketamine is probably better than versed for cardioversion or pacing because of minimal effects on BP or HR. Since any patient you are cardioverting in the field is likely unstable or hypotensive, ketamine makes more sense than a drug that will drop BP. ' (null)