chbare Posted July 1, 2009 Author Share Posted July 1, 2009 Yes we need to secure an airway. So we will need to sedate and paralyze. Versed at 0.1mg/kg. Then Vecuronium 0.1mg/kg. Does this relax the trismus allowing me to intubate? The restricted mouth opening can be due to either the involvement of temporomandibular joint or pathology of muscles which are responsible for mouth opening. Any signs of penetrating trauma to face/neck? Midazolam may be problematic with a suspected head injury related to blood pressure depression. This can be especially problematic at induction doses. What makes you think about vecuronium for initial paralysis? The slow onset and long action makes it a less desirable agent for the initial RSI. Take care, chbare. Link to comment Share on other sites More sharing options...
spenac Posted July 1, 2009 Share Posted July 1, 2009 (edited) Midazolam may be problematic with a suspected head injury related to blood pressure depression. This can be especially problematic at induction doses. What makes you think about vecuronium for initial paralysis? The slow onset and long action makes it a less desirable agent for the initial RSI. Take care, chbare. So would I be better using Fentanyl 3 mcg/kg for sedation as it has less effect on BP? Remember I'm a student still and thinking of drugs at my service. I did not use succinylcholine as it can increase ICP. Should I go with Rocuronium 1.2mg/kg instead as it has fast onset similiar to sucs with fewer cardiovascular side effects? Edited July 1, 2009 by spenac Link to comment Share on other sites More sharing options...
joesph Posted July 1, 2009 Share Posted July 1, 2009 so I missed a point earlier that I want to pick up was he wearing a helmet? Link to comment Share on other sites More sharing options...
chbare Posted July 2, 2009 Author Share Posted July 2, 2009 Not wearing a helmet. Roc is a consideration; however, you only have access to sux at this point. Many people still prefer sux because of the short duration of action. Roc is popular and perhaps even more so when sugammadex hits the market. Fentanyl is a good premedication consideration. I would also want a dedicated sedation agent. In many cases, people prefer etomidate for it's short onset, short duration, and hemodynamic stability. Take care, chbare. Link to comment Share on other sites More sharing options...
Kiwiology Posted July 2, 2009 Share Posted July 2, 2009 This is starting to go downhill and get funky; I'm into getting this guy a more advanced airway but if we can deliver him to the hospital faster than an Advanced Paramedic trained in rapid sequence intubation can locate us I am going to load him and transport. Link to comment Share on other sites More sharing options...
AnthonyM83 Posted July 2, 2009 Share Posted July 2, 2009 I'm considering RSI, but I won't do it until I have more information if I'm getting good compliance and sats continue to improve with BLS airway. Want things like pupils, full GCS, signs of herniation, trends in VS. If I do decide he needs RSI, I'm okay with using sux despite the ICP consideration, as it's short-acting and the patient outcome studies on using sux with head injuries have been variable. I'll use Fentanyl to premedicate and Etomidate to sedate. Maybe some propofol after if I have it. I'm also considering internal bleeding from the pelvic/hip injury. Confirm the rotation is of the entire leg, not just the foot (aka not an ankle fx). And I might just be foggy on this or the terminology, but what do you mean by flexion with adduction? Aren't they synonyms in this case? You flex the hip, so it's going to adduct (flex)? Link to comment Share on other sites More sharing options...
chbare Posted July 2, 2009 Author Share Posted July 2, 2009 Let's say you go ahead and do the RSI with etomidate and sux. You pass the tube with style and deliver the patient to the receiving ER without incident. What do you think is going on with this guys lower extremities? Take care, chbare. Link to comment Share on other sites More sharing options...
AnthonyM83 Posted July 2, 2009 Share Posted July 2, 2009 If he's bleeding internally, there's likely a lack of perfusion to the area (which is why I wanted to get perfusion and whatever neuro status I could on all extremities). As it relates to RSI, not much, except maybe only getting partial paralysis due to poor extremity perfusion. As far as the lower area itself, I think I get ya. Signs of hip dislocation. I'm going to let that be, as there's not much I can do. If it were a pelvic fracture, I would consider binding it with sheets, but seems like a hip dislocation... Link to comment Share on other sites More sharing options...
chbare Posted July 2, 2009 Author Share Posted July 2, 2009 Very close, what kind of dislocation? Anterior or posterior? Take care, chbare. Link to comment Share on other sites More sharing options...
AnthonyM83 Posted July 2, 2009 Share Posted July 2, 2009 Classic signs of posterior dislocation. Prop some pillows under the leg to maintain position. Otherwise not going to intervene on it. Link to comment Share on other sites More sharing options...
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