Kiwiology Posted May 17, 2010 Share Posted May 17, 2010 For neurogenic causes of coma and poor airway, we give fentanyl, midazolam and suxamethonium. Everybody else gets ketamine as well as fent and sux. Re ketamine and ICP http://www.metrohealthanesthesia.com/edu/ivanes/ketamine1.htm http://findarticles.com/p/articles/mi_7503/is_201003//ai_n53080607/?tag=content;col1 I don't have a secured airway at the moment so I would like to intubate this patient. It may be worth trying to pass the tube without medicines given this may be possible although if not I won't want to be destroying his BP and ICP by buggering around with laryngascopy. If not possible then I'd like to give him a couple mg of midaz and 1.5mg/kg sux and intubate. Link to comment Share on other sites More sharing options...
speedygodzilla Posted May 17, 2010 Share Posted May 17, 2010 (edited) Would you go straight to a surgical? It will take time to prep and we currently have all the criteria for a crash airway. Would you want to consider bag mask ventilation while prepping the patient? Is NPA placement absolutely contraindicated with our current findings? Our immediate goal may not be a "definitive" airway device but rather oxygenation and ventilation. Take care, chbare. No, I guess I was presuming that there could be facial trauma contradicting the use of NPA. You didn't list it cause there is none and now I understand that. So trans by air will be no faster? Thus just continue by ground. I would probably RSI. We don't have RSI here and I am a newbie medic so from what little I know about ketamine it raises BP thus presumably rasing ICP so it wouldn't be my first choice for RSI. What about nasotracheal intubation? Last I check the patient still had trismus and was breathing shallow on his own. Edited May 17, 2010 by speedygodzilla Link to comment Share on other sites More sharing options...
Kiwiology Posted May 17, 2010 Share Posted May 17, 2010 Ketamine does not have vasodialative properties of other meds like benzos and propofol. It appears the rise in BP is about 25% however this not sustained. http://www.metrohealthanesthesia.com/edu/ivanes/ketamine5.htm Would you rather give him some benzos or just sux him and intubate with no meds? I'd like to retract my previous statement, I would want to give this guy some ketamine and not midaz; I forgot about the low BP Link to comment Share on other sites More sharing options...
chbare Posted May 17, 2010 Author Share Posted May 17, 2010 You are able to successfully place a 7.5 to what appears to be the proper depth. You note chest rise and fall, lung sounds and have a good waveform and end tidal CO2. However, upon closer inspection, the chest rise is initially non symmetrical. You nothce that the right side of the chest begins to rise first, then after a slight delay, the left side begins to rise. Take care, chbare. Ketamine does not have vasodialative properties of other meds like benzos and propofol. It appears the rise in BP is about 25% however this not sustained. http://www.metrohealthanesthesia.com/edu/ivanes/ketamine5.htm Would you rather give him some benzos or just sux him and intubate with no meds? I'd like to retract my previous statement, I would want to give this guy some ketamine and not midaz; I forgot about the low BP It's a judgement call. I would most likely go with etomidate and sux; however, you could justify just going with sux due to a crash airway, but anecdotally (n=1), I feel that giving etomidate is quick and would not cause any harm to this patient. While many people in the United States still cling to the ketamine/head injury mantra, I wanted to simply point out the evidence for such beliefs is rather limited. Take care, chbare. No, I guess I was presuming that there could be facial trauma contradicting the use of NPA. You didn't list it cause there is none and now I understand that. So trans by air will be no faster? Thus just continue by ground. I would probably RSI. We don't have RSI here and I am a newbie medic so from what little I know about ketamine it raises BP thus presumably rasing ICP so it wouldn't be my first choice for RSI. What about nasotracheal intubation? Last I check the patient still had trismus and was breathing shallow on his own. Nasal is a consideration. I chose to go oral for the sake of the scenario, but considering nasal intubation, assuming you can keep him well saturated is a consideration. Take care, chbare. Link to comment Share on other sites More sharing options...
armymedic571 Posted May 17, 2010 Share Posted May 17, 2010 Since we are on this topic. Does anyone else use Etomidate? Not only does it have a rapid onset (1-2 minutes), but it has a shortn half life (3-5 minutes) for those fearing Trismus. I understand correctly. Can't Etomidate inadvertently reduce ICP??? I am not 100% as to it's mechanism of action. Link to comment Share on other sites More sharing options...
speedygodzilla Posted May 17, 2010 Share Posted May 17, 2010 You are able to successfully place a 7.5 to what appears to be the proper depth. You note chest rise and fall, lung sounds and have a good waveform and end tidal CO2. However, upon closer inspection, the chest rise is initially non symmetrical. You nothce that the right side of the chest begins to rise first, then after a slight delay, the left side begins to rise. Take care, chbare. It's a judgement call. I would most likely go with etomidate and sux; however, you could justify just going with sux due to a crash airway, but anecdotally (n=1), I feel that giving etomidate is quick and would not cause any harm to this patient. While many people in the United States still cling to the ketamine/head injury mantra, I wanted to simply point out the evidence for such beliefs is rather limited. Take care, chbare. Nasal is a consideration. I chose to go oral for the sake of the scenario, but considering nasal intubation, assuming you can keep him well saturated is a consideration. Take care, chbare. Well with that I go to possibly three things in order of suspect: 1) Right Main Stem Intubation 2) Flail Chest (but I would suspect that would already be noted with injuries. 3) Tension Pneumothorax Lungs sounds equal? Hard to bag? Trachea midline? My first step would be to pull the tube back alittle and check to see if that fixes it. What is next? If ABCs are controlled lets move on to a detailed exam. How is skin, color, temp, condition? How are vitals? Head to toe exam etc? Link to comment Share on other sites More sharing options...
chbare Posted May 17, 2010 Author Share Posted May 17, 2010 Well with that I go to possibly three things in order of suspect: 1) Right Main Stem Intubation 2) Flail Chest (but I would suspect that would already be noted with injuries. 3) Tension Pneumothorax Lungs sounds equal? Hard to bag? Trachea midline? My first step would be to pull the tube back alittle and check to see if that fixes it. What is next? If ABCs are controlled lets move on to a detailed exam. How is skin, color, temp, condition? How are vitals? Head to toe exam etc? Pulling the tube back a bit dose not change anything. Upon closer examination, you notice a left sided neck hematoma and slight right sided tracheae deviation. The chest wall is intact except for several abrasions, lung sounds are clear, bagging the patient is not difficult. The remainder of your exam is unremarkable except the problems that have already been identified. Take care, chbare. Since we are on this topic. Does anyone else use Etomidate? Not only does it have a rapid onset (1-2 minutes), but it has a shortn half life (3-5 minutes) for those fearing Trismus. I understand correctly. Can't Etomidate inadvertently reduce ICP??? I am not 100% as to it's mechanism of action. Yes, it does appear to be cerebral protective and the fact that MAP and CPP is typically not altered is another benefit. Take care, chbare. Link to comment Share on other sites More sharing options...
speedygodzilla Posted May 17, 2010 Share Posted May 17, 2010 Pulling the tube back a bit dose not change anything. Upon closer examination, you notice a left sided neck hematoma and slight right sided tracheae deviation. The chest wall is intact except for several abrasions, lung sounds are clear, bagging the patient is not difficult. The remainder of your exam is unremarkable except the problems that have already been identified. Take care, chbare. Well as long as the patient continues to appear oxygenated I would just continue care and move on to v.s, full body exam etc, while instructing the provider bagging to immediately let me know if anything changes. Abdomen distended? Lets go ahead and drop a NG tube to see if it helps. Link to comment Share on other sites More sharing options...
chbare Posted May 17, 2010 Author Share Posted May 17, 2010 Well as long as the patient continues to appear oxygenated I would just continue care and move on to v.s, full body exam etc, while instructing the provider bagging to immediately let me know if anything changes. Abdomen distended? Lets go ahead and drop a NG tube to see if it helps. Gastric intubation and decompression is performed. The patient continues to exhibit the asymmetrical chest wall movement. Take care, chbare. Link to comment Share on other sites More sharing options...
speedygodzilla Posted May 17, 2010 Share Posted May 17, 2010 Gastric intubation and decompression is performed. The patient continues to exhibit the asymmetrical chest wall movement. Take care, chbare. Well I am honestly not sure what is causing the asymmetrical chest wall movement other than just pure "trauma." If we have ruled out life threats we can treat, including the above I listed than it sounds like it is time to move on. Before moving on can you tell me more about ABCs. Airway establish, check. Breathing for the patient adequate rate quality and depth abnormal chest wall movement but adequate, check. Circulation? Intact? I beleive he had bilateral femur fracutures? Open? Bleeding Controlled? Skin color, temp, and condition? Or are we not ready to move on from the ABC/asymmetric chest wall movement? A guess I would throw out there is possibly a hemothorax which I don't have the training or equipment to treat. Link to comment Share on other sites More sharing options...
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