In message <01ea01c06155$00465e60$a650073e@tinypc>, Simon Carley
<[log in to unmask]> writes
>Question
(re. post-reduction of shoulder with midaz/morph)
>Since your major concern is respiratory depression do you leave the O2 mask
>on or take it off?
I wouldn't leave the patient until their sats are good, and staying good
on AIR, for the reasons you mention. I prefer to spare as much opiate as
possible by using a cocktail of entonox, ketorolac and just a sniff of
midazolam. Once XRayed, top up the midazolam, turn up the nitrous oxide
and reduce. Never needed to use reversal agents with this method -
observe resps / airway closely for the few minutes it takes the patient
to wake up naturally.
The combination of a skin-full of opiate and midazolam is a recipe for
disaster in this situation in inexperinced hands. We've had a
respiratory arrest (thankfully fully recovered due to timely
intervention from A&E Con) in the last few years due to cack-handed use
of industrial strength morph/midaz by ortho surgeon in A&E.
The pulse oximeter is one of the most dangerous pieces of kit in any
sedated patient breathing supplementary oxygen spontaneously. They
should only be used in this situation as an ADJUNCT to an experienced
observer (nurse / doc). I give a scenario very similar to Simon's to all
the new SHOs on induction and let them kill the virtual patient to make
the point. If it puts them off using midazolam / morphine at 2am without
supervision, then I've earnt my enormous salary.
Sampling ETCO2 is more informative (RR and surrogate of minute
ventilation).
Dr G Ray
Staff Grade
A&E
Sussex
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