Luke very kind of you to invite the whole list out for
a pizza, hope its a big venue. We'd better order in
advance - mine's a thin crispy one with chanterelle
mushrooms, sun dried tomatoes garlic and onion.
Yes its lunchtime.....
--- Luke Larkin <[log in to unmask]> wrote:
<HR>
<html><div style='background-color:'><DIV>
<P>Hey!</P>
<P>How the heck are you? WHere art thou? Back in
Lewisham?</P>
<P>I am in Dallas but willbe in Londontown on the 2nd
of Nov.</P>
<P>fancy a pizza?</P>
<P>Hope u r well</P>
<P>Peace</P>
<P>G Luke Larkin<BR><BR></P></DIV>
<DIV></DIV>
<DIV></DIV>>From: Doc Holiday <[log in to unmask]>
<DIV></DIV>>Reply-To: Accident and Emergency
Academic List <[log in to unmask]>
<DIV></DIV>>To: [log in to unmask]
<DIV></DIV>>Subject: Sedation using
morphine/midazolam etc.
<DIV></DIV>>Date: Thu, 18 Oct 2001 15:04:17 +0100
<DIV></DIV>>
<DIV></DIV>>A few points:
<DIV></DIV>>As often happens, there are more than
one ways of getting a
<DIV></DIV>>compliant
<DIV></DIV>>patient for a reduction, Midazolam
among them. I have no objection
<DIV></DIV>>to anyone
<DIV></DIV>>using Flumazenil in principle, so long
as they are aware of the many
<DIV></DIV>>good
<DIV></DIV>>points mentioned by others on the list,
especially the lower seizure
<DIV></DIV>>threshold in susceptible patients.
<DIV></DIV>>
<DIV></DIV>>Only a few days back here had a
colleague dealing with a male
<DIV></DIV>>patient,
<DIV></DIV>>around 20 years old, off his motorbike,
with a deformed femur
<DIV></DIV>>fracture and
<DIV></DIV>>slight agitation. A few days later, we
now know that there were no
<DIV></DIV>>other
<DIV></DIV>>lesions found other than the femur
shaft #. At the time, not
<DIV></DIV>>confident with
<DIV></DIV>>a femoral block aand with a
haemodynamically stable patient, my
<DIV></DIV>>colleague
<DIV></DIV>>went for a bit of morphine and
midazolam before reduction.
<DIV></DIV>>
<DIV></DIV>>Bronchospasm followed and sats began to
drop rapidly so, after a
<DIV></DIV>>quick tweek
<DIV></DIV>>and fix of the femoral deformity, he
tried to reverse the midazolam
<DIV></DIV>>with
<DIV></DIV>>flumazenil in addition to using the
usual anti-anaphylaxis measures.
<DIV></DIV>>(Again,
<DIV></DIV>>in retrospect and with another similar
reaction at a later stage, we
<DIV></DIV>>now
<DIV></DIV>>know this patient has a strong
histamine reaction to morphine).
<DIV></DIV>>
<DIV></DIV>>At the time, when Flumazenil was given,
the patient became more
<DIV></DIV>>agitated and
<DIV></DIV>>then went on to have two short
seizures. It was later discovered
<DIV></DIV>>that the
<DIV></DIV>>patient had had febrile seizures nearly
to age 10 and one further
<DIV></DIV>>possible
<DIV></DIV>>seizure as a teenager. CT on the day
was NAD. He later admitted to
<DIV></DIV>>Marijuana
<DIV></DIV>>& alcohol use, but denied any
Cocaine use, which was suspected.
<DIV></DIV>>
<DIV></DIV>>He will spend a few months on
anti-convulsants at least and then be
<DIV></DIV>>reviewed. There would normally also be
many implications as to
<DIV></DIV>>driving
<DIV></DIV>>ability etc... (well, lucky/unlucky for
him, he's in a country where
<DIV></DIV>>even a
<DIV></DIV>>blind-alcoholic-epileptic-drug-dependent-psycopath
can hold a
<DIV></DIV>>driver's
<DIV></DIV>>lisence without difficulty, so long as
he "takes it easy", so he's
<DIV></DIV>>not
<DIV></DIV>>worried...)
<DIV></DIV>>
<DIV></DIV>>Anyway, back to shoulder dislocations
and the like: I try to
<DIV></DIV>>premedicate
<DIV></DIV>>well with opiates (usually morphine
before patient goes to X-ray, if
<DIV></DIV>>they
<DIV></DIV>>are getting an X-ray). Then, with
everything set up and Oxygen on
<DIV></DIV>>and
<DIV></DIV>>monitors, I give Midazolam very slowly,
usually 2mg to start and
<DIV></DIV>>then 1mg at
<DIV></DIV>>a time with 2-3 minute bolus gaps and
good flush through. I educate
<DIV></DIV>>the
<DIV></DIV>>patient well before and during the
procedure as to what's expected,
<DIV></DIV>>and I
<DIV></DIV>>may top up the OPIATES if I think I'm
not heading towards a relaxed
<DIV></DIV>>patient
<DIV></DIV>>quickly enough. It is a rare day when I
don't succeed with 3-4mg of
<DIV></DIV>>midazolam total. On those handful of
occasions, I simply give
<DIV></DIV>>another 1mg
<DIV></DIV>>bolus here and there - have never
needed more than 7mg total ONCE.
<DIV></DIV>>But even
<DIV></DIV>>then, the patient is talking with eyes
open and merely looking
<DIV></DIV>>sleepy.
<DIV></DIV>>
<DIV></DIV>>Flumazenil never used, although I have
always made sure that there
<DIV></DIV>>is an
<DIV></DIV>>ampule of it available and not expired
within easy reach... Just a
<DIV></DIV>>bit
<DIV></DIV>>further from where my airway equipment
is!
<DIV></DIV>>
<DIV></DIV>>As soon as the procedure is done, I
retest axillary nerve sensation
<DIV></DIV>>strap
<DIV></DIV>>the limb down as usual. One favorite,
especially when I have
<DIV></DIV>>students or
<DIV></DIV>>junior colleagues to impress, is to
then encourage the patient to
<DIV></DIV>>fall
<DIV></DIV>>asleep, stay with them for 1 minute or
so and gently wake them up
<DIV></DIV>>right
<DIV></DIV>>there. Then we demonstrate how well the
amnesic effect of midazolam
<DIV></DIV>>works
<DIV></DIV>>(we usually place a bet on how far back
they will forget - the
<DIV></DIV>>patients
<DIV></DIV>>usually love this). I have done a few
without midazolam and have
<DIV></DIV>>noted no
<DIV></DIV>>amnesia. I THINK I might have had
perhaps one patient EVER who could
<DIV></DIV>>remember the procedure, but not sure.
It just seems to work, without
<DIV></DIV>>evident
<DIV></DIV>>risk nor Flumazenil.
<DIV></DIV>>
<DIV></DIV>>But I'm sure Propofol, "talk-down"
sedation and other methods,
<DIV></DIV>>especially
<DIV></DIV>>with adequate analgesia, do also safely
work. Then, of course, there
<DIV></DIV>>is the
<DIV></DIV>>"Lethal Weapon" method, but having seen
one presentation of a
<DIV></DIV>>#clavicle
<DIV></DIV>>after someone tried that (and still had
the dislocation afterwards)
<DIV></DIV>>I do not
<DIV></DIV>>often recommend it...
<DIV></DIV>>
<DIV></DIV>>Now... Has anyone had any success with
educating recurrent anterior
<DIV></DIV>>shoulder
<DIV></DIV>>dislocators on self-reduction???
<DIV></DIV>>
<DIV></DIV>>_________________________________________________________________
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