If you have a working diagnosis of cerebral irritation and the patient is
impossible to control/assess/transport, then the gold standard has got to be
a rapid sequence intubation. However, RSI is not without its pitfalls and
should not be undertaken if you are not happy with the drugs, your help or
getting the tube down (though you can always have a combitube in your back
pocket).
The patient you describe requires adequate cerebral perfusion with blood
containing a lot of o2. You need a good airway, good perfusion pressure and
no struggling!
You cannot provide a definitive airway in this patient without intubation.
In addition Intubation,paralysis and ventilation (done with approapriate
drugs) may well be beneficial to the cerebral insult (ie treat the cause AND
the symptom).
If unable to RSI then your approach seems reasonable although it is again
not without potentially life threatening problems:
1. Loss of the airway.
2. Failure to protect airway +/- aspiration
3. Loss of BP (CVS).
However, by reducing the effect of the patient fighting you, you may well
reduce ICP and increase cerebral oxygenation.
If you are aware of all the pro's and con's of what you are doing then the
decision is that of the doctor on the ground with the patient in front of
them. This is not a black and white question and therefore cannot have a
yes/no answer (mixing metaphors again).
Bottom line: RSI is the treatment of choice. If not happy to do this then
use some clinical judgement.
(I once used midazolam for a very combatitive patient following a near
hanging(he was a 6 foot body builder). He was extremely aggressive and was
lashing out at everyone, brought in by 6 persons!. I had not done
anaesthesia at that time and we could not do anything with him until we had
some form of sedation. Anaesthesia turned up 10 mins later at which point he
was intubated with difficulty +++).
Simon Carley
SpR in Emergency Medicine
Hope Hospital
Salford
England
[log in to unmask]
-----Original Message-----
From: Mark Nettleton <[log in to unmask]>
To: acad-ae-med <[log in to unmask]>
Date: 01 January 1999 18:41
Subject: sedation in head injuries.
>A local BASICS colleague and I have come in for some unwanted critiscism:
>"unwise" critiscism I hope.
>The critiscism involves our decision on 2 seperate occasions to sedate 2
>seperate patients behaving violently and aggresively with ambulance staff
>having both been involved in high speed RTA's.
>In both cases there was no immediately obvious injuries, suggestion of
>pre-existing intoxication or medical problems.Our working diagnoses were of
>cerebral irritation .
>In line of we what both believed at the time was reasonable practice we
>opted to sedate the patients with IV midazolam titrated to response to
allow
>safe airway management, oxygenation and more practically safe transport to
>A&E.
>Dr C John Eatons book "essentials of pre-hospital Immediate Medical Care"
>offers us support in our actions from the point of view of correction of
>hypoxia and prevention of exacerbating raised intracranial pressure through
>hypercapnia.
>The critiscism was voiced by a local A&E colleague with little pre-hospital
>experience .We would both feel happier answering her crtiscism backed by
>further evidence based material or guidelines.
>Can the list help?
>
>Dr Mark Nettleton MBBS MRCGP DGM Dip IMC RCS Ed
>
>
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