I have posted mailings before discussing the use of midazolam in head
injured patients and the concern voiced by non immediate care experienced
A&E colleagues.
The below plotted clinical scenario attracted some more recent critiscism. I
feel I took the right course but consensus views and anything evidence based
would help me feel better.
Case: 54 year old unrestrained female passenger in minibus , vehicle went of
road at speed through hedge. She extricated herself from vehicle then
collapsed-on my arrival- in back of ambulance paramedic had secured c
spine -placed suitable sized oropharyngeal airway in situ. Paramedic clearly
concerned re airway-marked trismus and biting on OP airway stridrous noisy
obstructed breathing.
Repositioning c jaw lift didn't help GCS 6, no external sign of other injury
except superficial abrasion ,vitals all normal .Brief primary survey normal.
Management decision: IV access midazolam 5mg titrated over 2 minutes till
trismus disappeared and then OP airway repositioned and airway controlled
manually with ease.
Decision then made to transport in view of my limited skill of rapid
sequence induction intubation, transport time 20 minutes, kit made ready to
provide further airway/ventilation support if needed.I accompanied crew to
A&E
The local A&E consultant seems to have a problem with the pre-hospital use
of drugs anyway but thats a different story.
Her view was that once IV midazolam is given we should have proceeded to
intubate prior to transportation.
Questions ? I've always believed that trismus occurs either due to cerebral
hypoxia or in fitting- is this right?
What would others have done ?
Should I as a GP dealing with approximately 150 immediate care patients and
a handful of severely head injured patients per annum boost my skill mix to
include rapid sequence induction?
How can I deal with my conflict with a single isolated A&E consultant?
Thoughts and answers please ?
Dr Mark Nettleton MBBS MRCGP DGM Dip IMC RCS Ed
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