Yes that's very interesting Jel. I would agree with you, his pain should've
been sorted firstly; morphine's very unlikely to seriously affect your BP,
especially in a young person with probably isolated head injury, and
haloperidol is as likely to drop your BP anyway. These cases are all about
trading off something for something else. While you might lose with BP and
resps, you'll gain with ease of i.v. access and oxygen administration etc,
and at least you'll be able to measure NIBP and SaO2 etc. You may lose a
point or two in GCS, but you'll get a more stable patient that you can work
with.

Rowley is quite right, in this situation standard intubation would seem to
be the way to go. Even that involves trade-offs. You gain a secure airway,
but you completely lose your ability to monitor GCS. Prehospital workers now
accept this, you simply have to move to CT quite quickly as you've lost that
"contact" with the patient, apart from their pupillary response.

Returning to agitation, books often quote that it might be hypoxia or
hypotension or hypoglycaemia, but I've only seen this with hypoglycaemia.
You should of course always check for the others if you're able! In my
experience agitation's usually due to the injury itself, although often
influenced by alcohol and previous personality; pain can be a factor too,
including full bladder. GCS is very difficult to gauge in the agitated
patient, and wasn't really designed for such patients. However they tend to
have open eyes (E4), are disoriented (V4), and move limbs but not to command
(M5). Their "open" eyes are however often "unseeing" so one could debate
whether you should give them E4 or E1. It's difficult to test pain response
too as they are too agitated! GCS is generally unhelpful in these cases.

Regardless of the cause of agitation, and even if it's hypoxia or
hypotension, one has to achieve "control" of the situation rather than just
holding the patient down, with nurses (for the elderly) or security (for the
young ones). An anaesthetist is ideal but even then you need some measure of
control before going for RSI. The pragmatic solution is to use analgesia or
sedation or tranquillisers depending on the individual case. If you think
pain is a big feature, use analgesia. If the patient is violently aggressive
(and these patients are unlikely to be hypoxic/hypotensive/hypoglycaemic -
they're too bloody strong), then you will normally need sedatives (midaz
etc). And if the patient is pleasantly confused (usually the elderly;
wandering, up and down off trolley with constant nurse supervision), then a
major tranq like haloperidol works a treat. You see the patient may settle
completely with these drugs, and may not need a GA at all before scan,
although the middle (violent) group usually do. If the patient settles
nicely on haloperidol, it makes for a safe awake scan without any need to
"wake them up" afterwards. In any case it's worth using something while you
await your anaesthetist; it will make their job a lot easier. And if you
really need an anaesthetist, remember they need good i.v. access, good
monitoring and good pre-oxygenation before RSI, so if you've already lightly
sedated someone, induction will be a lot safer. These are very challenging
patients!

Adrian Fogarty