# Hypotension and Sedation



## Flighteam (Nov 30, 2011)

Here what I had. A 16 year old boy was working on the farm when his right arm was caught in the PTO of his tractor and was amputated at the shoulder. Out of instinct he reached over with his left arm trying to free the right one, was caught and amputated several fingers and fractured multiple bones.

I was on the helicopter sent to the scene. Upon arrival ALS had no IV access, on 15L NRB, bleeding was controlled, and the patient had an altered LOC. No obtainable BP (by Doppler) in thigh, HR was in the 150s, RR 30s, and skin was pale, cool, and moist. 

We drilled both legs started NS open on pressure bags and decided to RSI him. We used Etomidate and Succinylcholine initally then were in a questioned state for long term sedation. We used vecuronium as our long term paralytic and mass bolused him multiple times with Fentanyl as analgesic and sedation.  Though Fentanyls not really a sedation drug under the circumstance we thought versed would be detrimental to the patient. 

What would you have done in this case?


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## usalsfyre (Nov 30, 2011)

Look up "oxygen opiate induction".

I would have done the same, with the understanding that the only thing keeping the kid alive is catecholamine drive provided by pain itself. From what I've read deep hemorrhagic shock states are somewhat anesthetic themselves. 

I've heard more than one anesthistist familiar with trauma say sometimes the best you can do is "sux an an apology".


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## Smash (Nov 30, 2011)

Not an easy call. I would be reaching straight for the ketamine in this situation both for initial induction and ongoing sedation, but I assume that is not an option for you?  In that case I would probably take the same route you have.  Midazolam would be pretty dicey given the tenuous hemodynamics.


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## systemet (Dec 1, 2011)

I'd do the same if ket wasn't available. Sounds horrible.


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## usafmedic45 (Dec 1, 2011)

Flighteam said:


> Here what I had. A 16 year old boy was working on the farm when his right arm was caught in the PTO of his tractor and was amputated at the shoulder. Out of instinct he reached over with his left arm trying to free the right one, was caught and amputated several fingers and fractured multiple bones.
> 
> I was on the helicopter sent to the scene. Upon arrival ALS had no IV access, on 15L NRB, bleeding was controlled, and the patient had an altered LOC. No obtainable BP (by Doppler) in thigh, HR was in the 150s, RR 30s, and skin was pale, cool, and moist.
> 
> ...



Under the old protocols, ketamine and fluid resuscitation would have been indicated if we decided that we absolutely had to intubate.  That said, even if you push a healthy dose of ketamine, there's honestly no real absolute need to tube the patient assuming you premedicate sufficiently with atropine or glycopyrrolate.  Most of the time, the tube is simply a CYA measure to be completely honest if the patient isn't in fulminant respiratory failure.

That said if the bleeding's controlled, fluid resuscitation.  The end point would be clear mentation and a satisfactory BP.  :censored::censored::censored::censored: pain control if you don't have a serviceable BP.  If his airway is really that bad (and honestly, this should be a temporary problem that will fix itself once you get his BP up) bag him as you pressure infuse him.  If you absolutely have to intubate him (and it doesn't sound like the case at all from your description), then I would just use the paralytic and worry about the pain control and sedation after his pressure comes up.  If he's altered already from hypotension, no sense in worsening it. Personally, I'd hold off on the tube.


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## Veneficus (Dec 1, 2011)

Sometimes intubation allows for sedation and pain control, not just respiratory failure. 

I accept injuries of such severity are rare, but i have seen them, particularly on large BSA burns.


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## usafmedic45 (Dec 1, 2011)

Veneficus said:


> Sometimes intubation allows for sedation and pain control, not just respiratory failure.
> 
> I accept injuries of such severity are rare, but i have seen them, particularly on large BSA burns.



This is very true, but in this case the benefit for that- at least immediately- is outweighed by the risks.  Bag the patient if necessary while you get his pressure up to the point where you have at least an arguable margin of safety, then knock him down for pain control if necessary.  Only if necessary....the risks with intubation are such that it should only be used in extremis (such as burns) when all other measures have failed to provide relief.


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