# Tbi



## Smash (Aug 23, 2009)

Ok, so tell me how and why you would manage this patient.

22 y/o male, no previous medical problems, no medications, no allergies.

Unrestrained rear seat passenger of car versus stationary truck on freeway, estimate speed 50mph+  Extricated by witnesses, lying on the road on your arrival.

Groaning and extends to pain, no eye opening.  Airway:  Trismus present, airway sounds soiled, blood and vomit from nose.  Breathing:  Laboured, tachypneic, equal chest wall movement, air entry to bases.  SpO2 87% on NRB.  Strong radial pulses, HR 90, sinus rhythm, BP 150/100.

Blood and CSF coming from R) ear, bilateral periorbital ecchymosis, some minor abrasions and haematomas to head and neck, no other significant injuries found.

You are 40 minutes transport time to nearest hospital (which luckily is the local trauma center) and there is no HEMS available.

What do you do, and why?


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## MrBrown (Aug 23, 2009)

Collar and scoop him, move into the truck

Wait a minute and see if the trismus loosens up, if so suction and drop an LMA.

Begin transport and either way if we are able to ventilate him or not I'd call for an Advanced Paramedic trained in rapid sequence intubation provided that we can intercept enroute significantly faster than we can deliver the patient to the hospital.  

The patient may not require RSI depending upon what his O2 sats are like and whether or not I can put an LMA in but I'd like an officer trained in it coming towards us anyway.


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## itzfrank (Aug 23, 2009)

Collar, Immobilize, Transport. RSI... or Versed. I need to relieve the trismus if possible. Otherwise Cric em. Airway/Ventilation seems like the only immediate life threat. Get that resolved, put a couple of lines in just in case, and transport and monitor. If he has a chance at all, he needs surgery NOW. Rapid Transport is killer in importance. (no pun intended)


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## Dominion (Aug 23, 2009)

itzfrank said:


> Collar, Immobilize, Transport. RSI... or Versed. I need to relieve the trismus if possible. Otherwise Cric em. Airway/Ventilation seems like the only immediate life threat. Get that resolved, put a couple of lines in just in case, and transport and monitor. If he has a chance at all, he needs surgery NOW. Rapid Transport is killer in importance. (no pun intended)



Same as above, the thing around here is nasal.  Attempt nasal before cric, we don't have the option of RSI.  :glare:


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## Akulahawk (Aug 23, 2009)

Sacramento area would be more like this:


 Collar & spine board
 Perform Nasotracheal intubation. Be very cautious because of likely basilar skull Fx.
Use EtCO2 detector (for confirmation of successful intubation)
GET OFF SCENE NOW!!!!
Two Large Bore IV.
 Diesel. Lots of Diesel.
They do not allow medication assisted intubation here. Period. RSI in the field by Paramedics (in this system) would be absolutely outrageous. If the patient starts seizing, then midazolam can be administered for that... which _might_ result in also relieving the patient's trismus.

Sacramento also does NOT include in their protocol any sort of guideline about what range to maintain the CO2 levels... it's just a device used to confirm placement. Sacramento is a bit behind on that... woefully so. Part of the reason for that has to do with how ALS came in to existence here.


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## Ridryder911 (Aug 23, 2009)

As previoulsy stated immobilization with RSI using Etomidate as it lowers ICP. I did not see the respiratory rate but after tracheal suctioning place patient possibly on PEEP as it too will reduce ICP, of course monitoring EtCo2. 

The sedation of RSI is not only for airway but to decrease agitation usually associated w/closed head injury patients thus increasing the ICP. 

Closely monitor nuero (detailed) assessment, and place Level I on neuro alert. 

* nasal intubations are contraindicated in patients with possible basilar as reported CSF is many times usually linked to cribriform plate fractures. Thus, blind ETI can enter brain matter through opening. 

R/R 911


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## Melclin (Aug 23, 2009)

Ridryder911 said:


> * nasal intubations are contraindicated in patients with possible basilar as reported CSF is many times usually linked to cribriform plate fractures. Thus, blind ETI can enter brain matter through opening.
> 
> R/R 911



Still without an airway he _will_ die. If you nasal tube him, you _might_ stick the tube in his brain. From what I hear the likelihood of tubing his brain is relatively low anyway....lower than his risk of death from not breathing. 

I realise he has an airway of sorts. But I think you'd have to weigh the risk of him losing it with more vomiting and aspriation, to the risk of sticking his brain with the ETT. 

If he lost it all together, nasal has to be on the cards regardless of the possibility of cribriform fractures..unless you could cric him.


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## Ridryder911 (Aug 23, 2009)

Melclin said:


> Still without an airway he _will_ die. If you nasal tube him, you _might_ stick the tube in his brain. From what I hear the likelihood of tubing his brain is relatively low anyway....lower than his risk of death from not breathing.
> 
> I realise he has an airway of sorts. But I think you'd have to weigh the risk of him losing it with more vomiting and aspriation, to the risk of sticking his brain with the ETT.
> 
> If he lost it all together, nasal has to be on the cards regardless of the possibility of cribriform fractures..unless you could cric him.



If one is properly educated and well clinically trained, crich is not that big of an issue. I have performed this procedure at least 4-5 times on patients directly related to head injuries and due to it was contraindicated for that specific reason. Actually, with the newer kits if one has been through advanced airway courses (w/cadavers) it is not a difficult procedure.

I went through a trauma cadaver lab that demonstrated that it was much easier to intubate the brain stem that had been predicted. The same reason that NG tubes is not utilized rather again OG tubes would be placed. 

With the development of other airways; even after RSI in my opinion would be a much better way to provide an airway than moving a tube blindly through passages that may have openings and weak spots, with less risk. 

R/r 911


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## VentMedic (Aug 23, 2009)

Akulahawk said:


> Sacramento also does NOT include in their protocol any sort of guideline about what range to maintain the CO2 levels...


 
We have gotten away from hyperventilating or blowing off a patient's CO2. We will instead maintain toward the lower side of normal. As well, if a patient has aspirated or there are still secretions present, that much be taken into consideration when looking at the numbers on an ETCO2. 

RSI, suction and oral intubation would be the preferred but understandably not possible in some parts of the country.   Yes, the CDC guidelines recommends that all tubes to be oral for a variety of reasons but again that may not be possible in prehospital. 

PEEP is controversial. If we see a need in the ICU to go much of 5 cmH20, all the cerebral monitoring devices will be placed. Primarily PEEP should be used only if there is an oxygenation problem and the head of the bed can be slightly elevated. Increases in Mean Airway Pressure can increase ICP. The Mean Arterial Pressure must be maintained to adjust for the increase in Mean Airway Pressure. PEEP can elevate PaCO2 and lower pH by extending the FRC. 

Adequate Cerebral Perfusion Pressure is the goal. Ischemia results from decreased CPP. 

CPP is essentially Mean Arterial Pressure - ICP. So if MAP is decreased from a change in Mean Airway Pressure, CPP is decreased. If the Mean Airway Pressure increases the ICP, CPP is decreased. 

There is a cycle that will result from each parameter. 

*The body's response to a decreased CPP is to raise blood pressure and dilate blood vessels in the brain. 

*This increases cerebral blood volume.

*This increases ICP.

*This decreases CPP.

*This causes the body to respond again and the cycle start over.


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## bstone (Aug 23, 2009)

Use EEG for prehospital monitoring of brain electrical activity.


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## Ridryder911 (Aug 23, 2009)

bstone said:


> Use EEG for prehospital monitoring of brain electrical activity.



Heck, why not do a burr hole and place a ICP device in it as well?

R/r 911


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## bstone (Aug 23, 2009)

Ridryder911 said:


> Heck, why not do a burr hole and place a ICP device in it as well?
> 
> R/r 911



Nah, we carry neurosurgeons on all our buses. They do that sort of work. I can be bothered to get my hands dirty.


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## Sasha (Aug 23, 2009)

bstone said:


> Use EEG for prehospital monitoring of brain electrical activity.



Learned that at Harvard, did you?


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## bstone (Aug 23, 2009)

Sasha said:


> Learned that at Harvard, did you?



Best care anywhere!


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## Akulahawk (Aug 23, 2009)

VentMedic said:


> We have gotten away from hyperventilating or blowing off a patient's CO2. We will instead maintain toward the lower side of normal. As well, if a patient has aspirated or there are still secretions present, that much be taken into consideration when looking at the numbers on an ETCO2.
> 
> RSI, suction and oral intubation would be the preferred but understandably not possible in some parts of the country.   Yes, the CDC guidelines recommends that all tubes to be oral for a variety of reasons but again that may not be possible in prehospital.
> 
> ...


I appreciate this review. I said nothing about blowing off CO2, just that Sacramento doesn't have within their protocols, anything beyond using an ETCO2 detector as a device to confirm ETT placement. About the only "newish" thing for me was Mean Airway Pressure effects upon MAP and from there, upon CPP. Even then, that was not exactly new to me. But like I said, I really do appreciate this review. 

If anything it got me irritated at Sacramento EMS all over again about their lack of a policy wrt ETCO2 monitoring... it's pretty darned easy to over-ventilate the patient. This, as is known, can cause cerebral vasoconstriction, and therefore while it lowers ICP, it also can cause a drop in cerebral perfusion, possibly below the ischemic threshold.


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## Akulahawk (Aug 23, 2009)

bstone said:


> Use EEG for prehospital monitoring of brain electrical activity.


Some surprising results might be found if EEG monitoring is instituted on Residents, some Nurses, and most EMS personnel... who haven't been caffeinated.


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## bstone (Aug 23, 2009)

Akulahawk said:


> Some surprising results might be found if EEG monitoring is instituted on Residents, some Nurses, and most EMS personnel... who haven't been caffeinated.



And even more interesting results found on those who publish to these forums.


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## VentMedic (Aug 23, 2009)

Akulahawk said:


> I appreciate this review. I said nothing about blowing off CO2, just that Sacramento doesn't have within their protocols, anything beyond using an ETCO2 detector as a device to confirm ETT placement. About the only "newish" thing for me was Mean Airway Pressure effects upon MAP and from there, upon CPP. Even then, that was not exactly new to me. But like I said, I really do appreciate this review.
> 
> If anything it got me irritated at Sacramento EMS all over again about their lack of a policy wrt ETCO2 monitoring... it's pretty darned easy to over-ventilate the patient. This, as is known, can cause cerebral vasoconstriction, and therefore while it lowers ICP, it also can cause a drop in cerebral perfusion, possibly below the ischemic threshold.


 
Just because it is not specifically written out does not mean you should not know the many uses of your technology or what the numbers mean for different situations. Of course, this would also mean an understanding of deadspace ventilation an V/Q mismatching.

Just following the recipe is what has gotten some to fail to understand other equipment like the pulse ox. Too few learn about Hb, COHb, MetHB, vasoconstriction and cardiac output to adequately use the SpO2 number for assessment. It should be used to confirm what you are already thinking and not the basis of your whole diagnosis. 



Akulahawk said:


> Some surprising results might be found if EEG monitoring is instituted on Residents, some Nurses, and most EMS personnel... who haven't been caffeinated.


 

Actually, they are usually the subjects for many studies and for those to gain more practice with.

However, the EEG is just like the pulse ox. Given the scenario:



Smash said:


> Unrestrained rear seat passenger of car versus stationary truck on freeway, estimate speed 50mph+ Extricated by witnesses, lying on the road on your arrival.
> 
> Groaning and extends to pain, no eye opening. Airway: Trismus present, airway sounds soiled, blood and vomit from nose. Breathing: Laboured, tachypneic, equal chest wall movement, air entry to bases. SpO2 87% on NRB. Strong radial pulses, HR 90, sinus rhythm, BP 150/100.
> 
> Blood and CSF coming from R) ear, bilateral periorbital ecchymosis, some minor abrasions and haematomas to head and neck, no other significant injuries found.


 
one should not need an EEG to see this patient probably has a TBI and that will be the protocol you will be dealing with in prehospital.


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## bstone (Aug 23, 2009)

I was being silly in saying prehospital EEG is needed. The man needs a neurosurgeon, not an EEG.


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## VentMedic (Aug 23, 2009)

Previous EEG on ambulances thread:

http://www.emtlife.com/showthread.php?t=14290


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## Smash (Aug 24, 2009)

*Can we avoid a hijack please*

This isn't really the place for nonsense about prehospital EEG. If you need an EEG to work out that this pt has a traumatic brain injury then this clearly isn't the job for you. 

For those good enough to reply sensibly, I'm curious about the 'why' regarding treatment. Why try to place an LMA or a tube (or not), and how do you expect your management to improve this persons outcome?  If you do want to manage the airway, what would be your preferred method and why? (not worrying about protocol)


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## ResTech (Aug 25, 2009)

The airway and head injury are obviously the priority injuries requiring treatment. Definitely immobilize however, if this patient is clenched and has what sounds like copious amounts of blood/fluids in the upper airway, initially I would consider placing a KED board under him and sitting him up (at least semi-fowlers) so the fluids don't accumulate and further occlude the airway. This positioning will also serve well for any ICP. Suction the best you can given the clenched jaw.  

In Maryland, ground Paramedics do not have RSI so if the mouth isn't able to be opened and the patient is already at 89% on a NRB, this is a very dire situation given the head injury and airway compromise so the patient would need to be criched. Given the initial head injury, the secondary head injury occurring from the hypoxia, and the upper airway compromise, I see clear indication for getting an airway ne way u can.. ie cric. 

Once the ETT is placed, I would ventilate to maintain EtCO2 at 35mmHG and continually monitor the airway and ventilatory status. Than the normal EKG and IV's x2 at KVO since blood pressure is sufficient.

Based on the info presented, I would rationalize the low O2 sat with the NRB is a result of obstruction of the upper airway from the large quantity of fluids present. If the SpO2 did not increase with intubation, then I would start searching for another cause such as a hemothorax or pneumothorax.  



> If you do want to manage the airway, what would be your preferred method and why? (not worrying about protocol)



You always want to try to stick with the less invasive treatment... RSI I think would be a good choice if available... a thought that comes to mind is what if for some reason the RSI doesnt work? Now you have an already critically head injured patient who is now more critical because he is not breathing and has no airway and no way to ventilate him. So perhaps in this scenerio going straight for the cric would be better than RSI. 

I would love to hear others thoughts on cric over RSI. Airway management as an area that scares me more than anything right now. Its not the performing of the skills that scares me... its the knowing when and what is best that I have a fear of in these critical situations that dont play out everyday. I run the scenerio like presented and am afraid of being too aggressive and say doing a cric when I shouldnt have and getting in hot water because of it.    

And beat feet to the bright lights and cold steel of the trauma room.


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## Ridryder911 (Aug 25, 2009)

It again all comes down upon education and not just training. My medics attend an aggressive airway management course that not has detailed anatomy and procedures taught by anesthesiologist, anatomist and ED physicians. Detailed study on specialized mannequins and then fresh cadaver performance. 

http://www.oumedicine.com/Workfiles/college of medicine/csetc/News/CSETC_OverviewInsert_runweb.pdf

So yes, an airway is one of the few instances that can change the outcome on trauma patients. Unfortunately, most ground units have not became so educated and entrusted to carry O- as many flight services do, so hemodynamically we are a race against time (no not the "golden hour" myth). 

So yes if RSI cannot provide an adequate airway only two other options of alternative airway such as King or similar, then as last resort crich. Which again, if properly educated upon is not that difficult of a procedure to perform successfully. 

Our neuro still prefer if possible the patient to be closely monitored as in EtCo2 and small PEEP to reduce ICP. Semi-fowlers is a great idea but in the field setting not a routine as most are on LSB and to really place in a degree of good is difficult to elevate the LSB with restriction within the aircraft (one can attempt if possible, though). 

One emphasis though is a good and thorough neuro assessment of the patient. Not the routine PEARL but a detailed CNS and evaluation of reflexes, etc. is important and noting changes is as important than some of the treatment. 

R/r 911


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## Smash (Aug 25, 2009)

Good answer ResTech, whether one agrees or disagrees with your treatment, you have provided a rationale that is clearly thought through.

I agree with Ridryder, in that advanced airway management (RSI and cric) are not things to be scared of, providing that the practitioner is suitably educated, trained and supported.  RSI in particular is treated by many as the boogyman, whereas it actually makes life easier for the medic and improves the outcome of TBI patients providing it is done appropriately.  This is not to say that one should not have a healthy respect for the risks involved of course.

Ridryder:  I agree with careful assessment of neuro prior to RSI, and no EtCO2 (waveform + numbers) means no RSI for me.  However I am interested to know whether you would consider ongoing paralysis (vec/panc/whatever) and sedation following intial induction and intubation, or would allow resumption of airway reflexes and respirations?


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## VentMedic (Aug 25, 2009)

Smash said:


> RSI in particular is treated by many as the boogyman, whereas it actually makes life easier for the medic and improves the outcome of TBI patients providing it is done appropriately.


 
The boogyman implies RSI can't be done because of the unknown.  We know the things that hinder the addition of RSI for the Paramedic.

Too many things that are not standard: 
Education 
Training 
Competencies 
Certifications 
Licensing 
Leadership 
Medical Oversight


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## TransportJockey (Aug 25, 2009)

Here in NM if a pt presents like that our sequence would be:
immobilize, cric, initiate transport, 2 large bores en route, PEEP valve inline with BVM, ETCO2 monitoring.
We are contraindicated for a Nasal ETT with facial trauma of the type described. We could call HEMS for RSI here, and possibly get an MCEP for it, but cric would be our first choice for a pt like this. He needs aggressive airway management, not calling and waiting.


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## Smash (Aug 25, 2009)

VentMedic said:


> The boogyman implies RSI can't be done because of the unknown.  We know the things that hinder the addition of RSI for the Paramedic.
> 
> Too many things that are not standard:
> Education
> ...





> providing that the practitioner is suitably educated, trained and supported.


..............................


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## ResTech (Aug 25, 2009)

I am curious why a few had mentioned using PEEP on this patient? I did a quick search on Google with PEEP and head injuries and the literature I read said that PEEP with the head injured patient really doesnt offer any effect and while the increase is inconsequential, it can raise ICP slightly.

The Shock-Trauma portion of my program did not mention anything about using PEEP on the trauma patient.


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## VentMedic (Aug 25, 2009)

smash,


So why do you think RSI is still the bougey man?

The other problem even with some EMS agencies that do RSI is that the recipe they are allowed is too conservative to even knock out a 80 y/o grandmother who only takes ASA as a med.    There have been times when a patient has been half-arsed paralyzed aften they had a decent respiratory drive and now are respiratory compromised and still fighting intubation.  Calling the doctor for more orders can be difficult as you have your hands full with an airway compromised patient and the doctor may be cautious with allowing more sedation/paralytics if you have exhausted your own Medical Director's protocol. 

The same for the hypothermia protocol.  Some are unable to sedate and paralyze after initiating the protocol when the patient shivers.  Some patients are now being documented upon arrival to the ED with almost a higher than normal temperature with this therapy.


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## Akulahawk (Aug 25, 2009)

VentMedic said:


> smash,
> 
> 
> So why do you think RSI is still the bougey man?
> ...


And there are those systems that do not allow the full-on RSI aka no paralytics, just benzos. I wouldn't be surprised if some systems don't (or can't) go to RSI because of the inability to do what's necessary in the event that the medic can't get the tube. Fortunately, those issues should be occurring less and less commonly now with use of the Combitube (and similar devices) and the use of the LMA in the field. Surgical cric and retrograde intubation techniques work too... but...

In other words, I feel that if a medical system is going to authorize RSI, that system has to authorize the full spectrum of airway procedures in the event (and it will) that RSI results in a failure to secure the airway. Lots of training would be required to ensure that everyone is trained in the technique and all necessary back-up airway measures. That's not too horrible a proposition if you're dealing with a relatively small number of providers. If you have hundreds... then you have to find a way to schedule all of them to have the appropriate training... and that can be a nightmare, no matter how you delegate the training...

Boogeyman? Not by far. Logistical training nightmare? Quite Possibly.


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## Smash (Aug 25, 2009)

VentMedic said:


> smash,
> 
> 
> So why do you think RSI is still the bougey man?
> ...



I would rather have not been tied up in the semantics of the term 'boogyman', however:

If you read my post you will see that *I don't think that RSI is the boogyman.  I refer instead to those agencies, such as you yourself describe that are overly cautious in the application of advanced airway management for whatever reason, or do not allow it at all (as seen in this thread with attempts to place LMAs or going straight to crics in this patient)

The service I work for performs approximately 200 drug assisted intubations per quarter, and this number is rising.  That doesn't include the intubations where sedation/paralysis are used post cold intubation.  So that is around 800 RSIs per yer.  We have a 97% first attempt success rate, and to date have not had to resort to cric in any RSI patients (it has been used in other patients) and the LMA as a rescue device has been used once.  We have been performing RSI for over 5 years on the ground and 10 on HEMS.

I was (and am) curious as to the rationale particularly of those providers who do not carry out RSI, and in asking what the 'preferred' method would be to treat this patient I wanted to guage to some extent the mindset of some (at least on this forum) who don't RSI in respect to airway/TBI management.

ResTech gave an excellent response, but most have been "Stick an EGD in" or "poke a hole in them and go to hospital".  Hardly optimal treatment for TBI with a poor airway.*


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## arsenicbassist (Sep 18, 2009)

Let's not forget that Versed for RSI increases ICP... Vecuronium would be my choice for a paralytic, as it is non-depolarizing.


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## Akulahawk (Sep 18, 2009)

arsenicbassist said:


> Let's not forget that Versed for RSI increases ICP... Vecuronium would be my choice for a paralytic, as it is non-depolarizing.


Is it Versed, the intubation attempt itself, or use of a depolarizing paralytic agent that causes the increased ICP?


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## Smash (Sep 18, 2009)

Versed _may_ increase ICP. The studies that I am aware of are extremely small series (10s of patients) that aren't really powered to show that. If you are aware of larger trials please post them they would be good to see. 

It is unusual to find a service that advocates the use of a non-depolarizing NMBA as the primary agent used in induction, particularly a medium duration one such as vecuronium. Sux is more commonly used for it's rapid onset and short duration which is seen as safer in the prehospital field. Longer term paralysis is commonly achieved by either vecuronium or pancuronium. 

If I was going to use a non depolarizer during induction I would choose a sHort acting one such as mivacurium or atracurium followed by panc or vec. Thus would allow resumption of respirations in a short time frame should intubation fail thereby minimizing the likelihood of of a can't intubate can't ventilate situation.


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## Lifeguards For Life (Sep 18, 2009)

Akulahawk said:


> Is it Versed, the intubation attempt itself, or use of a depolarizing paralytic agent that causes the increased ICP?



the intubation procedure itself or sux could both cause increase in ICP, midazolam causes hypotension not icp


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## Lifeguards For Life (Sep 18, 2009)

Smash said:


> Versed _may_ increase ICP. The studies that I am aware of are extremely small series (10s of patients) that aren't really powered to show that. If you are aware of larger trials please post them they would be good to see.
> 
> It is unusual to find a service that advocates the use of a non-depolarizing NMBA as the primary agent used in induction, particularly a medium duration one such as vecuronium. Sux is more commonly used for it's rapid onset and short duration which is seen as safer in the prehospital field. Longer term paralysis is commonly achieved by either vecuronium or pancuronium.
> 
> If I was going to use a non depolarizer during induction I would choose a sHort acting one such as mivacurium or atracurium followed by panc or vec. Thus would allow resumption of respirations in a short time frame should intubation fail thereby minimizing the likelihood of of a can't intubate can't ventilate situation.



I think Rocuronium is the fastest acting non depolarizing agent, with the fastest onset


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## Smash (Sep 18, 2009)

Versed has high potential to cause hypotension, however there has been at least one small series that showed an increase in ICP subsequent to the administration of versed, so there is that potential.  However it was a small series and not statistically significant.  I'm not aware of any otheres, although there may be some larger studies.

Intubation/laryngoscopy will cause an increase in ICP.  The larynx is one of the most highly inervated structures in the body, and messing around with it will cause significant sympathetic response which is something we want to avoid in TBI.  This is why it is advisable to have as part of your process fentanyl (or something similar) to blunt that sympathetic response and minimize the rise in ICP.

Rocuronium indeed has the fastest onset time of the Nondepolarizing NMBA (about 60 seconds), however it also lasts for about 45 minutes, which defeats the purpose of using a short acting drug such as mivacurium or atracurium.

The reason why sux is popular is because it very rapidly achieves complete muscle relaxation, however it also wears off very quickly, allowing resumption of spontaneous resps should you be unable to ventilate.  Using atracurium will achieve a similar goal.  If you use roc you are leaving yourself open to having a patient whom you can't ventilate being paralysed for 45 minutes or so.  Not a good plan!


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## Akulahawk (Sep 18, 2009)

Smash said:


> Versed has high potential to cause hypotension, however there has been at least one small series that showed an increase in ICP subsequent to the administration of versed, so there is that potential.  However it was a small series and not statistically significant.  I'm not aware of any otheres, although there may be some larger studies.
> 
> Intubation/laryngoscopy will cause an increase in ICP.  The larynx is one of the most highly inervated structures in the body, and messing around with it will cause significant sympathetic response which is something we want to avoid in TBI.  This is why it is advisable to have as part of your process fentanyl (or something similar) to blunt that sympathetic response and minimize the rise in ICP.
> 
> ...


That's my understanding with Roc too, in that it does have a fast onset, but a relatively long duration... which I'd hate to be stuck in a paralyzed, can't intubate/ventilate situation... Knowing that Sux does work fast and has a short duration makes it attractive for field use. I'm not familiar with mivacurium or atracurium... but that's mostly because I haven't been exposed to those agents to include in my knowledge base.


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## Smash (Sep 18, 2009)

Atracurium and mivacurium are fast acting non-depolarising NMBAs with a reasonably short duration of action.  Atracurium is used reasonably widely in ORs, mivacurium is a relatively new drug and I haven't seen it around much.  There is another even newer one cistracurium (I think, not sure on spelling) in a similar vein.

The advantage of use in the OR is that there are less concerns with a can't intubate, can't ventilate scenario than in the field.  Theoretical advantages also include the increased range of patients who could be RSI'd, such as hyperkalemic, penetrating eye injurys, pt's with sux apnoea or malignant hyperthermia and so forth.  However given that these conditions are relatively rare, I suspect the risk/benefit scales will continue to swing towards sux for a while yet.

Going back to sux, the putative rise in ICP caused by fasciculations can be attenuated by a number of methods such as pretreatment with a small dose of a non-depolarizing NMBA, lidocaine, or easier still, adequate induction agent


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## thegreypilgrim (Sep 19, 2009)

Smash said:


> What do you do, and why?



Delegate spinal axis immobilization and cutting off clothes with shears.
Delegate OPA insertion and assisted-ventilation with BVM while trying to suction the crap out of his mouth as much as possible and while I set up RSI equipment.
Have someone strip out a line, and hopefully I have another medic on scene with me to get the IV started. 
Go ahead and execute RSI:
 - make sure pt is being preoxygenated
                                      - Lidocaine 1.5 mg/kg IVP
                                      - Fentanyl 3 mcg/kg or MS 10-20 mg IVP
                                      - Etomidate 0.3 mg/kg IVP
                                      - Succinylcholine 2 mg/kg IVP
Confirm tube placement with EtCO2 and waveform capnography - use capnography to guide ventilations
_*LOAD PT AND GET GOING*_
Rapid Trauma Assessment en route
Have someone finish patching pt up to ECG
Start 2nd large bore IV, be aggressive with fluids to maintain BP/vitals at current values
Check glucose...kind of irrelevant but it's on my PCR and technically the pt is "altered" so it should be done
Notify trauma center of what we're bringing in and our ETA
Slap the defib pads on the pt's chest in case he codes en route


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