# Prehospital Sedation of the Combative Patient in the presence of a TBI



## Handsome Robb (Nov 9, 2012)

I'm going to preface this one with RSI is NOT an option. We don't do it and frankly on this call I'm glad because it took 3 docs 4 attempts and a glidescope to tube this guy. 

Scenario: Mid 40s male crossing the street struck by an unknown sized automobile at an unknown speed. Pt thrown approximately 20 feet and landed on his head on the concrete sidewalk. +LOC x "3-4 minutes". Upon arrival pt is found being fought onto a backboard by fire personnel and the first ALS unit already on scene. GCS of 9 (2/3/4), snoring, irregular respirations, decreased to 7 (1/3/3) upon arrival to the trauma center.

Superficial to partial thickness abrasions and lacerations to entire left side of the body. PERRL @4mm but sluggish, jaw is trismussed and remains trismussed throughout the transport, besides abrasions and what else was already noted the head/neck are unremarkable. Chest has above noted abrasions, no crepitus, no sub-q air, equal rise and fall bilaterally, clear to auscultation bilaterally. Abdomen is distended and firm. Pelvis is stable, urinary incontinence noted. Crepitus just proximal to midshaft left femur, no  shortening or rotation. +CMS in all extremities. Ok + pulses and motor in all extremities, unable to asses sensation due to ALOC and combativeness 

Vitals: HR 150s sinus without ectopy, BP unobtainable due to pt's combativeness (180/82 per TC after RSI), 100% on a NRB mask, RR 8-10 snoring and irregular, CBG was good...can't remember what it was right off the top of my head.

H/A/M: Unknown, girlfriend was struck by the same vehicle and has ALOC as well.

My question is, can/would you sedate this patient? It took me and a FF all we had just to get bilateral lines in this guy. I argued with myself all the way to the hospital about giving him versed. His ICP is increased and it's just getting worse with all this fighting however I've been told a million times we cannot sedate combative TBI patients "because they are altered" and "we don't have a protocol for it". In the end I didn't end up giving him anything as he started posturing and stopped being combative. I spoke with a bunch of supervisors as well as our MD and was told to sedate next time, which I agree with and if I could go back and change it I would. 

What are thoughts about prehospital sedation, not RSI, in the pt presenting with a TBI? What options do you have? How does your service view it? Dose-wise how much, what route and why?

This one kinda got to me, I know no matter what I did he was going to herniate but there's still that part of me kicking myself in my new medic *** about how I should have "slowed the process" by knocking this guy down.

Please pardon any grammatical errors seeing as its 0530 and I'm coming off of a 12


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## Veneficus (Nov 9, 2012)

I think it makes the case for thiopental.


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## Handsome Robb (Nov 9, 2012)

Veneficus said:


> I think it makes the case for thiopental.



Any particular reason why you chose that over some of the more common prehospital meds? Does anyone use thiopental prehospitally? Or in the hospital anymore? I know propofol is usually the go to for most facilities that I've been around these days.


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## Veneficus (Nov 9, 2012)

NVRob said:


> Any particular reason why you chose that over some of the more common prehospital meds? Does anyone use thiopental prehospitally? Or in the hospital anymore? I know propofol is usually the go to for most facilities that I've been around these days.



Barbiturates are shown to be neuroprotective.

It is not used in the US routinely, if it is even still available, however, it is used around the world.


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## Handsome Robb (Nov 9, 2012)

Veneficus said:


> Barbiturates are shown to be neuroprotective.
> 
> It is not used in the US routinely, if it is even still available, however, it is used around the world.



Copy that, thank you!

As far as medications usually used prehospitally in the US for sedation is there a particular one you'd reach for? I haven't heard of many EMS systems carrying barbiturates but I'm sure they are out there.

All we have available to us on the ground is versed. Our HEMS guys have more options but I wasn't calling a bird for this guy. By the time they'd have gotten off the ground I would've been calling my report.


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## Veneficus (Nov 9, 2012)

NVRob said:


> Copy that, thank you!
> 
> As far as medications usually used prehospitally in the US for sedation is there a particular one you'd reach for? I haven't heard of many EMS systems carrying barbiturates but I'm sure they are out there.
> 
> All we have available to us on the ground is versed. Our HEMS guys have more options but I wasn't calling a bird for this guy. By the time they'd have gotten off the ground I would've been calling my report.



I would go with midazolam because I am very comfortable using it.


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## Handsome Robb (Nov 9, 2012)

Veneficus said:


> I would go with midazolam because I am very comfortable using it.



Right on, thank you!

I know Vene makes us all look dumb but I'd like to hear from others as well


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## RocketMedic (Nov 9, 2012)

All we have for this currently at my service is midazolam, but we were always told that "versed makes dead" for inducing like this. Still, I really do think that midazolam is the best option as it stands, or potentially etomidate if you're that lucky. Did his trismus resolve with GCS deterioration? Remember, sedation is not defasciculation (I know I spelled that wrong). IMO (another new medic's perspective), I'd rather have a medic slow-play me than jump straight to our systems' 'sedate-to-intubate' madness, especially with combativeness and trismus. That being said, I'm learning that we can't always be afraid of the airway.

Here, with that same call, I'd be very reluctant to sedate, but if I could get a line in early and he met size guidelines for a King, I'd hit him with 5.0 of midazolam and attempt ETI with the King as a backup airway. If I wasn't able to get a line, I'm thinking self-ventilation.

Hypertension isn't his friend, but uncontrolled brain herniation and attendant airway problems are going to kill him before cerebral hypoxia from a diminished MAP. Poop sandwich, all we can really do is transport to neurosurgery and keep his airway as protected as possible.


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## 18G (Nov 9, 2012)

I definitely would have sedated this patient. As mentioned, agitation is going to increase the ICP. And not to mention the agitation inhibits the team from providing efficient care and safe transport. 

Versed would be my choice of sedative - 5mg slow IVP. Versed also provides protection for seizures and greater airway issues. As in the patient seizes, stops breathing, develops hypoxia which just increased mortality to 50%, now has trismus, vomiting, etc, etc. 

I would have attempted intubation only after the Versed was onboard or when the posturing started and patient calmed. This is a significant sign of herniation and indicates need for controlled ventilation. Definitely would have been monitoring EtCO2 via N/C filter set. The recommended is target EtCO2 at 30mmHg in this patient with signs of herniation.   

I would have attempted a nasal airway as long as the nares were free of blood and/or fluid. Yes, I know the old head injury, shouldn't place a nasal airway doctrine. But if I cant intubate, patient won't tolerate an OPA, and has snoring respirations, this indicates need for an NPA. 

I'm curious to hear where the "Versed makes dead" theory comes from. Probably from the same two resident physicians who argued with me that Versed absolutely could not be used for my agitated, CVA patient the other night and chose to instead give me orders for diazepam.


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## Veneficus (Nov 9, 2012)

18G said:


> I'm curious to hear where the "Versed makes dead" theory comes from. Probably from the same two resident physicians who argued with me that Versed absolutely could not be used for my agitated, CVA patient the other night and chose to instead give me orders for diazepam.



I would be curious about that too. I have never heard it.

From the mechanism of action standpoint, alcohol, benzos, and barbiturates all act at different sites on the GABA receptor, understanding that, the action is not going to be what kills people. 

You may have respiratory depression, but no more than if you RSIed the person. 

Hemodynamic instability should be managable with fluid, but I would be very conservative with fluid in the head injured. Over fluid resuscitation is linked to increased mortality in this group.

If the pt is multisystem with TBI and hemorrhage, then you are in real trouble and you just need to worry about getting to the hospital. 

I would also point out that the paralytics were developed so that less anesthetic agents (like high dose benzo or opioid) could be used. Prior to them high dose benzo and opioid was the only option. 

This "versed makes dead" sounds like it came from somebody who either had a bad experience or needed a memory aid because they didn't understand exactly what they were doing or why.


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## Handsome Robb (Nov 9, 2012)

The key to this is I was *NOT* looking to tube this guy, just knock him down a bit so I could get a good mask seal and he'd stop thrashing about. His ICP is already through the ceiling and him fighting with us isn't helping that fact at all. This guy was a big dude and basically solid muscle vs me and my 5'8" 155 pound self, thank goodness for the fire department. It actually took 3 docs at least 3 attempts, maybe 4, before they finally tubed him with a glidescope. With the facial trauma and his external anatomy I knew this guy was going to have one helluva difficult airway. 

Trismus never resolved, I thought he may be seizing but the way he was moving his extremities at first didn't seem like a seizure to me. With that said I've only seen a handful of active seizures. Trauma Doc didn't seem to think he was seizing either.

The only airway option that crossed my mind was a crich if he started desaturating but we were pretty close to the Trauma Center, about 8 minutes code 3, and I'm not sure how I would've managed it with how combative he was unless he got so hypoxic he stopped fighting but I don't really like that option...Had we been further away who knows what would have happened, HEMS may have come into play and they have most all the airway toys the ER does but in my system they are only helpful if they are dispatched simultaneously with you. His GCS changed pretty abruptly basically as we were rolling through the doors into the hospital.


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## Veneficus (Nov 9, 2012)

NVRob said:


> It actually took 3 docs at least 3 attempts, maybe 4, before they finally tubed him with a glidescope. With the facial trauma and his external anatomy I knew this guy was going to have one helluva difficult airway.



If everyone was so concerned about the airway, at what point was it decided not to simply cric this guy?


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## Jon (Nov 9, 2012)

This is one of the fun protocols in PA. We have an "agitated behavior" protocol for sedation. In a case like this, I can sedate first, ask questions later. I don't have RSI. If I do knock out his respiratory drive, I've got a couple of airway options, including cric'ing him.

It's not going to do him or I any good to fight the whole way to the hospital.


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## Handsome Robb (Nov 9, 2012)

I should put this out here. I'm a brand new medic and have lots lo learn, I rated him a 7 on the GCS upon arrival to the hospital 1/3/3. With that said he would posture and then go back to thrashing although not nearly as violently then go decorticate then back to thrashing. It was very odd to me, I've never seen someone truly posture but from the way this guy started curling up towards his core intermittently it was the only way I could describe it.

Unfortunately ETCO2 by nasal cannula isn't an option. Our FTOs are supposed to start using it to "test the waters" here in the next couple of weeks but we will see what they have to say about it.

FWIW he had blood in his nares and left ear but also was bleeding from extraneous abrasions and lacs on his face so it's tough to say if it truly was from his nares or not. A NTI crossed my mind since he still was technically spontaneously breathing but I'm not sure how I feel about what that would do to his ICP and I think I'd be hung out to dry if I used a nasal airway in a head injury patient.


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## Handsome Robb (Nov 9, 2012)

Veneficus said:


> If everyone was so concerned about the airway, at what point was it decided not to simply cric this guy?



Had we been further away and he continued to deteriorate I may well have been the person to do it. It was the only viable option in my mind but like I said, he maintained his SpO2% decently well with a NRB mask. Never vomited otherwise I'm sure things would have gotten much worse much faster.


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## mycrofft (Nov 9, 2012)

Barbituates have a bad rep in the US don't they? Versus using benzos, which have some of the properties of barbs, but with MUCH less  respiratory depression potential. (Historically, barbs were overprescibed in the Sixties and early Seventies, leading to dependences and abuse, withdrawls, and overdose/unintentional synergy deaths). That might account somewhat for why they aren't looked upon favorably. 

Silly question, but in the head-injured snorers I've seen, they seem to be valsalva-ing to force respiration. Does placement of a surgical or trans-oropharyngeal appliance, by opening the airway, reduce this? Or do they just keep bearing down to breathe?


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## 18G (Nov 9, 2012)

NVRob said:


> The key to this is I was *NOT* looking to tube this guy, just knock him down a bit so I could get a good mask seal and he'd stop thrashing about.



The definition of airway management is not intubation so as long as you had the airway under control intubating probably wasn't essential in this case. Some studies indicate decreased mortality others indicate increased mortality with pre-hospital intubation in the TBI patient. 

I wasn't there but it sounds like the airway was not well controlled and you were not able to reliably ensure a prevention of hypoxia. Both hypotension and hypoxia increase mortality in the TBI patient by 50%.

Were you able to give Versed on standing order or did you have to consult? I would imagine on a priority patient such as this someone on your crew consulted with the trauma center. The trauma center didn't advise anything regarding sedation or airway?

I think this patient would have benefited from Versed: better airway control,better oxygentation and controlled ventilation, reduced ICP, and seizure prophylaxis. I would have attempted one intubation attempt.


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## Smash (Nov 9, 2012)

This is an interesting question that comes up frequently where I work as we have a set range of GCS below which we can RSI (your guy would get a tube), above which we cannot.  Unfortunately it is usually the people above the line that are the most combative and hardest to manage.  
Many people take the "ZOMG you'll drop the BP and KILLZ them!" tack.  We know that hypotension is bad for the head injured patient with (presumably) elevated ICP.  However I find it hard to imagine that having a BP of 300/200mmHg whilst they  bite the end off the yankauer sucker (had this happen once) is good for them either.

Did you try some pain relief?  My approach would be some hefty whacks of fentanyl first.  Don't forget that this person has a broken leg and a broken head: painful injuries that would make me pretty unhappy too.  It may not be enough, but I think it is a good start to treat the pain first and see how they react.  It may get them settled enough and should have minimal effect on BP for most patients.  

If that fails, I then go with small doses of IV midazolam, while at the same time trying to do all I can to minimize stimulation from external sources (not easy in the back of an ambulance).  I have found that it usually doesn't take a great deal to achieve a reasonably relaxed patient with small boluses.  I typically use 1mg or so, repeated fairly quickly, and I have found that I usually get a good response after only a few milligrams, with no particular effect on BP or respiratory status.  I use midazolam for two reasons: I know it well, and it's all I've got!  Depending on what (theoretical) other options I may have I would still feel comfortable with midazolam due to my experience with it.


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## lightsandsirens5 (Nov 9, 2012)

Kind of related here, but I thought I read a study on this very concept a while back. Something about how sedating a combative TBI pt can decrease brain oxygen consumption by over 300%. Which would be a good thing when oxygen consumption is already way elevated and supply is theoretically down.

I wish I could find that paper I had. It was amazing.


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## mycrofft (Nov 9, 2012)

I bet it would reduce O2 concentration overall, but what's going on in that brain vault?

(I am assuming here that "combative" means ;ashes out and tries to sit up or get up an walk, not assuming a fighting stance or grabbing and using a weapon, etc? More like "lashing out"?).


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## Christopher (Nov 9, 2012)

Veneficus said:


> This "versed makes dead" sounds like it came from somebody who either had a bad experience or needed a memory aid because they didn't understand exactly what they were doing or why.



While I've not heard that "memory aid", I would be concerned about causing hypotension in this patient. But you figure 5 mg IM isn't going to bottom them out either.


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## 18G (Nov 9, 2012)

The greatest incidence of hypotension from Versed comes from the rate of administration. Administer it slow and you greatly reduce the chance of hypotension. Diluting helps also.


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## jwk (Nov 9, 2012)

Veneficus said:


> Barbiturates are shown to be neuroprotective.
> 
> It is not used in the US routinely, if it is even still available, however, it is used around the world.



It's not commercially available in the US any longer.  It got a bad (undeserved) rap as the drug of choice for execution by lethal injection.  Now even foreign sources won't allow it to be sold for use in the US out of a misguided anti-capital punishment concern.


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## lightsandsirens5 (Nov 9, 2012)

jwk said:


> It's not commercially available in the US any longer.  It got a bad (undeserved) rap as the drug of choice for execution by lethal injection.  Now even foreign sources won't allow it to be sold for use in the US out of a misguided anti-capital punishment concern.



Maybe not in the field, but I've seen them used in the hospital plenty.

Oh, to have Thiopental on the trucks......wouldn't that be nice? Course it wouldn't get used that often. But it'd still be nice.


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## medicsb (Nov 9, 2012)

I know that thiopental and barbituates are generally considered neuroprotective, but benzos have some experimental data showing "neuroprotection", too.  Ultimately, for me, cases like this are about safety - a combative patient is a combative patient and is a danger to self, you, and others.  Unless there is an immediately reversible cause, sedation is the best option (RSI might only better in the very few systems that can intubate with good success).


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## Maine iac (Nov 9, 2012)

This pt would absolutely get chemicals from me. To a certain extent he is not a trauma pt until he can be controlled.

I have a few options where I work. The first option is Versed or Versed/Haldol up to 5mg/10mg. Although since this is not a psychosis related illness I might stay away from Haldol.

My second option is Ketamine. 4-5mg/kg IM and the guy should be out.

If the guy is starting to fight- what good is it if he hits you in the face and you go down?

If I am using Versed and 5 isnt working I can call for an additional 5mg (typically my transports are too short to chat with a doc).

I have found, through some trail and error, that it is the behavioral emergences  that you must walk in to the scene and take IMMEDIATE control. There is no time to think about what you are going to do- the plan must be in your head before walking in the door.


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## Handsome Robb (Nov 9, 2012)

I haven't figured out how to multiquote on the iPad so here it goes.

@18g. No contact was made with the TC other than my radio report, my transport time was only 8 minutes so I didn't have time. Theoretically I have a couple protocols I could operate under and give versed on standing orders. Our seizure protocol and our combative protocol but aloc is a relative contraindication for versed. Hindsight being 20/20 I should have sedated this guy, it was definitely a learning experience. As far as his airway, I pride myself in my ability to manage an airway with BLS techniques pretty well, I agree his was not managed well however he did maintain his SpO2% decently well with the NRB mask, never saw it drop below 90%. This man needs definitive airway and ventilatory control but unfortunately I wasn't able to provide that it his situation.

@Smash. Fentanyl crossed my mind as well as a fent/versed cocktail. With the suspected femur fracture I can give up to 300 mcg of fent and 5 mg of versed on standing orders. 100 mcg/1 mg q5. Not sure how QA/QI would like doing conscious sedation on a pt with a GCS of 9.

@Maine. I wouldn't qualify this as a behavioral emergency, it was a multisystems trauma. We know the etiology of his behavior. Haldol is not an option in my mind for this patient. This guy wasn't fighting with us, per say, more just thrashing and flailing about. No coordinated movements.

Keep 'em coming!


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## Maine iac (Nov 9, 2012)

Rob, I fully agree that it is a trauma pt. But my point was you must gain control of the pt before you can manage his injuries- which for me means this is a behavioral pt.

And my guess is that is the protocol you would be under for giving him meds- unless you have RSI protocols, or a trauma sedation protocol.


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## Veneficus (Nov 10, 2012)

Maine iac said:


> This pt would absolutely get chemicals from me. To a certain extent he is not a trauma pt until he can be controlled.
> 
> I have a few options where I work. The first option is Versed or Versed/Haldol up to 5mg/10mg. Although since this is not a psychosis related illness I might stay away from Haldol.
> 
> My second option is Ketamine. 4-5mg/kg IM and the guy should be out



Haldol would not be on my list of choices for a TBI patient.


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## lightsandsirens5 (Nov 10, 2012)

Smash said:


> Did you try some pain relief?  My approach would be some hefty whacks of fentanyl first.  Don't forget that this person has a broken leg and a broken head: painful injuries that would make me pretty unhappy too.  It may not be enough, but I think it is a good start to treat the pain first and see how they react.  It may get them settled enough and should have minimal effect on BP for most patients.



Is there not evidence (probably anecdotal) that point to bolus dosing opioids in a pt with increased ICP actually transiently increases ICP, therefore decreasing CPP?

Additionally there have been some studies into the use of opioids in this case specifically MS, so it might not really be relevant) in drip infusion form in the TBI pt. If I remember correctly, an elimination or significant decrease in these drugs also resulted in lessened need for ICP lowering, overall lower ICP several days SP and an overall increased prognosis.

I believe the study was done out of Canada. I just read it the other day on PubMed or something...... I am just too dang tired to find it right now.


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## Maine iac (Nov 10, 2012)

Veneficus said:


> Haldol would not be on my list of choices for a TBI patient.



Nor would it be mine- "Although since this is not a psychosis related illness I might stay away from Haldol".

This pt is still combative (whether he is knowingly resisting or it is base reflex to resist being strapped down and poked/prodded doesn't matter) and will be sedated, or slowed down.

As I said before I have 3 options to choose from under my behavioral emergencies protocol: Versed, Versed + Haldol, or Ketamine; since haldol works on psychosis it would not be appropriate, thus my options are Versed or Ketamine.


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## Handsome Robb (Nov 10, 2012)

Maine iac said:


> Nor would it be mine- "Although since this is not a psychosis related illness I might stay away from Haldol".
> 
> This pt is still combative (whether he is knowingly resisting or it is base reflex to resist being strapped down and poked/prodded doesn't matter) and will be sedated, or slowed down.
> 
> As I said before I have 3 options to choose from under my behavioral emergencies protocol: Versed, Versed + Haldol, or Ketamine; since haldol works on psychosis it would not be appropriate, thus my options are Versed or Ketamine.



Sorry, read my post and realized it could be misconstrued as confrontational. Not my intent at all, sorry if I came off that way. 

I've heard mixed things about Ketamine in the presence of increased ICP/TBI. Tried to read about it on shift tonight but our 6 car accidents and motorcycle vs car at 95 mph had me kinda busy. Also, our HEMS service carries ketamine but we don't have it on the ground yet, it's supposed to make an appearance in the next protocol revisions but we will see if it actually happens.

Looking back on it and in the future our seizure protocol would be appropriate for this guy. 2 mg versed IV q3 max of 10 mg. ALOC + trismus and flailing extremities could be argued as seizure-like activity. By no means am I condoning twisting protocols or "creative" charting. With that said, after talking with our MD and a few supes that was the general consensus. 

Our combative protocol is versed 2 mg IV titrated to effect or 5 mg haldol IM/IV q 5 max of 15 mg. This protocol using versed may be the more appropriate protocol to use, for me.

@lights - I've heard the same thing but fent is commonly used to blunt spikes in ICP during RSI so take it for what it's worth.


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## lightsandsirens5 (Nov 10, 2012)

Rob, this study had to do with spiking ICP in the presence of TBI. I'm thinking the reason they use fent in RSI is because the pain causes the rise in ICP, and the fent blunts the pain? Must be something about once a TBI exists, then it's bad? I dunno, I am all so ignorant...lol! 

I'll find that article later today, I'm on my way to a memorial service right now.


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## medicsb (Nov 10, 2012)

NVRob said:


> Looking back on it and in the future our seizure protocol would be appropriate for this guy. 2 mg versed IV q3 max of 10 mg. ALOC + trismus and flailing extremities could be argued as seizure-like activity. By no means am I condoning twisting protocols or "creative" charting. With that said, after talking with our MD and a few supes that was the general consensus.



Why not just call medical command for orders?


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## FLdoc2011 (Nov 10, 2012)

Ultimately you're kind of limited by your protocols and unfortunately didn't have RSI available.   

We do occasionally use barbiturates, usually phenobarbital on out ICHs when we just can't control their ICP.  Usually the usual sedation and other ICP treatment measures work fine.  

Just sounded like this guy needed to be intubated and sedated.   GCS is borderline already for intubation criteria,  not to mention evidence of increased ICP and likely impending respiratory failure.    

I'm guessing if y'all had RSI then that would've been the done in field?  

Certainly would not fault you for sedating from what it sounds like.  Certainly not going to get any better with pt thrashing about.


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## Shishkabob (Nov 10, 2012)

Fighting with a head injury?  You go night-night with some IN Versed.


We can't help the TBI if we're too busy fighting you on scene.


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## Handsome Robb (Nov 10, 2012)

@medicsb the entire call lasted 12 minutes from marking on scene to putting the patient on the trauma table, I didn't have time to call I was too busy trying to keep this guy from doing anymore damage to himself. I work in an urban system, our transport times are less than 10 minutes on average.

@FLdoc if we had RSI this guy more than likely would've gotten tubed in the field by myself and my supervisor while the other crew dealt with the other patient but like I said, he had an extremely difficult airway and I have my doubts if we actually could've intubated him in the field. The bougie definitely would've been worth its weight in gold. I, unfortunately, never pulled the trigger on sedating this guy. I learned a ton from this call and know what I will differently next time.


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## Maine iac (Nov 10, 2012)

Rob it is good to see that you analyze this call to see what you can improve on. 

There is some interesting literature on being prepared and reviewing a difficult call.

We all learn, sometimes quickly and painfully, but it is key to analyze what worked and what didn't

This is an interesting link I found:

http://emupdates.com/2012/09/26/the-usual-state-of-readiness/

also

http://emcrit.org/podcasts/mind-resuscitationist-reid/

As I stated in an earlier post behavioral emergencies, which this was as you just stated, is one of the calls that I play through in my head for that exact reason that you have to take control quickly.


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## medicsb (Nov 10, 2012)

NVRob said:


> @medicsb the entire call lasted 12 minutes from marking on scene to putting the patient on the trauma table, I didn't have time to call I was too busy trying to keep this guy from doing anymore damage to himself. I work in an urban system, our transport times are less than 10 minutes on average.



I'm not trying to be a jerk, but you stated that there were firefighters and another ALS unit on scene, how it that you don't have time to call but you have time to get 2 IVs?  RSI would have taken much more time than calling.  I've worked urban with short transport times and have been in nearly exact situations... still had time to call (it was required where I worked).  Let the firefighters and other ALS crew members wrestle while a call is made (shouldn't take more than 1 minute).    

I know it can be a pain in the *** to call, but it is something to consider when there is no protocol.  Instead of thinking about creative writing it might be better to think, "I'll just make a quick call."


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## RocketMedic (Nov 10, 2012)

NVRob said:


> @medicsb the entire call lasted 12 minutes from marking on scene to putting the patient on the trauma table, I didn't have time to call I was too busy trying to keep this guy from doing anymore damage to himself. I work in an urban system, our transport times are less than 10 minutes on average.
> 
> @FLdoc if we had RSI this guy more than likely would've gotten tubed in the field by myself and my supervisor while the other crew dealt with the other patient but like I said, he had an extremely difficult airway and I have my doubts if we actually could've intubated him in the field. The bougie definitely would've been worth its weight in gold. I, unfortunately, never pulled the trigger on sedating this guy. I learned a ton from this call and know what I will differently next time.



Bougie: never leave home without it.


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## Handsome Robb (Nov 10, 2012)

medicsb said:


> I'm not trying to be a jerk, but you stated that there were firefighters and another ALS unit on scene, how it that you don't have time to call but you have time to get 2 IVs?  RSI would have taken much more time than calling.  I've worked urban with short transport times and have been in nearly exact situations... still had time to call (it was required where I worked).  Let the firefighters and other ALS crew members wrestle while a call is made (shouldn't take more than 1 minute).
> 
> I know it can be a pain in the *** to call, but it is something to consider when there is no protocol.  Instead of thinking about creative writing it might be better to think, "I'll just make a quick call."



Not being a jerk, I asked for opinions. Our engines are 4 man engines with 3 basics and an intermediate so all they can really do is BLS and start a line if they can actually hit it. We had two very sick patients and the other ALS crew was tied up with their also altered patient.

I got both IVs en route, had RSI been an option it would've been performed on scene but I knew from the get go it wasn't and this guy needed it so I didn't want to spend a ton of time doinking around on scene. I got on scene and he was already boarded, we pulled our gurney out walked it over put him on it and moved to the truck and started going. I wish it was "just a quick call" but unfortunately we routinely have to wait a few minutes before a doc can even come to the phone after the charge nurse answers and pages them overhead.


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## RocketMedic (Nov 10, 2012)

Sounds like you did the best you could in a bad situation.


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## triemal04 (Nov 10, 2012)

As easy as it would be, I actually don't mean this in a completely derogatory way.

If the reporting of the call, including times are accurate, this to me screams "very new, very inexperienced paramedic who is very new to working alone and panicked."  You had a patient with a pretty clear TBI who was combative to the point you couldn't really assess, let alone treat.  While you weren't allowed to intubate, you were allowed to mask-ventilate, but were/would have been unable to do so due to the patient fighting.  You had a patient with trismus (or at least a clenched jaw due to them being highly agitated and combative) which mixes very poorly with vomitting, something they are definetly at risk for.  To say nothing about how increased ICP doesn't go well with being combative.  Yet, despite apparently knowing all this you elected to spend less than 4 minutes on scene and essentially run for the hospital while doing nothing.  Let's think this through:

Which is better:
1- Deliver a patient who needs to be assessed and intubated to the ER in a very combative state where nothing can be done until the patient is calmed.  This may cause the ER to "ramp up" more than they need to and potentially make mistakes/miss things that they wouldn't otherwise.  While this will depend on the ER, it should be a concern.
2-  Take a couple extra minutes, get orders for sedation, and give them the same patient but in a very CALM setting (both the patient and yourself), and in a state that is more benefical to their health, and who you now know more about.
3-  Go outside your protocols, knowing that, because no protocol can be written to cover every situation, and you are acting appropriately and in the patient's best interest and will immedietly inform your supe and medical director you will not face discipline.  Of course this only works in a good system.  And then give them the patient from #2.

Which do you think would be more appropriate?  

Would this guy have been intubated right away no matter what?  Almost certainly.  Do you think that maybe if he had been properly sedated prior to arrival there wouldn't have been as much of a rush (percieved by you or not)?  Perhaps if that was the case he would have been better prepped for intubation and the doc would have been successful on the first pass.  Perhaps knowing that taking a little extra time can make things go better for the patient and run smoother for the ER would be good, and knowing that dumping every patient on the ER is bad.

To continue.  What makes you so certain you wouldn't have been able to intubate this patient?  Because 3 doc's using the Glidescope had trouble?  Really?  How profiecent are each of them at using the Glidescope?  How often do they do it?  How many times did they use it while learning?  How often do they intubate period and how good are they?  The Glidescope is not the same as DL and takes practice.  Were they in a rush due to the patient's state?  Was the patient in an optimal conditon to intubate (full sedation and paralysis)?  Making the immediate assumption that because a ER doctor is unable to intubate means that you wouldn't be able to either is wrong.  IF you are truly profiecent at intubation of course.  If not all bets are off.

And to close:


NVRob said:


> Let me ask you this, I spent an extra two minutes on scene of a nasty 100 mph motorcycle accident so my partner and I could drop bilateral large bore lines because I wouldn't have had time to do both en route. Total scene time was 14 minutes. Did I do it wrong?


So you are unwilling to spend extra time doing something that will be beneficial to the patient in both the short and long term, but are willing to waste time doing something that is likely unneccasary, not helpful, and possible harmful?  You were willing to spend 14 minutes with that patient to start IV's but only 4 for another who actually needed something?

Things to be thinking very hard about right now.


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## Veneficus (Nov 12, 2012)

triemal04 said:


> Which is better:
> 1- Deliver a patient who needs to be assessed and intubated to the ER in a very combative state where nothing can be done until the patient is calmed.  This may cause the ER to "ramp up" more than they need to and potentially make mistakes/miss things that they wouldn't otherwise.  While this will depend on the ER, it should be a concern.



What?

If the ER is making mistakes and missing things because they have a patient who is agitated and needs intubated, they are certainly not following the ATLS guidlines and are likely not capable enough to receive such a patient anyway.

Past selecting the proper facility to drive to, this is not a concern of the paramedic.



triemal04 said:


> 2-  Take a couple extra minutes, get orders for sedation, and give them the same patient but in a very CALM setting (both the patient and yourself), and in a state that is more benefical to their health, and who you now know more about..



While it is nice, it is a luxury, not a requirement. In the suspected TBI patient, with a short transport, just bringing them in is not a bad solution. Not the best, but local protocol will dictate that, not the most appropriate medical practice.



triemal04 said:


> 3-  Go outside your protocols, knowing that, because no protocol can be written to cover every situation, and you are acting appropriately and in the patient's best interest and will immedietly inform your supe and medical director you will not face discipline.  Of course this only works in a good system.  And then give them the patient from #2...



What if something goes wrong and instead of pt #2, you have pt #4, in cardio-respiratory arrest?

I don't think it is a good idea to suggest to people to go outside of their protocol. If they work in a system where it is accepted even if not permissible, if something goes wrong, they could be the one who gets all the blame.

Which do you think would be more appropriate?  



triemal04 said:


> Do you think that maybe if he had been properly sedated prior to arrival there wouldn't have been as much of a rush (percieved by you or not)?  Perhaps if that was the case he would have been better prepped for intubation and the doc would have been successful on the first pass..



Pure speculation.

This patient could easily have been a difficult airway prior to facial trauma. 

Also if he required OMFS reconstruction, they prefer nasal tracheal tubes or trachs. Which unless things have changed, are not indicated for paramedics in patients with facial trauma?

I support the use of sedation in this case, but I think this post is getting a little off the map and not all of the conclusions are accurate.




triemal04 said:


> Perhaps knowing that taking a little extra time can make things go better for the patient and run smoother for the ER would be good, and knowing that dumping every patient on the ER is bad..



I do not see bringing a trauma patient to the ER in no worse condition than found as bad. Certainly I would not call it dumping. If this patient truly had a TBI, then treatment is at the hospital. 

The purpose of prehospital airway intervention is not to make things go smoother in the ED, it is to make sure the airway is secure and protected so the patient doesn't die. 

Nobody ever died from not having a plastic tube in their trachea. They die from not having the ability to get air in and out. 

In this case, the airway was controlled and the patient ventilated. Perhaps not in the most effective way, but the goal had been met.



triemal04 said:


> To continue.  What makes you so certain you wouldn't have been able to intubate this patient?  Because 3 doc's using the Glidescope had trouble?  Really?  How profiecent are each of them at using the Glidescope?  How often do they do it?  How many times did they use it while learning?  How often do they intubate period and how good are they?  The Glidescope is not the same as DL and takes practice.  Were they in a rush due to the patient's state?  Was the patient in an optimal conditon to intubate (full sedation and paralysis)?  Making the immediate assumption that because a ER doctor is unable to intubate means that you wouldn't be able to either is wrong.  IF you are truly profiecent at intubation of course.  If not all bets are off



Is this some sort of a joke?

I will concede that in many places ERs are staffed with any doc they can find, who may or may not be proficent at intubating with the equipment available. But many ofthe assumptions you have made here are bordering on hubris, not logic. 

How do you know these docs were not board ceritfied EMs who spend far more time on intubation than medics? How do you know one or more was not an anesthesiologist, who probably puts more tubes in a shift than 99% of paramedics in a month?

There is a lot you are assuming and most of it is around an incapable doctor and a more capable medic or a medic exceeding their role. 

I mentioned it in PM, but I will put it here. On a TBI patient with facial trauma, with a predetermined difficult airway, surgical cric would be my first choice and it would take a considerable amount of things going right to deter that decision. 

And to close:



triemal04 said:


> So you are unwilling to spend extra time doing something that will be beneficial to the patient in both the short and long term, but are willing to waste time doing something that is likely unneccasary, not helpful, and possible harmful?



Like sitting on a street corner with a trauma patient deciding to deviate from protocol while trying to prove he can intubate somebody better than the doctors in the ER because they might not be proficent?




triemal04 said:


> Things to be thinking very hard about right now.



I agree.


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## the_negro_puppy (Nov 12, 2012)

Our ICP's here can use Midazolam for "agitated head injuries to facilitate assessment and treatment"

IV 1-2.5mg repeated at 1-2mg increments every 5 minutes until pt is cooperative or allows O2 + spinal immobilisation. Should be avoided in cases of hypovolemia.


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## triemal04 (Nov 12, 2012)

Veneficus said:


> If the ER is making mistakes and missing things because they have a patient who is agitated and needs intubated, they are certainly not following the ATLS guidlines and are likely not capable enough to receive such a patient anyway.
> 
> Past selecting the proper facility to drive to, this is not a concern of the paramedic.


I'm glad that you've never seen an ER, even one staffed by very competant providers get thrown for a loop so to speak, for however brief a time when a patient in extremis is thrown into their lap.  Like I said, how much of a concern this is will depend on the ER, and on the local EMS service(s).  If they are used to a patient being delivered with little to nothing being done then I'd hope it wouldn't be as much of a concern.  If they are used to a well treated patient being delivered it may be something to consider.



Veneficus said:


> While it is nice, it is a luxury, not a requirement. In the suspected TBI patient, with a short transport, just bringing them in is not a bad solution. Not the best, but local protocol will dictate that, not the most appropriate medical practice.


Yes, and again, this will depend on the ER and is where knowing their capabilities comes into play.  And this is where knowing when to pick up the phone comes into play.



Veneficus said:


> What if something goes wrong and instead of pt #2, you have pt #4, in cardio-respiratory arrest?


If done correctly you diminish this possibility, though it is absolutely still there.  But a apneic or hypoventilating patient who is sedated is much easier to handle than one who is combative.  Add in that the "trismus" seen very well may have been the patient clenching their jaw due to the agitation, and leaning towards sedation in the field would be appropriate.



Veneficus said:


> I don't think it is a good idea to suggest to people to go outside of their protocol. If they work in a system where it is accepted even if not permissible, if something goes wrong, they could be the one who gets all the blame.


That's correct.  That wasn't written in the best way.  Regardless, it would appear that his own protocol's did allow him to give a sedative, but he didn't.  



Veneficus said:


> Which do you think would be more appropriate?


Without having been there and knowing anything about the system I think #2 is what should have happened.  It's in the patient's best interest, and adding even 2 minutes of extra time on scene to start the process of obtaining orders would likely not have been harmful, but probably beneficial.



Veneficus said:


> Pure speculation.


Of course it is!  Only one person on this forum was actually there, and it wasn't either of us.  I could be wrong.  I could be right.  Wether or not you are willing to admit it to yourself, it is something that should be thought about.



Veneficus said:


> This patient could easily have been a difficult airway prior to facial trauma.
> 
> Also if he required OMFS reconstruction, they prefer nasal tracheal tubes or trachs. Which unless things have changed, are not indicated for paramedics in patients with facial trauma?


Sure.  Or an easier one.  Going off incomplete info makes it hard to know what happened.  And I will gaurentee that with the patient presented nothing other than an orotracheal tube or crich would have been initially placed.  My point with this is that there are a lot of variables in this case, and what was done/not done prehospital may have affected what happened during the initial treatement in the ER.  



Veneficus said:


> I do not see bringing a trauma patient to the ER in no worse condition than found as bad. Certainly I would not call it dumping. If this patient truly had a TBI, then treatment is at the hospital.


I would call not making any effort to treat the patient, in however small a way dumping.  You have a patient who is hypoventilating and who you are unable to mask ventilate due to the patient's state.  But no steps where taken to correct this.   



Veneficus said:


> The purpose of prehospital airway intervention is not to make things go smoother in the ED, it is to make sure the airway is secure and protected so the patient doesn't die.
> 
> Nobody ever died from not having a plastic tube in their trachea. They die from not having the ability to get air in and out.
> 
> In this case, the airway was controlled and the patient ventilated. Perhaps not in the most effective way, but the goal had been met.


This airway was unsecured and not controlled.  Completely.  Maybe 8 spontaneous breathes a minute...irregularly...snoring...clenched jaw...unable to mask ventilate due to the patient fighting...and nothing was done.



Veneficus said:


> Is this some sort of a joke?
> 
> I will concede that in many places ERs are staffed with any doc they can find, who may or may not be proficent at intubating with the equipment available. But many ofthe assumptions you have made here are bordering on hubris, not logic.
> 
> ...


I'm not assuming anything.  I'm not saying that is what happened.  I'm saying that to make the immediate assumption that "the MD couldn't do it so neither could I" is not always accurate.  It very well may be, or it may not be.  How do you know that these were board certified EM's who spent much more time on intubation than medic's?  If they are, how do you know how often they intubate a patient?  How do you know how profiecent there are at it?  How do you know how well they use a glidescope?  It would appear that someone else is making assumptions.  

I'm not saying anything I've said is exactly what happened; what I am saying is that these are all things that should be thought about before coming to a conclusion. 



Veneficus said:


> Like sitting on a street corner with a trauma patient deciding to deviate from protocol while trying to prove he can intubate somebody better than the doctors in the ER because they might not be proficent?


Don't misquote me, I know how much you dislike it.  I'm not saying that he should have tried to intubate this patient; the capability isn't there.  But this patient should have been sedated in the field.  Not overly sedated, and done very cautiously, but it still should have been done.  If that would have meant that a couple extra minutes would have been spent on the scene to start the process, it would have been appropriate.  After all, it would appear that he is proud to spend extra time doing something that is likely not needed...so why not do the same for something that could help?

I'm not suggesting to take what I say as gospel or that I'm completely right in all that I've said; hard to be without knowing everything that happened.  What I am saying is that this case, as presented by a very new and relatively inexperienced paramedic raises several red flags.  They may be justified or not in this specific instance, but all are worth considering for the future.


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## RocketMedic (Nov 12, 2012)

The Army answer would be "load and go", with Versed and a crike tossed in for good measure, at best.

EDIT: Sometimes, it's better to undertreat a patient and have a job than to overtreat and have a lawsuit. It's not the best medicine, but we are not emergency physicians and we do not have the tools or educations to be assuming that risk. Yes, Rob, in this case, Versed was indicated (I think we've beaten that horse to death, and it's taught me too). However, triemal04, there's nothing wrong with grabbing an unstable patient and bolting L/S if we don't know what else to do. 

I'd rather take an ***-chewing than get fired, and I'd rather get canned than to avoidably kill someone through inaction or malpractice on my behalf. A lawsuit is the nightmare scenario, and is a lot less likely to result from "load and go, didn't quite know what to do so I brought them here, I'm young and this was scary; I need to see Education" than "I, Paragod, Defender of Life and Airways, sat with a difficult airway and tried to do a half-assed RSI because my service carries just enough midazolam to tempt me. Protocol? THIS IS A LIFE WE'RE TALKING ABOUT!

I'd rather be Johnny & Roy calling for Dr. Brackett than Chicago Fire, in popular terms.


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## Handsome Robb (Nov 12, 2012)

Triemal04, if you want to say you think I'm a :censored::censored::censored::censored:ty medic just come out and say it. Yes I am young, and inexperienced only having about 3 months under my belt being out on my own as an ALS provider. Panicked is not the word I would use to describe me in this situation but if that's what you think then there isn't much that's going to change your mind. 

Hindsight is 20/20, it's real easy to sit here and monday morning quarterback my call and tell my I'm an idiot. The whole reason I started this thread was because I had a question and wanted to learn from this, I know it wasn't handled as well as it could have been and I know what I would do differently this time. 

I've been told by multiple medics, including my FTO, at the company that I work for that using the "Combative Patients" protocol or sedating in the presence of an altered TBI pt was a no-no per QA/QI and I like my job and am still in my probationary period so no, I will not deviate from protocol and risk my livelihood for a complete stranger.

Two attempts were made in the ER with direct laryngoscopy before the glidescope came out. A couple ER physicians and a Trauma Surgeon at the only Trauma Center in my area, I'd say they are pretty competent but I'm just a snot nosed new paramedic so take it for what it's worth. 

The fact that I asked the Trauma Surgeon what more I could have done as they were wheeling my guy out of the trauma room and into CT and he said "Nothing, you got him here quickly with IV access and he was oxygenated with an acceptable SpO2%" makes me think that I hardly "dumped" this patient on the ER. So you're advocating I sit on scene while I call and wait anywhere from 2-4 minutes to get a doc on the phone to get sedation orders while my patient continues to further his journey down herniation road with an unsecured airway rather than recognizing there was nothing I could do within my protocols for this man and taking him to somewhere that could do something about it. But then I'm wrong for taking the extra minute to get a second line started on scene with a guy who had a lot of potential to end up going to surgery and receiving blood products during it?


I posted this thread because I knew I had a lot to learn from this call and I've learned a lot from the responses. With that said, I didn't create this topic to have my competency questioned. I'd be more worried about the medics that had a call similar to this and never went out and asked for help to learn from it. I was under the impression I could reach out to my peers here with questions when I ran into something I didn't understand and needed help learning about it but since me looking for help causes people to question my competency and statements such as "no effort was made to treat this patient" I guess I wont be asking anymore. Constructive criticism is helpful, "you suck at your job nOoBiE" is not.

You've made it pretty clear in previous threads that you don't like me, Triemal04, not sure what I did to you. Were you never a new medic? Have you never had a call that you were unsure what to do so you just transported to patient to the ER or are you that good that you always know what to do for every single patient you see no matter what is going on? If that's the case congratulations because you're the only one at that party.


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## Sharky (Nov 12, 2012)

NVRob said:


> Right on, thank you!
> 
> I know Vene makes us all look dumb but I'd like to hear from others as well



Speak for yourself.


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## Veneficus (Nov 12, 2012)

triemal04 said:


> I'm glad that you've never seen an ER, even one staffed by very competant providers get thrown for a loop so to speak, for however brief a time when a patient in extremis is thrown into their lap.  Like I said, how much of a concern this is will depend on the ER, and on the local EMS service(s).  If they are used to a patient being delivered with little to nothing being done then I'd hope it wouldn't be as much of a concern.  If they are used to a well treated patient being delivered it may be something to consider.



Truthfully, the only EDs I have seen anywhere in my travels that get thrown for aloop on a patient like this are community hospitals that shoul not be recieving these types of patients anyway.

Some of the same community hospitals also have level III trauma center designations. Because if is financially beneficial.

In the trauma centers I have worked at in the past and in the the one I am currently at, this type of patient is an everyday occurance, it wouldn't even get anyone excited enough to take out their phone and snap a couple of pictures.




triemal04 said:


> Yes, and again, this will depend on the ER and is where knowing their capabilities comes into play.  And this is where knowing when to pick up the phone comes into play.



Agreed.



triemal04 said:


> If done correctly you diminish this possibility, though it is absolutely still there.  But a apneic or hypoventilating patient who is sedated is much easier to handle than one who is combative.  Add in that the "trismus" seen very well may have been the patient clenching their jaw due to the agitation, and leaning towards sedation in the field would be appropriate.



I already agreed to that.



triemal04 said:


> Without having been there and knowing anything about the system I think #2 is what should have happened.  It's in the patient's best interest, and adding even 2 minutes of extra time on scene to start the process of obtaining orders would likely not have been harmful, but probably beneficial.



I am very cautious between what should happen. I agree that versed in this situation would have been a good idea. I think if you are going to start with 2mg on anything except an elderly patient it will likely be 2 or more doses before and effect. However, in a facial trauma patient, combative, where ventilation is difficult, with trismus, "can't intubate, can't ventilate" is a real possibility, and I think a greater focus should be the discussion of maintaining the airway and not whether or not simply sedating the patient was a good idea. 

For sure a combative patient will have to be sedated and sooner is better than later. But I think it is erroneous to attribute successful sedation with successful intubation. 




triemal04 said:


> Of course it is!  Only one person on this forum was actually there, and it wasn't either of us.  I could be wrong.  I could be right.  Wether or not you are willing to admit it to yourself, it is something that should be thought about.



I think you are right in the expected outcome. I admit I would be very surprised by any other outcome. But when I read your response it look like direction to "do what you need to and apologize later" and I do not think that is good advice.



triemal04 said:


> Sure.  Or an easier one.  Going off incomplete info makes it hard to know what happened.  And I will gaurentee that with the patient presented nothing other than an orotracheal tube or crich would have been initially placed.  My point with this is that there are a lot of variables in this case, and what was done/not done prehospital may have affected what happened during the initial treatement in the ER.



I think we will just have to agree to disagree on how much.  



triemal04 said:


> I would call not making any effort to treat the patient, in however small a way dumping.  You have a patient who is hypoventilating and who you are unable to mask ventilate due to the patient's state.  But no steps where taken to correct this. .



Sometimes discretion is the better part of valor.

When I am unsure of myself I seek another opinion or more skilled of a provider. Before I attempt something I think is outside of my ability. 

I don't see any dfference here. A relatively new provider taking a conservative approach. 

Just because I would sedate somebody and reach for a knofe doesn't mean everyone should. There was also a time where it wasn't the best idea for me to do it either.   




triemal04 said:


> This airway was unsecured and not controlled.  Completely.  Maybe 8 spontaneous breathes a minute...irregularly...snoring...clenched jaw...unable to mask ventilate due to the patient fighting...and nothing was done.



That does appear to be a statement of fact. But as I said, sometimes a conservative approach is better than a overzealous approach when experience and skill is in question.




triemal04 said:


> I'm not assuming anything.  I'm not saying that is what happened.  I'm saying that to make the immediate assumption that "the MD couldn't do it so neither could I" is not always accurate.  It very well may be, or it may not be.  How do you know that these were board certified EM's who spent much more time on intubation than medic's?  If they are, how do you know how often they intubate a patient?  How do you know how profiecent there are at it?  How do you know how well they use a glidescope?  It would appear that someone else is making assumptions.



I live the life of being able to do things when others fail. But that is not my point in that statement. 

My point is, we do not know the qualifications of these doctors and there are requirements for ongoing skill usage and training. That is not something that is common in EMS. It means they have a better chance of success. I am not saying they will always be or that nobody else can. But I think it is a good indicator it was a difficult airway.




triemal04 said:


> I'm not saying that he should have tried to intubate this patient; the capability isn't there.  But this patient should have been sedated in the field.  Not overly sedated, and done very cautiously, but it still should have been done.  If that would have meant that a couple extra minutes would have been spent on the scene to start the process, it would have been appropriate.  After all, it would appear that he is proud to spend extra time doing something that is likely not needed...so why not do the same for something that could help?.



I again agree he should have been sedated. In my experience working with versed, I think it would have taken longer to sedate him on scene because of the dose incriments. 

I think this patient, based on limited description was likely going to be a very difficult airway. I think it was a prudent decision for a new provider to defer to the ED rather than get into a situation beyond his ability to manage. (can't intubate, can't ventilate, on an apnic patient.) Because if the sedation caused apnea and there was no ability to intubate ad difficulty ventilating, we are looking at a new and likely scared provider holding a knife in his hand without experienced oversight.

The first time I ever did a cric was in an OR, with an extremely respected surgeon looking over my shoulder. I was scared. (I am not sure more by which, the "helpeful" advice I was getting in the form of some ball busting, or actually cutting somebody)

I could only imagine being a new unsupervised paramedic trying that in the street. It probably wouldn't go well. 



triemal04 said:


> I'm not suggesting to take what I say as gospel or that I'm completely right in all that I've said; hard to be without knowing everything that happened.  What I am saying is that this case, as presented by a very new and relatively inexperienced paramedic raises several red flags.  They may be justified or not in this specific instance, but all are worth considering for the future.



I agree. 

Not only from the point of the provider, but from the system.


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## Veneficus (Nov 12, 2012)

NVRob said:


> Two attempts were made in the ER with direct laryngoscopy before the glidescope came out. A couple ER physicians and a Trauma Surgeon at the only Trauma Center in my area, I'd say they are pretty competent but I'm just a snot nosed new paramedic so take it for what it's worth.



Failed intubation of a surgeon does not count towards the total 

Most surgeons are not very good at it because they hardly ever do it. In most training programs they aren't even permitted to RSI.

But he probably could have willed the trach in using the force


----------



## triemal04 (Nov 12, 2012)

Veneficus said:


> Truthfully, the only EDs I have seen anywhere in my travels that get thrown for aloop on a patient like this are community hospitals that shoul not be recieving these types of patients anyway.


And I've seen it happen at hospitals that have been a level 1 or 2.  With attendings and residents both.  It shouldn't be happening often, no matter what type of patient is brought in; if it is then there is a problem.  But to think that it can't/won't/doesn't, or that what we do/don't do in the field won't potentially have an effect isn't a good idea.  If people in EMS should be thinking about what the long-term outcome and care for the patient will be and considering how what we do initially may effect their care in the ICU (or in whatever unit they end up in) then this is a valid concern.  Whether or not it is acted on will vary, but to say that it should not be considered is wrong.



Veneficus said:


> I am very cautious between what should happen. I agree that versed in this situation would have been a good idea. I think if you are going to start with 2mg on anything except an elderly patient it will likely be 2 or more doses before and effect. However, in a facial trauma patient, combative, where ventilation is difficult, with trismus, "can't intubate, can't ventilate" is a real possibility, and I think a greater focus should be the discussion of maintaining the airway and not whether or not simply sedating the patient was a good idea.


Yes, but in this specific case the ability to maintain an airway was not there because, as presented, mask-ventilation was impossible due to the patient's combative state.   



Veneficus said:


> For sure a combative patient will have to be sedated and sooner is better than later. But I think it is erroneous to attribute successful sedation with successful intubation.


Maybe.  Believe me, I'd very much like to agree; I like having faith in the capabilities of an ER.  My point was, and remains, that this patient was mismanaged, and, while far from a certainty, it must be asked if this mismanagement may have played a part in what happened during the initial rescucitation.



Veneficus said:


> I think you are right in the expected outcome. I admit I would be very surprised by any other outcome. But when I read your response it look like direction to "do what you need to and apologize later" and I do not think that is good advice.


Yea, I'll admit that was poorly worded and not the best advice.  I've been lucky to only work in places that had guidelines that contained a similar clause in them; not so with many people.  As I said, calling for orders for versed, or even knowing that a "relative contraindication" is not an absolute would have been the appropriate course to take.



Veneficus said:


> I think we will just have to agree to disagree on how much.


That's fine.  I'm not expecting anyone to agree, especially since I could be fully wrong.  What I'm expecting, or hoping, is that, in the future, it will be thought about, and taken into account before a decision is made.



Veneficus said:


> *Sometimes discretion is the better part of valor*.
> 
> *When I am unsure of myself I seek another opinion or more skilled of a provider*. Before I attempt something I think is outside of my ability.
> 
> ...


It is, and I agree with both bolded statements.  Which is my issue.  Despite knowing, for whatever reason, that this was someone who could benefit from a benzo, no attempt was made to take the steps neccasary to administer one.  Instead, as presented, it was toss 'em in the back and beat feet for the ER.



Veneficus said:


> My point is, we do not know the qualifications of these doctors and there are requirements for ongoing skill usage and training. That is not something that is common in EMS. It means they have a better chance of success. I am not saying they will always be or that nobody else can. But I think it is a good indicator it was a difficult airway.


Probably.  Given how frequently the average paramedic will intubate it's very likely.  But to make a blanket assumption like that is innacurate.  Especially when you take into account that a trauma surgeon was one of the MD's attempting intubation.  If anything, that is proving my point; in all honesty when do you think the last time that doc intubated was, and how well were they initially taught?



Veneficus said:


> I again agree he should have been sedated. In my experience working with versed, I think it would have taken longer to sedate him on scene because of the dose incriments.


I never said that they should have sat on scene until the patient was completely sedated.  That probably wouldn't have been a good idea.  But spending a couple extra minutes to pick up the phone and at least start the process of getting orders before leaving and then administer those drugs while enroute would have been a better course of action. 



Veneficus said:


> I think this patient, based on limited description was likely going to be a very difficult airway. I think it was a prudent decision for a new provider to defer to the ED rather than get into a situation beyond his ability to manage. (can't intubate, can't ventilate, on an apnic patient.) Because if the sedation caused apnea and there was no ability to intubate ad difficulty ventilating, we are looking at a new and likely scared provider holding a knife in his hand without experienced oversight.


It could be.  And this should have been something that went through anyone's mind who is in a similar situation.  But again, as presented, the only impediment to mask-ventilation was the patient fighting.

As I said, I'm not saying that I'm right or wrong, just that, as presented and coupled with some other comments, there's some very concerning things here.


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## Maine iac (Nov 12, 2012)

NVRob said:


> I've been told by multiple medics, including my FTO, at the company that I work for that using the "Combative Patients" protocol or sedating in the presence of an altered TBI pt was a no-no per QA/QI and I like my job and am still in my probationary period so no, I will not deviate from protocol and risk my livelihood for a complete stranger.



Did you ask your FTO how they would have treated this pt then?

If you think the answer might be incorrect I would talk to a doctor and inquire about what would be the right thing to do.

I find it interesting that this doesn't fall into the combative pt... because he was fighting.

In my ambulance, if you are not following my commands and *pose a risk to yourself or myself* you will be restrained and if need be chemically slowed.


Rob, have you personally called for orders before? The only reason I ask is because I always thought that whole process would take a while, but when I made my first call it got connected through right away. I was calling for pediatric sedation orders on a violent kid, and for me I have to call dispatch who calls the hospital then I wait on the hospital channel for them to answer. When dispatch could hear the kid screaming at us in the background things got connected through fast and I got my orders quickly.

Something else to consider is as soon as you get on scene, and think you might need sedation orders for a combative TBI pt have your partner call for them while you and the FF work on extrication and back boarding. That way by the time you are in the ambulance and maybe have a line you have the orders and can act on it.... or if it turns out you don't actually need them then oh well... the hospital at least will have a heads up that a critical pt is coming their way.


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