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

[Handsome Robb]

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

 

[Veneficus]

I think it makes the case for thiopental.

 

[Handsome Robb]

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.

 

[Veneficus]

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.

 

[Handsome Robb]

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.

 

[Veneficus]

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.

 

[Handsome Robb]

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

 

[RocketMedic]

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.

 

[18G]

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.

 

[Veneficus]

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.

 

[Handsome Robb]

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.

 

[Veneficus]

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?

 

[Jon]

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.

 

[Handsome Robb]

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.

 

[Handsome Robb]

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.

 

[mycrofft]

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?

 

[18G]

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.

 

[Smash]

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.

 

[lightsandsirens5]

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.

 

[mycrofft]

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"?).