19 Year Old Male ALOC

[BigBad]

I do not think anyone is trying to argue the patient did not need to be RSI'd but it needs to be done the correct way. I am sure the ER doctor did a proper RSI induction and not a half *** sedative only attempt.

And what you described is getting close to that whole "Practicing medicine without a license" thing...

Never did i say push these medications to rsi him. You are however trained to manage his airway should it need be. If he is being combative, treat it so you can treat your patient My protocols allow me to manage my patients. If my patients are managing me then im behind the 8 ball.

 

[Akulahawk]

I do not think anyone is trying to argue the patient did not need to be RSI'd but it needs to be done the correct way. I am sure the ER doctor did a proper RSI induction and not a half *** sedative only attempt.

And what you described is getting close to that whole "Practicing medicine without a license" thing...

There's a big difference in sedating a combative patient who's pulling lines out and resisting airway assistance vs. "slamming" the wrong medications in an attempt to make the patient lose his gag reflex (and respiratory drive) to pass a tube. I agree you want to stay ahead of the curve and not wait for your patient to crash, but in this case, the patient at least breathing seems better to me than taking that away and risking still not being able to get the tube. If the patient stops breathing spontaneously and loses his gag reflex, intubate away. Also, you're choosing to fast push IV Versed in someone this profoundly hypotensive? Again, wouldn't be my chosen course of action. The ED doc properly intubating this patient with a full repertoire of drugs is really not the same scenario as you describe.

I certainly agree that this patient needs airway control, among other things... but it certainly wouldn't be my choice either to fast push droperidol or versed into a patient that's hypotensive either. to me, that just screams BIG BAD OUTCOME!

 

[Akulahawk]

Never did i say push these medications to rsi him. You are however trained to manage his airway should it need be. If he is being combative, treat it so you can treat your patient My protocols allow me to manage my patients. If my patients are managing me then im behind the 8 ball.

No, but you implied it... or at least indicated that you thought that the fact that it's a side-effect that you'd desire (being able to intubate him) is one of the reasons you'd give those drugs.

If you can manage the combativeness, that's great... great care should be undertaken to prevent him from losing his respiratory drive and maintain vascular tone. Otherwise that may put you in a very unenviable position of can't intubate/ventilate and must do CPR because you caused him to crump by using sedatives that can dump pressure... and this patient is probably several liters dry to begin with.

 

[usalsfyre]

Never did i say push these medications to rsi him. You are however trained to manage his airway should it need be. If he is being combative, treat it so you can treat your patient My protocols allow me to manage my patients. If my patients are managing me then im behind the 8 ball.

I'll go ahead and say it, cowboy bull puckey like this is what will get intubation taken away from paramedics (and rightfully so). This course of action is dangerous to the patient and patently stupid. The reason you don't have RSI in your protocols is your medical director (apparently in a very intelligent move) has decided field medics can't be trusted with it. You do nothing with actions and statements like this to dissuade that notion. I suggest you learn a bit about physiology and pharmacology before you try to manage airways at the big kids table.

 

[NomadicMedic]

I was just writing something along these same lines!

 

[Handsome Robb]

I agree with both of y'all but I like this thread so hopefully it doesn't die.

If the pt is combative and impeading proper care im not going to sit and wait for him to crash. The story you painted for me equals droperidol.. Why else did the doctor RSI him?

While I agree with you, there is no way I an "chart around" giving a sedative then attempting airway control. Like I said in the OP he was doing a decent job of protecting his own airway, just wasn't really happy with the BVM assisted ventilation and the NPA.

I'm not waiting for him to crash either but I also cannot work outside of protocols or my state and county defined scope of practice. I hate medicine by cookbook but at the end of the day I need to pay my bills and only have one job so...

The doc used sux and etomidate for the intubation. First thing that happened when we rolled into the ER since I had my partner call ahead after id already given my report and tell them I was having difficulty controlling the his airway.

As far as crumping, I was more worried about hemodynamic stability rather than his airway. While his spo2 wasn't great, it wasn't god awful either. On the other hand, his MAP sucked.

I have no issues "painting outside the lines" in the best interest if I can justify why I did or did not do something but blatantly violating my scope is not something I'm willing to do. No patient is worth losing my livelihood over, sorry.

We don't carry droperidol, only versed, so I'm thinking this kid is going to require at least 7 mg IV (using .15mg/kg, which is 7 times the amount I can give, IV , on standing orders in a single dose). Realistically probably even more than that to render him sedated enough to allow for an intubation without paralytics. (Thinking probably .2-.3 mg/kg.) That much versed, slammed, with a BP like he had sounds like a great recipe for causing him to decline into a PEA arrest. So, in that case, not only did I violate protocol and my scope but I also killed my patient....sounds like an easy job for a lawyer to take my card, my job and all my money along with a bunch from my agency as well.

 

[BigBad]

I'll go ahead and say it, cowboy bull puckey like this is what will get intubation taken away from paramedics (and rightfully so). This course of action is dangerous to the patient and patently stupid. The reason you don't have RSI in your protocols is your medical director (apparently in a very intelligent move) has decided field medics can't be trusted with it. You do nothing with actions and statements like this to dissuade that notion. I suggest you learn a bit about physiology and pharmacology before you try to manage airways at the big kids table.

Not only do I have rsi, i have central lines big dog.....again im treating combative behavior.

 

[chaz90]

Not only do I have rsi, i have central lines big dog.....again im treating combative behavior.

Oh sweet baby Jesus. Please don't let field central line access come back to life.

I suppose I'll allow myself to be baited for the obvious questions though. Why, if you have RSI, would you not use those drugs to facilitate intubation of a conscious patient instead of slamming Versed and Droperidol? 100% of the time, combativeness ceases post paralytic administration. Also, this still doesn't address the issue of hypotension exacerbated by rapid IV sedative administration.

 

[VFlutter]

Not only do I have rsi, i have central lines big dog.....

Hold on while I get on my knees and bow down to you...

Do yourself a favor and don't brag about outdated interventions that have no proven benefit and most likely cause more harm than good, Big Dog.

 

[Handsome Robb]

Not only do I have rsi, i have central lines big dog.....again im treating combative behavior.

This is starting to make sense to me now...

Ill echo Chaz and say why droperidol or versed when you carry medications to do a proper RSI? I'm assuming you're catering your response to my system since I stated we do not RSI. Still, I don't see how it would be an option in your eyes with a profoundly hypotensive patient.

Yes treating combative behavior is all fine and dandy if that's all that's going on but I'm not willing to risk a CV/CI scenario with a attention who has no respiratory drive and can no longer protect their airway...always wanted to do a crich but not because I created the situation to indicate it.

I don't claim to be the smartest, best paramedic in the world. Far far far from it, I still haven't come close to wiping all the green off of me yet, but "treating the combative behavior" with high dose, vasoactive sedatives is not an option for this patient in my eyes. Maybe I made it seem like he was more combative than he really was...yea he freaked when I went to drop the NPA and kept turning his head when I tried to bag him but after he was restrained physically and I got control of his head between my forearms it wasn't nearly as severe as I may have made it sound and for that I apologize.

 

[usalsfyre]

Not only do I have rsi, i have central lines big dog.....again im treating combative behavior.

Good for you. Me personally I'd rather have the education needed as to when's and how's of properly taking an airway (and why it damn well may be fatal in this case if done with the wrong pharmacology), but why do that when you can be macho?

The point of "slamming versed or droperidol" to control a combative patient that needs intubation (per you) is what exactly? My guess is you have VERY narrowly defined RSI guidelines, and so you feel the need to side step the system. Again you exemplify "cowboy".

 

[Akulahawk]

Not only do I have rsi, i have central lines big dog.....again im treating combative behavior.

That's all fine, well, and good. If you've got RSI can you're able to use it, why use other drugs to treat his combativeness and allow you to intubate him as a side-effect and not document your use of those drugs for that? Remember, both droperidol and midazolam have (as very common side effects) the ability to cause hypotension. Feel like worsening the problem when the patient's BP is something like 70/? Have you forgotten that this patient is also probably very dry. At best, his BP is what, 100/50 and I'd bet that's with his vasculature about as constricted as it's going to be in an attempt to maintain pressure. What does that mean? It means that you're going to want to select a drug that doesn't normally cause hypotension when it's administered. One of those drugs is etomidate. Guess what was the induction agent the Doc used?

If you're truly good at RSI and doing Central Lines, at the BIG DOG level, you'd already know this. You'd be able to call-in to med control and be able to get an order for RSI using etomidate instead of droperidol or midaz because you know those choices aren't good. It sounds very much like you don't understand how poor of a choice either of those agents really is for that specific situation.

Incidentally, slamming either droperidol or midaz to deal with a combative patient when their BP is so very low is quite dangerous. If it was absolutely necessary to sedate that patient, I'd use some very low doses just to lightly sedate the patient without dumping his pressure. That should be sufficient to allow him to tolerate the BVM. That or just physically restrain him and augment his ventilatory efforts with the BVM a few times per minute, which is what the OP did.

Don't get me wrong: I'm all for being very highly aggressive in providing care for my patients. It's that I'm also very much pro-appropriate care and sometimes that appropriate care is doing essentially nothing to the patient except judicious monitoring and keeping a very close watch on the patient. I've done both. Oh, and I don't "forget to document" things when the desirable side-effect happens to be off-protocol and my actual goal. I have no issue with running several protocols simultaneously, but you can certainly bet that I can articulate exactly why I used each one.

 

[eprex]

I would have (and you hit most of these)

Gotten a set of vitals immediately

Gone to the nearest ER. This is a true emergency

Ventilated him way sooner

 

[Handsome Robb]

I would have (and you hit most of these)

Gotten a set of vitals immediately

Gone to the nearest ER. This is a true emergency

Ventilated him way sooner

May I ask why you would have ventilated him "way sooner"? Not trying to start a fight, just wondering your reasoning behind it. He's created a respiratory alkalosis to attempt to compensate for his severe metabolic acidosis, I'm not to keen on trying I overrule his body's natural compensatory mechanisms. Like I said, his SpO2 wasn't great but wasn't god awful either. His BP tanking is what had me on edge, especially with the increased intrathoracic pressure created by positive pressure ventilation causing a reduction in preload in a patient who's extremely volume depleted.

Closer hospital could go both ways. Tiny facility with no available ICU beds (critical care divert), one physician and 2 maybe 3 nurses for an 11 bed ER. Not exactly the greatest nurse to patient ratio for someone this sick who's going to require a great deal of attention in the beginning of his "stabilization".

Vitals I wholeheartedly agree on and it's a change I've made. Unless its a crew that I trust I repeat vitals right off the bat. Unfortunately I generally have to do them myself now because I lost a little faith in my very green partner and her ability to obtain a manual BP or be honest when she can't hear it after what happened on this call. I don't remember how brought it up but someone made the statement that its possible she picked a number near what fire had because she couldn't hear them and I asked her about it and she told me, reluctantly, that's what happened and then we had a very firm discussion about it. Smart girl, gonna be one helluva provider one day but she's got a lot to leave to solidify her basics. Made that a priority lately. She was asking me a lot of really complex questions and coming up with complex differentials and what not, looking for zebras rather than horses if that makes sense.

 

[RocketMedic]

For combative behavior but more so to manage the pt airway effectively without documenting it that way.

Are you an idiot?

 

[rmabrey]

I would have slammed 5mg of droperidol or 2mg of versed, if his sats are tanking, i have no trouble bagging him all the way to the hospital. Drop an opa and tube him if needed. Weve all been there man, good job.

I dont have much to add that everyone else hasn't covered, but as much of a trainwreck as this patient already is, I doubt you would have to slam 2mg of versed to get the desired (or undesired) effect you're looking for.

 

[Carlos Danger]

I would have slammed 5mg of droperidol or 2mg of versed, if his sats are tanking, i have no trouble bagging him all the way to the hospital. Drop an opa and tube him if needed. Weve all been there man, good job.

"Slamming" droperidol in an acidemic, hyperkalemic, hypotensive patient is a potentially fatal.

And why would you use a neuroleptic medication in a patient who is agitated due to poor perfusion, anyway? I can see possibly using a couple mg of midazolam as a premedication to make them compliant for pre-oxygenation while you prepare to intubate, but that's about it.

Yet you have protocols for central lines and RSI......just brilliant. I'm sure you never unnecessarily expose patients to the risks of those procedures.

And we wonder why paramedicine hasn't advanced......