59YOM - OD, Suicide attempt

[KingCountyMedic]

:rofl:

 

[KingCountyMedic]

Wow this is a friendly place huh?

If I am within driving distance of a hospital and the flight time vs. drive time is absolutely not going to make a bit of difference and the patient is a suicidal then yea I'll drive thanks. Obviously some of you have never lost close friends in helicopter crashes. It may sound harsh but I will never risk a flight crew for someone that has attempted to take their own life unless it is absolutely the only option. If you are working someplace that has no local hospital then obviously things are different.

If you have a patient that is looking like sepsis, the best way to manage that patient is RSI ASAP. Take away the demand of breathing and let the body handle the other problems, not tubing these people is just pushing them to end organ failure and death.

And if it is a poly drug OD with opiates and benzos I'm not going to push more opiates and benzos:wacko:

 

[epipusher]

WTF does one have to do with the other? If you are going to criticize the policy go ahead, but making wild emotion based accusations is silly.

 

[Smash]

Wow this is a friendly place huh?

If I am within driving distance of a hospital and the flight time vs. drive time is absolutely not going to make a bit of difference and the patient is a suicidal then yea I'll drive thanks. Obviously some of you have never lost close friends in helicopter crashes. It may sound harsh but I will never risk a flight crew for someone that has attempted to take their own life unless it is absolutely the only option. If you are working someplace that has no local hospital then obviously things are different.

It doesn't sound harsh so much as it not making sense in the context of this scenario. I have no problem with not flying a combative patient if nothing has been done to mitigate the risks, and in fact I have no problem in not flying this patient at all. However if, as you have stated, you have intubated this patient, why then would you not fly him? (if indeed aero-medical transport was necessary at all)

If you have a patient that is looking like sepsis, the best way to manage that patient is RSI ASAP. Take away the demand of breathing and let the body handle the other problems, not tubing these people is just pushing them to end organ failure and death.

I'll certainly grant that in some setting early RSI may be an important step in the management of a patient with sepsis/severe sepsis/septic shock, but jumping straight in with a tube seems to be missing a large number of quite important steps in the mean time.

And if it is a poly drug OD with opiates and benzos I'm not going to push more opiates and benzos:wacko:

So with respect to this patient, if the decision was made to intubate him, how would you actually go about doing this, and how would you maintain that ETT if or when it was passed?

 

[usafmedic45]

Obviously some of you have never lost close friends in helicopter crashes.

I've lost ten friends in HEMS crashes including one less than two weeks ago. Also, I'm the last one to ever advocate HEMS transport unless it's a last resort.

 

[KingCountyMedic]

Didn't really clarify myself I guess

RSI to me is using a lot of drugs, MS, Valium, Versed, Etomidate, Anectine, Rocuronium or Vecuronium. Where I work we are very aggressive with airway management. We sedate and paralyze most all tubed patients unless it isn't needed. "If you are thinking about securing the airway with a tube, DO IT"

So if I ever say "I'd tube this guy ASAP" it means I'd use every RX at my disposal, didn't mean it to sound barbaric or nothing.

 

[Ramathorn90]

O's via NRB and intervene with PPV if no improvement in sat or breathing condition during assessment.

IV- 16G because I love em'

Fluids for possible sepsis 2nd to his HR 130 ST, 103.2 temp, and ALOC. (Monitoring for fluid overload)

Transport with the pretty lights if no improvement in breathing condition.

En route, try a bite of narcan and call it a day after turning the Pt over.

 

[Smash]

Didn't really clarify myself I guess

RSI to me is using a lot of drugs, MS, Valium, Versed, Etomidate, Anectine, Rocuronium or Vecuronium. Where I work we are very aggressive with airway management. We sedate and paralyze most all tubed patients unless it isn't needed. "If you are thinking about securing the airway with a tube, DO IT"

I assume not all of those drugs at once, or together. Specifically for this patient, I would be curious to know how you would actually go about securing his airway?

 

[Handsome Robb]

I assume not all of those drugs at once, or together.

I'm hoping the same thing.

 

[KingCountyMedic]

I assume not all of those drugs at once, or together. Specifically for this patient, I would be curious to know how you would actually go about securing his airway?

Seriously?

Etomidate 20mg, Anectine 120mg, Rocuronium 50mg.

Monitor VS, HTN? Maybe some Valium.

 

[Handsome Robb]

Seriously?

More of the way it was listed then you talked about 'aggressive' airway control.

King County holds their medics to very high standards, we all know this.

10/10 for props 2/10 for delivery No offense intended

 

[KingCountyMedic]

have a good night, stay safe

 

[Aidey]

Seriously?

Etomidate 20mg, Anectine 120mg, Rocuronium 50mg.

Monitor VS, HTN? Maybe some Valium.

You would use etomidate in a potentially septic patient?

 

[Smash]

Seriously?

Etomidate 20mg, Anectine 120mg, Rocuronium 50mg.

Monitor VS, HTN? Maybe some Valium.

Why would I not be serious? How will I learn things if I don't ask questions?

Aidey already bet me to the punch with the etomidate question. I assume you would include some hydrocortisone or something similar if you were using etomidate rather than midazolam in this patient?

Would you routinely provide ongoing sedation and analgesia to this kind of patient?

Why not skip the succinylcholine altogether if you are going to use rocuronium for ongoing paralysis anyway?

 

[systemet]

Wow this is a friendly place huh?

It's lovely!

If I am within driving distance of a hospital and the flight time vs. drive time is absolutely not going to make a bit of difference and the patient is a suicidal then yea I'll drive thanks. Obviously some of you have never lost close friends in helicopter crashes. It may sound harsh but I will never risk a flight crew for someone that has attempted to take their own life unless it is absolutely the only option. If you are working someplace that has no local hospital then obviously things are different.

I've been lucky not to. And I don't wish it on anyone.

If there no expected benefit from rotary wing transport, then it's silly to do it in any patient. And part of the responsibility for the horrific amount of deaths in flight belongs to us for using the capability in inappropriate situations.

But that's any patient. I just don't see why you'd be reluctant to fly an OD patient. If they're sick enough to fly, they're sick enough to RSI. At that point the risk is minimised. Place some restraints, use a longer acting NMBA, and sedate appropriately.

 

[Handsome Robb]

Would you routinely provide ongoing sedation and analgesia to this kind of patient?

Why not skip the succinylcholine altogether if you are going to use rocuronium for ongoing paralysis anyway?

First question: Yes. It's cruel to paralyze someone and not sedate them. We 'do no harm' correct? Paralyzation without proper sedation/analgesia is harmful psychologically. People always criticize Medication Assisted Intubation with the 'if you aren't going to do it right, don't do it at all' argument. I'd say that applies here. If your gonna RSI this pt, keep them anesthetized.

Question two: Faster onset would be my thought. As long is it's not contraindicated why wait for a pharmacological paralytic agent like roc to kick in while oxygenation is compromised when sux allows for intubation conditions within 45 seconds, then continue the paralysis with a longer duration medication such as rocuronium or vecuronium? Also a med such as rocuronium or pancuronium can be used as a defasciculating agent if given prior to administration of the paralyzing dose of succinylcholine as I'm sure you know.

I just don't see why you'd be reluctant to fly an OD patient. If they're sick enough to fly, they're sick enough to RSI. At that point the risk is minimised. Place some restraints, use a longer acting NMBA, and sedate appropriately.

Agreed. If they need a chopper the bad, paralyze, sedate and breathe for them. They can't do anything dangerous to the crew after the have been RSI'd.

If your hand is forced into flying someone with suicidal thoughts/actions, RSI them. Document the heck out of why you did it, but flight crew's life comes first.

 

[KingCountyMedic]

Where I'm at we only have a small number of choppers and our hospitals are all pretty close. We typically only fly trauma patients and that's fairly rare as well. We have no policy about who we choose to fly or not fly. It's entirely up to us.

The use of Etomidate is sepsis is still an ongoing debate on the west coast. For now we still use it in most patients that we RSI. Will that change? who knows?

As far as sedation for the intubated patient we carry Valium, Versed, Morphine. We initially use Anectine as a short acting paralytic and once the airway is secure we give a long acting paralytic. Sometime a small defasciculating dose of Vec or Roc is given prior to the Anectine. In treating a patient that has poly OD'd on benzos and opiates I would be very hesitant to start pushing more. I'm not saying I would absolutely never give them any but more than likely I'd hold off and continually re-evaluate.

The reason we use sux first is that it's quick and it doesn't last. This is good. If you encounter a difficult airway the patient isn't left paralyzed for 45 minutes to an hour.

In my view this gentlemen in question had too many potential issues going on to leave breathing on his own. Aspiration risk and myocardial demand are a couple good reasons to protect that airway. I always put at least two large bore lines in every intubated patient because they may need it later whether it be fluid or multiple meds/antibiotics.

We have a huge area covered in our part of the state by only 3 helicopters so I'm really, really picky about what I give them. I'd hate to take a chopper out of service for an intentional OD that more than likely has a life ending disease, probably wants to be a DNR if they aren't already..........does that make sense? If we had tons of choppers maybe it's be a different story. Also my transport is free, the choppers here will run you 10-20 grand per flight easy.

 

[KingCountyMedic]

More of the way it was listed then you talked about 'aggressive' airway control.

King County holds their medics to very high standards, we all know this.

10/10 for props 2/10 for delivery No offense intended

:beerchug:

I'm new at this forum stuff I'll work on delivery

 

[KingCountyMedic]

Also please forgive the snappy attitude of earlier posts, bad mood and booze. Should stay away from posting while under the influence :wacko:

 

[Melclin]

Also please forgive the snappy attitude of earlier posts, bad mood and booze. Should stay away from posting while under the influence :wacko:

Meh I say this about once a month. Never sticks.

It can be a bit of a shock coming here some time. You expect the low and lazy conversation of a break room and you assume a certain amount of short hand.

In some of the groups its more like a formal conference. You have to be ready to justify what you say/do. I think thats a good thing. If you can't justify it to a bunch of faceless people on the internet, then you have to wonder about the wisdom of having done it in the first place. Keeps you on your toes.

There are so many idiots out there in addition to so many different scopes of practice and norms, that sometimes you have to expand on what is obvious to you, put our regional shorthand to the side. Its absurd to you that someone might try to intubate this pt without drugs or with a smattering of midaz, so its self evident when you say RSI that you mean a certain cocktail. Unfortunately I wouldn't put it past some people, and some systems to espouse intubating this guy without drugs, perhaps nasally, or with a couple of mgs of midaz. Hence the questions, and generally, a little extra detail in the original posts.