Has anyone treated a...

[Handsome Robb]

Eff you guys and your AAA talk. Had one just now. 82 year old, previous AAA with a graft done 5 years ago. Totally normal on the couch then BAM 10/10 tearing left quadrant abdominal pain, absolutely inconsolable, 80s/50s, mildly tachycardic, cool place and diaphoretic.

I was wondering your thoughts on ketamine in these patients. I gave 200 mcg of fentanyl, 100 mcg x2 and it didn't touch her pain and she was only ~ 105lbs soaking wet.

I ended up giving 25 mg of ketamine IV which did the trick but I was going back and forth on whether I should give it or not.


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[E tank]

Eff you guys and your AAA talk. Had one just now....

I ended up giving 25 mg of ketamine IV which did the trick but I was going back and forth on whether I should give it or not.
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Tempt the gods...at least we weren't talking about 600 pound dudes with PE's at the top of 8 flights of stairs and no working elevator...ooops!


Anyway...I do ketamine first. It's my go to for these folks on the table when they're "awake" and dying but have a blood pressure and they need to be prepped and draped before going to sleep and/or the surgeons are cutting down the groins for placement of a blood loss control balloon up the aorta before the surgery starts.

By the time they get to us, they're so exhausted even a little fentanyl or versed is enough to cause apnea. Ketamine way more forgiving and with the doses that we're talking about big swings in the BP and HR are not an issue.

 

[Handsome Robb]

Tempt the gods...at least we weren't talking about 600 pound dudes with PE's at the top of 8 flights of stairs and no working elevator...ooops!


Anyway...I do ketamine first. It's my go to for these folks on the table when they're "awake" and dying but have a blood pressure and they need to be prepped and draped before going to sleep and/or the surgeons are cutting down the groins for placement of a blood loss control balloon up the aorta before the surgery starts.

By the time they get to us, they're so exhausted even a little fentanyl or versed is enough to cause apnea. Ketamine way more forgiving and with the doses that we're talking about big swings in the BP and HR are not an issue.

You're telling me, in another group on facebook we were talking about hypertensive emergencies and we're talking about Cardene and the call after our AAA was a transfer for a hypertensive emergency on...a cardene drip.

Good to know. I've had mixed experience with ketamine, I've had it make people profoundly anxious and downright angry for a few minutes so I was a little nervous about agitating her further but I gave it slowly into a running line and it worked fantastically. I got an earful from the nurse for not giving her a fluid bonus and I very politely told her she was an idiot and that I was perfectly happy with where her pressure was.


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[VentMonkey]

I hate CA EMS...carry on.

#RandomJealousOfThoseWithKetamineRant

 

[E tank]

Good to know. I've had mixed experience with ketamine, I've had it make people profoundly anxious and downright angry for a few minutes...

Yeah...you have to choose the patient and dose wisely. Whacking someone in their 40's or 50's with 50 mg push is risking some serious dysphoria, but 10 mg at a time in older folks that are really sick and in pain is pretty safe. Not to say the sick elderly can't have a dysphoric reaction, just less likely in my experience.

 

[Nova1300]

I think a good strategy in these patients is generous fentanyl with cardizem on top.

If you get their hemodynamics where you want them with Ca or Beta blockers, and THEN try to provide analgesia, you might end up bouncing their BP down and up more than you'd like to as you adjust the drips.

Hefty doses of precedex are also awsome in these patients, although clearly not an option in the prehospital environment.