Patient with distracting injuries

usafmedic45

usafmedic45

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EMS Patient Care Advocate said:
Ok, I will back off. Makes sense. Sorry
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It isn't a huge deal if there is an honest question, but I know several of the more prominent members of this forum have commented that you tend to start threads over anything you hear about (or so the perception is). Personally, I have no serious problem with it- so long as you are judicious and receptive to constructive criticism- but you should be aware of how others perceive these threads at times.
 
OP
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EMS Patient Care Advocate

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usafmedic45 said:
It isn't a huge deal if there is an honest question, but I know several of the more prominent members of this forum have commented that you tend to start threads over anything you hear about (or so the perception is). Personally, I have no serious problem with it- so long as you are judicious and receptive to constructive criticism- but you should be aware of how others perceive these threads at times.
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How things are perceived is important to me. I also dont always know what other perceptions are without hearing them. Thank you for letting me know. I guess I never know what else will spike good conversation, thats why I have been librally posting. I had a feeling something was up.
 
Bullets

Bullets

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i wouldnt have even thought of spinal immobilization once the patient denied neck or back pain.

Only issue is securing the patient to the bench seat with a lap belt. i would have tried to get him to sit on the cot, and remove any other clothing while enroute to the trauma center
 
Akulahawk

Akulahawk

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Spinal precautions on a patient who may have pos MOI, but exam shows neg findings? I don't think so... My concerns with this guy is getting him basically naked (providing for some modesty) getting a line started as sterile a manner as I can, getting orders for much morphine, I think he may need more than I have in the truck... Then start working on fluid replacement via Parkland. Followed by get him to a burn center and continually reassess for the need to intubate him.
 
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Handsome Robb

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Your doing more harm than good forcing him onto a backboard. Give him so fent IN then get a line enroute.

There are other options to control this guys airway, nasal intubation anyone? He will probably tolerate it better once you get the fent on board as well.
 
usafmedic45

usafmedic45

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Is there any concern giving morphine when you cannot obtain a BP due to peripheral site being burned?
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Just chase it with diphenhydramine. Most of the hypotension associated with morphine is due to the associated histamine release. Diphenhydramine is an effective way to minimize the risk of it. Besides, you'll be obtaining vascular access so any hypotension is easily corrected.
 
Akulahawk

Akulahawk

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usafmedic45 said:
Just chase it with diphenhydramine. Most of the hypotension associated with morphine is due to the associated histamine release. Diphenhydramine is an effective way to minimize the risk of it. Besides, you'll be obtaining vascular access so any hypotension is easily corrected.
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If I have a protocol allowing (or can get an order for) a diphenhydramine chaser with morphine administration, I'd absolutely do it. AFAIK, we don't have access to other opiates out here (yet?) for pain control. :wacko:
 
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Handsome Robb

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Akulahawk said:
AFAIK, we don't have access to other opiates out here (yet?) for pain control. :wacko:
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No fentanyl? That's crazy. If you didn't have another narcotic option besides morphine and really were uncomfortable giving it I'd go for nitronox. Sure it's not nearly as strong, but something is better than nothing...

We have Fentanyl 1-2 mcg/kg max single dose of 100 mcg either IV or IN with a total max dose of 300 mcg IV or 2.5 mcg/kg IN and then can call and get orders for more if we really need it. Second option is morphine 2-5 mg IV q 15 mins no max. Intermediates (me until I finish school) have nitronox provided it isn't contraindicated.

Our medical director is pretty liberal about pain management.
 
usafmedic45

usafmedic45

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Honestly, my take on anything approaching serious burns is that it's an indication for ketamine with or without intubation. Nothing short of aggressive dose of narcotics coupled with good sedation or flat out dissociation is adequate for pain control in these situations.
 
Aidey

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We can't do conscious sedation, but we can RSI. My plan for major burn patients is to give them the max doses of fent and versed and RSI. It is the only humane thing I can do if there burns are bad.
 
usafmedic45

usafmedic45

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Aidey said:
We can't do conscious sedation, but we can RSI. My plan for major burn patients is to give them the max doses of fent and versed and RSI. It is the only humane thing I can do if there burns are bad.
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If I can even remotely justify (and I usually can) RSI in these cases, I would take that approach as well. You are right that it is often the only humane thing that can be done, at least from a legal perspective.
 
Akulahawk

Akulahawk

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usafmedic45 said:
Honestly, my take on anything approaching serious burns is that it's an indication for ketamine with or without intubation. Nothing short of aggressive dose of narcotics coupled with good sedation or flat out dissociation is adequate for pain control in these situations.
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The few burn patients I've seen have required a lot of narcotics for adequate pain control. The last emergent burn patient I saw (flown in, I was on ground transport for the short ride from the pad) got 350 mcg fentanyl and that still wasn't enough. And yes, the patient was still breathing at a normal rate and depth. Good SpO2 if I recall... Fortunately, no airway involvement. This was about 8 years ago.

Believe me, that left a HUGE impression with me about burns and pain control...
 
Akulahawk

Akulahawk

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NVRob said:
No fentanyl? That's crazy. If you didn't have another narcotic option besides morphine and really were uncomfortable giving it I'd go for nitronox. Sure it's not nearly as strong, but something is better than nothing...

We have Fentanyl 1-2 mcg/kg max single dose of 100 mcg either IV or IN with a total max dose of 300 mcg IV or 2.5 mcg/kg IN and then can call and get orders for more if we really need it. Second option is morphine 2-5 mg IV q 15 mins no max. Intermediates (me until I finish school) have nitronox provided it isn't contraindicated.

Our medical director is pretty liberal about pain management.
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I just double checked our meds list out here and nitronox, fentanyl, ketamine... all still not on the list. We do have morphine and midazolam though. Diazepam was removed from the list several years ago. Our morphine max dose is 30 mg, in 10 mg increments q 5 min titrated to effect - for burns. For other trauma types, we can max-out at 20 mg, given in 2-5 mg increments q 5 min as long as there's no head or torso injury, GCS 15, and BP >90 for each incremental dose.
 
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