Christopher
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While I've not heard that "memory aid", I would be concerned about causing hypotension in this patient. But you figure 5 mg IM isn't going to bottom them out either.
Prehospital Sedation of the Combative Patient in the presence of a TBI
- Thread starter Handsome Robb
- Start date
While I've not heard that "memory aid", I would be concerned about causing hypotension in this patient. But you figure 5 mg IM isn't going to bottom them out either.
18G
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The greatest incidence of hypotension from Versed comes from the rate of administration. Administer it slow and you greatly reduce the chance of hypotension. Diluting helps also.
It's not commercially available in the US any longer. It got a bad (undeserved) rap as the drug of choice for execution by lethal injection. Now even foreign sources won't allow it to be sold for use in the US out of a misguided anti-capital punishment concern.
lightsandsirens5
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Maybe not in the field, but I've seen them used in the hospital plenty.
Oh, to have Thiopental on the trucks......wouldn't that be nice? Course it wouldn't get used that often. But it'd still be nice.
I know that thiopental and barbituates are generally considered neuroprotective, but benzos have some experimental data showing "neuroprotection", too. Ultimately, for me, cases like this are about safety - a combative patient is a combative patient and is a danger to self, you, and others. Unless there is an immediately reversible cause, sedation is the best option (RSI might only better in the very few systems that can intubate with good success).
This pt would absolutely get chemicals from me. To a certain extent he is not a trauma pt until he can be controlled.
I have a few options where I work. The first option is Versed or Versed/Haldol up to 5mg/10mg. Although since this is not a psychosis related illness I might stay away from Haldol.
My second option is Ketamine. 4-5mg/kg IM and the guy should be out.
If the guy is starting to fight- what good is it if he hits you in the face and you go down?
If I am using Versed and 5 isnt working I can call for an additional 5mg (typically my transports are too short to chat with a doc).
I have found, through some trail and error, that it is the behavioral emergences that you must walk in to the scene and take IMMEDIATE control. There is no time to think about what you are going to do- the plan must be in your head before walking in the door.
I have a few options where I work. The first option is Versed or Versed/Haldol up to 5mg/10mg. Although since this is not a psychosis related illness I might stay away from Haldol.
My second option is Ketamine. 4-5mg/kg IM and the guy should be out.
If the guy is starting to fight- what good is it if he hits you in the face and you go down?
If I am using Versed and 5 isnt working I can call for an additional 5mg (typically my transports are too short to chat with a doc).
I have found, through some trail and error, that it is the behavioral emergences that you must walk in to the scene and take IMMEDIATE control. There is no time to think about what you are going to do- the plan must be in your head before walking in the door.
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I haven't figured out how to multiquote on the iPad so here it goes.
@18g. No contact was made with the TC other than my radio report, my transport time was only 8 minutes so I didn't have time. Theoretically I have a couple protocols I could operate under and give versed on standing orders. Our seizure protocol and our combative protocol but aloc is a relative contraindication for versed. Hindsight being 20/20 I should have sedated this guy, it was definitely a learning experience. As far as his airway, I pride myself in my ability to manage an airway with BLS techniques pretty well, I agree his was not managed well however he did maintain his SpO2% decently well with the NRB mask, never saw it drop below 90%. This man needs definitive airway and ventilatory control but unfortunately I wasn't able to provide that it his situation.
@Smash. Fentanyl crossed my mind as well as a fent/versed cocktail. With the suspected femur fracture I can give up to 300 mcg of fent and 5 mg of versed on standing orders. 100 mcg/1 mg q5. Not sure how QA/QI would like doing conscious sedation on a pt with a GCS of 9.
@Maine. I wouldn't qualify this as a behavioral emergency, it was a multisystems trauma. We know the etiology of his behavior. Haldol is not an option in my mind for this patient. This guy wasn't fighting with us, per say, more just thrashing and flailing about. No coordinated movements.
Keep 'em coming!
@18g. No contact was made with the TC other than my radio report, my transport time was only 8 minutes so I didn't have time. Theoretically I have a couple protocols I could operate under and give versed on standing orders. Our seizure protocol and our combative protocol but aloc is a relative contraindication for versed. Hindsight being 20/20 I should have sedated this guy, it was definitely a learning experience. As far as his airway, I pride myself in my ability to manage an airway with BLS techniques pretty well, I agree his was not managed well however he did maintain his SpO2% decently well with the NRB mask, never saw it drop below 90%. This man needs definitive airway and ventilatory control but unfortunately I wasn't able to provide that it his situation.
@Smash. Fentanyl crossed my mind as well as a fent/versed cocktail. With the suspected femur fracture I can give up to 300 mcg of fent and 5 mg of versed on standing orders. 100 mcg/1 mg q5. Not sure how QA/QI would like doing conscious sedation on a pt with a GCS of 9.
@Maine. I wouldn't qualify this as a behavioral emergency, it was a multisystems trauma. We know the etiology of his behavior. Haldol is not an option in my mind for this patient. This guy wasn't fighting with us, per say, more just thrashing and flailing about. No coordinated movements.
Keep 'em coming!
Rob, I fully agree that it is a trauma pt. But my point was you must gain control of the pt before you can manage his injuries- which for me means this is a behavioral pt.
And my guess is that is the protocol you would be under for giving him meds- unless you have RSI protocols, or a trauma sedation protocol.
And my guess is that is the protocol you would be under for giving him meds- unless you have RSI protocols, or a trauma sedation protocol.
Haldol would not be on my list of choices for a TBI patient.
lightsandsirens5
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Is there not evidence (probably anecdotal) that point to bolus dosing opioids in a pt with increased ICP actually transiently increases ICP, therefore decreasing CPP?
Additionally there have been some studies into the use of opioids in this case specifically MS, so it might not really be relevant) in drip infusion form in the TBI pt. If I remember correctly, an elimination or significant decrease in these drugs also resulted in lessened need for ICP lowering, overall lower ICP several days SP and an overall increased prognosis.
I believe the study was done out of Canada. I just read it the other day on PubMed or something...... I am just too dang tired to find it right now.
Nor would it be mine- "Although since this is not a psychosis related illness I might stay away from Haldol".
This pt is still combative (whether he is knowingly resisting or it is base reflex to resist being strapped down and poked/prodded doesn't matter) and will be sedated, or slowed down.
As I said before I have 3 options to choose from under my behavioral emergencies protocol: Versed, Versed + Haldol, or Ketamine; since haldol works on psychosis it would not be appropriate, thus my options are Versed or Ketamine.
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Sorry, read my post and realized it could be misconstrued as confrontational. Not my intent at all, sorry if I came off that way.
I've heard mixed things about Ketamine in the presence of increased ICP/TBI. Tried to read about it on shift tonight but our 6 car accidents and motorcycle vs car at 95 mph had me kinda busy. Also, our HEMS service carries ketamine but we don't have it on the ground yet, it's supposed to make an appearance in the next protocol revisions but we will see if it actually happens.
Looking back on it and in the future our seizure protocol would be appropriate for this guy. 2 mg versed IV q3 max of 10 mg. ALOC + trismus and flailing extremities could be argued as seizure-like activity. By no means am I condoning twisting protocols or "creative" charting. With that said, after talking with our MD and a few supes that was the general consensus.
Our combative protocol is versed 2 mg IV titrated to effect or 5 mg haldol IM/IV q 5 max of 15 mg. This protocol using versed may be the more appropriate protocol to use, for me.
@lights - I've heard the same thing but fent is commonly used to blunt spikes in ICP during RSI so take it for what it's worth.
lightsandsirens5
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Rob, this study had to do with spiking ICP in the presence of TBI. I'm thinking the reason they use fent in RSI is because the pain causes the rise in ICP, and the fent blunts the pain? Must be something about once a TBI exists, then it's bad? I dunno, I am all so ignorant...lol!
I'll find that article later today, I'm on my way to a memorial service right now.
I'll find that article later today, I'm on my way to a memorial service right now.
Why not just call medical command for orders?
Ultimately you're kind of limited by your protocols and unfortunately didn't have RSI available.
We do occasionally use barbiturates, usually phenobarbital on out ICHs when we just can't control their ICP. Usually the usual sedation and other ICP treatment measures work fine.
Just sounded like this guy needed to be intubated and sedated. GCS is borderline already for intubation criteria, not to mention evidence of increased ICP and likely impending respiratory failure.
I'm guessing if y'all had RSI then that would've been the done in field?
Certainly would not fault you for sedating from what it sounds like. Certainly not going to get any better with pt thrashing about.
We do occasionally use barbiturates, usually phenobarbital on out ICHs when we just can't control their ICP. Usually the usual sedation and other ICP treatment measures work fine.
Just sounded like this guy needed to be intubated and sedated. GCS is borderline already for intubation criteria, not to mention evidence of increased ICP and likely impending respiratory failure.
I'm guessing if y'all had RSI then that would've been the done in field?
Certainly would not fault you for sedating from what it sounds like. Certainly not going to get any better with pt thrashing about.
Shishkabob
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Fighting with a head injury? You go night-night with some IN Versed.
We can't help the TBI if we're too busy fighting you on scene.
We can't help the TBI if we're too busy fighting you on scene.
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@medicsb the entire call lasted 12 minutes from marking on scene to putting the patient on the trauma table, I didn't have time to call I was too busy trying to keep this guy from doing anymore damage to himself. I work in an urban system, our transport times are less than 10 minutes on average.
@FLdoc if we had RSI this guy more than likely would've gotten tubed in the field by myself and my supervisor while the other crew dealt with the other patient but like I said, he had an extremely difficult airway and I have my doubts if we actually could've intubated him in the field. The bougie definitely would've been worth its weight in gold. I, unfortunately, never pulled the trigger on sedating this guy. I learned a ton from this call and know what I will differently next time.
@FLdoc if we had RSI this guy more than likely would've gotten tubed in the field by myself and my supervisor while the other crew dealt with the other patient but like I said, he had an extremely difficult airway and I have my doubts if we actually could've intubated him in the field. The bougie definitely would've been worth its weight in gold. I, unfortunately, never pulled the trigger on sedating this guy. I learned a ton from this call and know what I will differently next time.
Rob it is good to see that you analyze this call to see what you can improve on.
There is some interesting literature on being prepared and reviewing a difficult call.
We all learn, sometimes quickly and painfully, but it is key to analyze what worked and what didn't
This is an interesting link I found:
http://emupdates.com/2012/09/26/the-usual-state-of-readiness/
also
http://emcrit.org/podcasts/mind-resuscitationist-reid/
As I stated in an earlier post behavioral emergencies, which this was as you just stated, is one of the calls that I play through in my head for that exact reason that you have to take control quickly.
There is some interesting literature on being prepared and reviewing a difficult call.
We all learn, sometimes quickly and painfully, but it is key to analyze what worked and what didn't
This is an interesting link I found:
http://emupdates.com/2012/09/26/the-usual-state-of-readiness/
also
http://emcrit.org/podcasts/mind-resuscitationist-reid/
As I stated in an earlier post behavioral emergencies, which this was as you just stated, is one of the calls that I play through in my head for that exact reason that you have to take control quickly.
I'm not trying to be a jerk, but you stated that there were firefighters and another ALS unit on scene, how it that you don't have time to call but you have time to get 2 IVs? RSI would have taken much more time than calling. I've worked urban with short transport times and have been in nearly exact situations... still had time to call (it was required where I worked). Let the firefighters and other ALS crew members wrestle while a call is made (shouldn't take more than 1 minute).
I know it can be a pain in the *** to call, but it is something to consider when there is no protocol. Instead of thinking about creative writing it might be better to think, "I'll just make a quick call."
RocketMedic
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Bougie: never leave home without it.