Should i have given versed?

[mrhunt]

So! Scenario time sorta.

39yo M, A&0X0 GCS approx 12 (language barrier) involved in a quad accident with no helmet or gear. Mutiple system trauma but most notably GCS that declines about halfway enroute to trauma center, Pt has a LARGE hematoma to L-aspect of head that nearly doubles in size by Hospital arrival. Pt VERY clearly has a head bleed which is confirmed as a subdural & epidural as well as skull fracture later by ER staff.
Pt becomes combative and restraints are applied which are sufficient at keeping pt safe and from pullling out his IV's and C-Collar etc.

Vitals are actually stable but He's intially hypoxic @ 85% RA with crackles to all lung fields. There is no indication of Pneumo or further and with hx of asthma i associated those lung sounds to that likely. NRB placed @ 15lpm and SP02 increased to 95%. Resp rate 22 to 24 and lowered when pt calms down (briefly) and not agitated. Pulse 120's on 4 lead, BP rock solid at 120's systolic the whole time.

I took a second medic on board due to transport of multiple pt's (second pt a green-tag requiring next to no care) and Second medic suggested possibly versed for chemical restraint. I held off on this due to Not only physical restraints being appropriate in maintaining safety of the pt, but also due to Pt's initial Hypoxia. Pt's mentation enroute is noted to begin to have brief periods of Lethargy / unconsciousness lasting about 10 seconds and then going right back to moderate bouts of agitation / combative behavior.

to be clear, his GCS Maintained at approx 12 for whole transport. There was intact gag reflect (obviously) so its not like we were about to take this guys airway by any means. My partner was more suggesting this due to pt just becoming more annoying during a 35 minute transport with constant "take this off of me!" type requests. Our protocols Dont list ANY Contra-indications for versed administration but i was uncomfortable based on head injury and being unable to note a further decline in GCS as well as causing increased Resp depression (since he was already hypoxic initally to begin with)

What would you have done?

 

[Carlos Danger]

Inb4 all the "BUT WHAT ABOUT SPECIAL K?!?!" comments lol.

Not to discount the importance of physical exam and mental status evaluation, but this guy is going to be scanned immediately and any neurosurgical interventions are going to be based on that far more than anything else, and from the sounds of it he may require sedation or intubation for that. Plus, a single dose of versed is going to completely wear off in less than 30 min in most people, so I wouldn't even expect it to be much of a confounder anyway. Of course there are plenty of people who will say you should avoid it, but if some mild sedation keeps this guy from increasing his ICP as he struggles against his restraints and pulls out his IV, I'd say it is perfectly appropriate.

 

[wcspa]

Inb4 all the "BUT WHAT ABOUT SPECIAL K?!?!" comments lol.

Not to discount the importance of physical exam and mental status evaluation, but this guy is going to be scanned immediately and any neurosurgical interventions are going to be based on that far more than anything else, and from the sounds of it he may require sedation or intubation for that. Plus, a single dose of versed is going to completely wear off in less than 30 min in most people, so I wouldn't even expect it to be much of a confounder anyway. Of course there are plenty of people who will say you should avoid it, but if some mild sedation keeps this guy from increasing his ICP as he struggles against his restraints and pulls out his IV, I'd say it is perfectly appropriate.

Agree with all of the above.

 

[medichopeful]

What would you have done?

As presented, I would have done a BGL and if that was normal, I would DSI him. Combative, in and out of consciousness, pulling at tubes/lines, and initially hypoxic post head-injury with coarse lung sounds like a pretty reasonable intubation to me. He's going to almost certainly be intubated in the ER so they can scan him. Intubating him would also allow you to keep him sedated, and that would help decrease ICP.

Without the ability to do RSI, I don't think some versed would be detrimental and would probably be beneficial to keep his ICP down and him a little more calm so he doesn't hurt himself more.

 

[FiremanMike]

Inb4 all the "BUT WHAT ABOUT SPECIAL K?!?!" comments lol.

I mean, yeah.. lol

In the case as was described, I would have initiated an RSI/DSI. I’m ok with mild sedation in some cases, but if the patient has a head injury that I can see and is acting that combative, I’m inclined to just take their airway..

Of course, this all depends on manpower, your pre intubation airway assessment, availability of competent manpower, etc.

Also, you’ll want to keep a close eye on that patients shock index, which is approaching 1..

 

[Carlos Danger]

In the case as was described, I would have initiated an RSI/DSI. I’m ok with mild sedation in some cases, but if the patient has a head injury that I can see and is acting that combative, I’m inclined to just take their airway..

When I worked in HEMS, I would have intubated this guy almost reflexively. It was the way I was trained and was the culture and expectations at the places I worked. However, in retrospect we were way more aggressive than necessary and put a lot of patients at risk unnecessarily.

As described here, I think you can make a good argument either way. The presentation makes it seem likely that he has a TBI and will end up intubated at the hospital anyway, but of course there was no way to know that for sure.
You could always try some mild sedation and then intubate if he deteriorates.

 

[mrhunt]

Thanks for the replies everyone.

Also, No RSI capabilities here so that wasn't an option.
Pt WAS almost immediately intubated at trauma center and Confirmed Skull fracture with subdural AND epidural Bleed.

Overall i think it was sorta a "doesnt really hurt him either way" sorta thing looking back.
Did it hurt him to NOT give versed? No, not really. Would it have hurt him to GIVE versed? Probally not, but probally wouldnt have done alot for him either besides being slightly more mellow.

 

[Combatdoc]

Thanks for the replies everyone.

Also, No RSI capabilities here so that wasn't an option.
Pt WAS almost immediately intubated at trauma center and Confirmed Skull fracture with subdural AND epidural Bleed.

Overall i think it was sorta a "doesnt really hurt him either way" sorta thing looking back.
Did it hurt him to NOT give versed? No, not really. Would it have hurt him to GIVE versed? Probally not, but probally wouldnt have done alot for him either besides being slightly more mellow.

 

[Combatdoc]

I agree Versed wouldn't have been detrimental, the one thing that would have concerned me was the crackles (Rales for us old timers). That, to me, would indicate cardiac trauma, even with the consistent rate and BP. I probably would have sedated and intubated following MAI protocols. Covers the intubation for the neuro later and helps clear any possible fluid issues in the lungs. IMHO.

 

[mrhunt]

I completely agree with you combat doc. However, RSI isnt in our protocols so that wasnt an option.

He definately had multi-system trauma to be sure.

 

[johnrsemt]

Versed won't affect the breathing, it will affect the agitation: so calming him down, probably would have lowered the HR, would have helped with the pain, and quite possibly lowered the ICP slightly (at least the agitation caused ICP).

 

[mrhunt]

Im sorry, And im most likely mis-interperting your verbiage here....... but how will versed NOT affect someones breathing / cause resp depression?

Since when? What am i missing here?

 

[ffemt8978]

Im sorry, And im most likely mis-interperting your verbiage here....... but how will versed NOT affect someones breathing / cause resp depression?

Since when? What am i missing here?

I was wondering the same thing.

 

[Carlos Danger]

Im sorry, And im most likely mis-interperting your verbiage here....... but how will versed NOT affect someones breathing / cause resp depression?

Since when? What am i missing here?

Versed by itself has minimal impact on respiratory drive in normally used doses.