Trauma-List - Stay on Target! (was Pacing Vs. Airway Management & GM seizures)

[Karim Brohi]

Dear all

A gentle reminder that this is a trauma-list, and trauma should be the focus
of discussions.  There are anaesthesia and paramedic discussion groups for
this kind of thing.

In general, cross-posting to lists is a bad idea too.  Pick the list that's
most appropriate to your case/question.  Otherwise things just get confusing
- especially for us list-owners.

Thanks

Karim

On Sun, May 18, 2008 at 2:43 AM, mark miller <markandjac at optusnet.com.au>
wrote:

> This scenario should be treated in the same manner as a VF arrest. You have
> a (potentially) readily reversible origin of LOC/airway threat (ie CHB
> induced hypotension). Fix the brain perfusion first and you may avert the
> need to intubate. Intubation itself could precipitate asystole here.
>
> TC Pacing is an option but seems to be rarely done (in NSW) pre-hospital
> and
> poorly tolerated. Despite ischaemia, I'd start with small doses of 1:10,000
> adrenaline (say 10mcg increments) and volume loading. No harm in
> atropinisation but commonly fails. He isn't being poisoned by his GP
> (industrial strength BBlocker and CaCBlocker combos are a common cause of
> this situation around here, esp in the elderly) so nothing to reverse in
> that regard. Reperfusion may be in order after you fix this problem.
>
> This is similar to airway management in the postictal patient. I agree with
> Bill G, Treat the underlying, commonly reversible, cause of LOC and give
> them time to "awaken" (on their side, with a nurse and with suction
> available). This , I believe, is a safer and much less resource intensive
> option than subjecting them all unnecessarily to RSI and later extubation
> in
> ED or ICU. The aspiration risk seems small, possibly less (anecdote) than
> the risks posed by intubation becoming "standard of Care" and a whole lot
> of
> inexperienced airway operators feeling obliged to tube these guys.
>
> Mark Miller
> FACEM
>
>
> -----Original Message-----
> From: Gavin SUTTON [mailto:Gsutton at pgwc.gov.za]
> Sent: Saturday, 17 May 2008 7:22 AM
> To: trauma-list at trauma.org
> Subject: Pacing Vs. Airway Management
>
> Just a question if I may...
>
> Pre-hospital case, 55 year-old male patient with Hx of IHD and
> hypertension.
> He is on pharmapress and Isordil. He has defaulted for 6 months. His EKG
> shows a sinus rhythm of 110 with ischemia. While the paramedics are
> treating
> the patient, he becomes unresponsive, the ECG shows 3rd degree HB and he
> has
> a BP of 80 systolic. He has very poor tidal volume.
>
> What would you do?
>
> 1. Begin external pacing immediately
> 2. Sort out the patient's airway first (intubation) and ventilate with a
> bag-valve-mask resuscitator - 100% O2, and then begin external pacing if no
> improvement
> 3. Transport to hospital while maintaining basic airway techniques and
> ventilation- 45 minutes away
>
> Many thanks
>
> Gavin
>
> Gavin Sutton
> Head: Department of Training
> Emergency Medical Services
> Western Cape Department of Health
> South Africa
>
> Tel. +27 21 938-4118
> Fax.+27 21 938-4269
>
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