Sedating the Head Injured Patient
	Date: Fri, 29 Nov 1996 17:58:42 -0500 (EST) From: [petersz@pathcom.com] Hello Our hospital does not usually keep a patient with a head injury if it is a bleed which can be treated. However when these patients come into ER they often need to be intubated and placed on a vent. for airway protection.We already know that the hospital where the patient is going to does not like their patients to have any sedation on board so that presumably they can be better assessed.What drugs then are best to be used for intubating the patient if any ? Should any drugs be used to sedate the patient while on the vent ? They are often difficult to vent because of acute hyperventilation and they fight the vent. Sometimes they hyperventilate so much that their pCO2 is in the low 20's mmHg. Should they be sedated in this case? Thanks for your replies Peter, R.R.T. Toronto
	Date: Sat, 30 Nov 1996 07:16:50 -0500 From: Louis Brusco Jr., M.D. [lb86@columbia.edu] We use Propofol infusions for all our head trauma patients for the fist 48-72 hours. It allows us to keep them deep to prevent self-extubation, etc., but allows us to stop it and get an accurate neuro exam when needed. Our neurosurgeons now know to call ahead when they are 15-20 minutes from arriving in the unit to allow the nurse to stop the infusion and o a wake-up test with the neurosurgeon. Louis Brusco Jr., M.D. Director, Critical Care Anesthesiology Co-Director, Critical Care Anesthesiology St. Luke's-Roosevelt Hospital Center, NYC
	Date: Sat, 30 Nov 1996 07:40:25 -0500 From: George Prudden [gprudden@cpcug.org] Peter, This is a common problem whether you intend on keeping the head-injured patient or not. I'm with the Neurosurgery service at a regional trauma center; we keep our heads in-house. Here, in general, is what we do: 1) Get a decent baseline neurological exam. GCS, what extremities are moving, that sort of stuff. 2) If the patient is getting intubated, then put them to sleep. We use pentothal and sux (usually) to relax them. 3) Once intubated, we usually give Norcuron and Ativan. That gives you about an hour of neuromuscular blockade, which is enough time to do the diagnostics. 4) At that point, we let the patient get light and re-evaluate them. Personally, I think that not sedating a confused, combative patient is cruel and unusual punishment. Additionally, all that thrashing causes elevations of the intracranial pressure, which is not what you want at that point. If we are transferring the patient to another facility (cord injury, for example), we always sedate and paralyze for transport. I don't want the people in the ambulance or helicopter wrestling with a patient. George Prudden, PA-C
	Date: Sat, 30 Nov 1996 16:28:40 -0500 From: Peter Meade [PMCANDO@aol.com] Ditto!! I agree with the use of propofol in these situations too! Peter Meade, MD SICU Director King/Drew Med Ctr Los Angeles
	Date: 01 Dec 96 18:11:58 EST From: Dr E Shearer [101366.3435@CompuServe.COM] You cannot seriously be suggesting you send an acutely head injured patient on a transfer without securing the airway. This means intubating the patient and ensuring the ETT remains in by sedating AND paralysing the patient. If your referring hospital are too afraid to acept your clinical examination of the patient then use the following; Suxamethonium to intubate +/- etomidate Atracurium for paralysis Propofol and alfentanil infusions for sedation. Hyperventilate to pCO2 of 4Kpa Monitor arterial pressure directly and ECG This sedation wears off within 30 mins of stopping it. Euan Shearer Consultant in ICU Liverpool, England 101366.3435@compuserve.com
	Date: Sun, 8 Dec 1996 17:55:57 +0100 From: Giancarlo Rossi [rossi@xtreme.it] I think it's sufficient, to allow intubation, to use Diazepam 20 mg i.v. For what concerning sedation I suggest the use of Propofol because it has a very short halftime and the patient is ready to be evaluated about 10 min after Propofol is stopped. We usually start with a dose of 2 mg/Kg/h because the drug can give hypotension (not good in head traumas). Using Propofol usually allow to get the patient ventilated without barotrauma Why you MUST paralyse this patient? A good sedation is enough to ensure ETT remains in the pt trachea and usually neuromuscolar blockers always give hemodinamics problems Giancarlo Rossi, MD Specialista in Anestesia e Rianimazione I^ U.O. Anestesia e Rianimazione Spedali Riuniti di Livorno Viale Alfieri - 57100 LIVORNO - ITALIA
	Date: 09 Dec 96 17:36:00 EST From: Dr E Shearer [101366.3435@CompuServe.COM] Rubbish. In order to sedate an unco-operative head injured patient sufficiently to safely tolerate an ETT on a bumpy journey the BP will be in his boots, never mind the effect this will have on subsequent attempts to assess his neurology. It is a mis-conception that NMB's markedly affect BP, IPPV does but not the NMB's. It would be disastereous to have a patient with closed head injury and suspected raised ICP to be coughing and gagging on the ETT. You MUST paralyse then prior to transport. Dr Euan Shearer Consultant in Anaesthesia & ICU, Liverpool. England 101366.3435@compuserve.com
	Date: Tue, 10 Dec 1996 13:42:59 +1030 (CST) From: William Griggs [wgriggs@medicine.adelaide.edu.au] There is no doubt that paralysing patients is one alternative for transport. However does your statement regarding sedation and haemodynamic changes imply that you would usually accept a partially awake but paralysed patient? This would seem to me to be suboptimal care and I would reserve it for only occasional use for a minimal time during an unstable primary transfer. Adequate sedation or even using sedation alone really only becomes a problem from a haemodynamic viewpoint if the patient is underfilled, which ideally should be avoided in secondary transfer. In the primary transfer setting every effort should, of course, be made to restore adequate circulating volume as soon as possible and then to also ensure that the patient is asleep - both of these, along with adequate oxygenation and ventilation are needed to minimise secondary brain injury. In summary, for transport I usually add relaxants to sedation but not always. Rarely a case may require the "POAA" approach (pancuronium, oxygen, apologize afterwards). As far as subsequent attempts to assess neurology, if a decision has been made to intubate (presumably based on clinical findings) then you are committed to CT scanning the brain. For a second person to perform a further clinical assessment when a CT scan will be done anyway is virtually pointless. After a normal scan a patient may be awakened relatively safely over time and further assessment may then be done clinically. IMHO receiving institutions that say they don't want patients sedated and ventilated so that they can assess these patients themselves are compromising patient care for the sake of their own egos. If they are unhappy with the referral institution's assessments, then they should get off their backsides and go out to their referring agencies and provide some education. Bill ************************************************************** Dr William M Griggs Director, Trauma Services Senior Consultant, Intensive Care Unit Royal Adelaide Hospital South Australia 5081
	Date: Tue, 10 Dec 1996 18:43:10 -0000 From: Nick Macartney [macartn@ibm.net] I have sat and lurked on this subject, and can resist no longer. Until 2 weeks ago, the scanner at this hospital was only operational 0900-1700 Mon-Fri. As we all know most trauma is outside these hours, and seems to be at midnight if you have to get up to respond. I would take the view that if the GCS is less than 8 (maybe 9), the patient needs a tube _before_ a scan, even if done on site. Especially if done off site. The way we ran it was simple. Do the GCS, and document it. The ICU staff attend all trauma calls, and they are in no doubt after one case how to do the score. The adjective brutally comes to mind. I frequently demonstrate how to do it. After doing it, we give a general anaesthetic. No, we don't use Alfentanil/Lignocaine to reduce the pressor response to intubation. I regard it as more important at trauma to be able to have an escape path if you fail to intubate, and Alfentanil might block it. Having intubated, we sedate and curarise. The patient is fully monitored. I take the view that they must be kept in an ICU environment from that point. Arterial line, triple lumen central line, aseptically inserted, urinary catheter etc. The mechanical ventilator is attached, and a set of gasses checked, and then they make the trip to another hospital. Curarising a patient will make a negligible/nil difference in their blood pressure. After all, that is why he companies go to such trouble. It is obvious that if the patient is awake, the blood pressure will go up, but if the _doctor_ escorting the patient is unable to manage this, they should not be doing it. I do most transfers in this hospital myself, as the ICU consultant. As for the neurology assessment at the other end, my view is that the CT is what is needed, with or without surgery/ICP bolts. I tend to give a large dose of relaxant to stop such stupidity as I sometimes see from junior neurosurgeons Dr NJD Macartney MBBS FRCA ICU, Chase Farm Hospital Enfield Middlesex EN2 8JL
	Date: Tue, 10 Dec 1996 18:36:16 -0500 From: Mark Fulton, MD. [fulton.34@osu.edu] This is rediculous. The foundation of management of closed head injury is serial observation. You treat the patient, not the film. We have all seen many patients with initially "normal" head CTs who have had poor outcomes. On many occasions we have been told a patient has a GCS of 3-4 but they are going to paralyze him because "he is trying to pull his tube out". You do the math... The incidence of erroneous neurologic exams is very high. There are many patients with an intracranial lesion that can be well managed without surgery if you have a good exam. If the flight crew gives the patient 20mg of pavaulon 3 minutes prior to landing, they have made the decision to operate for you. Without an exam, you go to the OR. This is a recurring problem for us. There is no doubt that some patients will need chemical paralysis for transport, but the decision should be discussed with the receiving doc, and a judicious, individualized plan agreed upon. Mark A. Fulton, MD Ohio State University Dept. of Neurosurgery N007 Upham Hall 473 W. 12 Ave. Columbus, Ohio 43210 fulton.34@osu.edu
	Date: Tue, 10 Dec 1996 19:14:29 -0500 (EST) From: Dr. Kevin Gerold [kgerold@umabnet.ab.umd.edu] If you need to acutely paralyze a head traumatized patient to gain control of the situation in the short term, there are several short acting muscle relaxants with a very predictable offset. Atracurium, mivacurium, cisatracurium, maybe rocuronium. There is no defensible argument that a patient needs an operation because the clinical exam was lost from the administration of a parlytic. Critical care transport teams need the tools, ie short acting agents, to address the task at hand. K Gerold Critical Care Medicine/Anesthesiology RA Cowley Shock Trauma Center University of Maryland Baltimore, MD
	Date: Wed, 11 Dec 1996 11:10:01 +1030 (CST) From: William Griggs [wgriggs@medicine.adelaide.edu.au] Mark Fulton wrote in response to my comments >This is rediculous. The foundation of management of closed >head injury is serial observation. You treat the patient, not >the film. We have all seen many patients with initially >"normal" head CTs who have had poor outcomes. On many >occasions we have been told a patient has a GCS of 3-4 but >they are going to paralyze him because "he is trying to pull >his tube out". You do the math... The incidence of erroneous >neurologic exams is very high. This emphasises my second point. If you have referring institutions who can not manage patients as well as you, then help them. Visit them and educate them, perhaps even earn their respect. If you have a good relationship with them then you should be able to talk with them better over the acute case. If they feel they just get criticism, they won't talk to you or listen for that matter. This does not hurt you or them - it hurts the patient. The answer is to fix the erroneus neurological exams. >There are many patients with an intracranial lesion that can >be well managed without surgery if you have a good exam. If >the flight crew gives the patient 20mg of pavaulon 3 minutes >prior to landing, they have made the decision to operate for >you. Any flight crew that gives 20mg of pancuronium to any patient at any time is in serious need of reeducation. Take the initiative - try to ensure that the flight crew and yourselves all feel that you are part of the same team - not enemies or competitors. Offer to provide CME for them - teach them to do good exams, teach them about shorter acting relaxants, even teach them about dosage - hopefully if your institution has competent teachers you can get them to give you reliable exam results that you can count on, and appropriately packaged patients. >Without an exam, you go to the OR. This is a recurring problem for us. Again, teach the referring docs and/or flight crew to do good exams. Regardless of the previous exam, and we all know they change with time, I stand by my statement that you will still need the CT scan and also that any normal dosage of anaesthetic drugs should be reversible after 30-45 minutes at most. This means that by the time you have the CT scan and done a primary and secondary survey you should be able to wake and examine the patient if that is what you feel will be best. >There is no doubt that some patients will need chemical >paralysis for transport, but the decision should be discussed >with the receiving doc, and a judicious, individualized plan >agreed upon. Absolutely - but working in a major referral hospital as I do, it is essential to win the confidence and support of the referring groups so that this will happen. Standing on the outhouse roof beating our chests shouting "We are the best and you're all incompetent" impresses no-one and results in phone calls saying "We are referring this patient to you and he's already left." The receiving doc must have the confidence of the referring doc or again the patient suffers. A trauma system is not one hospital. Enough preaching - someone else have a go at the pulpit. Bill ************************************************************** Dr William M Griggs Director, Trauma Services Senior Consultant, Intensive Care Unit Royal Adelaide Hospital South Australia 5081
	Date: Wed, 11 Dec 1996 22:04:12 -0500 From: Mark Fulton, MD. [fulton.34@osu.edu] I am in full agreement with you that educating physicians and trauma teams in the proper neurologic evaluation of trauma patients is important. That is something we are also involved with on a daily basis. I also agree that neuro-trauma care should be a team effort, and in most cases, it is. I do not believe our referral base is afraid of us. We treat them with the great respect they deserve. But, there is still a critical role for serial examination of head injured patients. This is ultimately going to determine the course of therapy once they arrive at our tertiary facility. You operate on the patient, not the CT.... Unless, of course, you have no current exam because they are paralyzed. I am arguing for the prudent use of paralytics in a method that will allow safe transfer, as well as assessment as soon as possible. Many clinicians and flight crews seem to be oblivious to our concerns. It is critical to pick the agent, dose, and indication. --Mark A. Fulton, MD Ohio State University Dept. of Neurosurgery N007 Upham Hall 473 W. 12 Ave. Columbus, Ohio 43210 fulton.34@osu.edu
	Date: 11 Dec 1996 14:31:14 GMT From: Phillip Meyer [gOrliaguet.necker@invivo.remcomp.fr] What a suprising controversy in 1996 Many years ago it was probably very interesting to see the patient with a head trauma deteriorating under the eyes of the surgeon in order to see on what side the burr hole had to be done. It was many years ago before CT-scan and ICP monitoring and even before EEG and artificial ventilation. It is now clearly demonstrated that ET and controled ventilation are probably the most efficient emergency interventions to prevent secondary brain injury. However ET is probably also the most efficient stimulus for rising ICP whatever the level of conscioussness is (see the recent letter in the Lancet by Moulton et Al.). So, if you need to intubate a patient with severe head trauma and potentially raised ICP you need general anesthesia . If you ventilate a patient with severe head trauma, the goal is to have moderate hyperventilation with a patient adaptated to the ventilator settings not to connect a machine on a tube. For this purpose, you need general anesthesia. Do you ever need muscle relaxant for general anesthesia maintenance, that is the question. We do not use it systematically at our institution for severe head trauma. If you see somebody saying that it is dangerous to sedate, intubate and ventilate a severely head injured patient before admission because he will not be efficiently examinated by a highly qualified neurologist try to explain that medical ( good)practice has changed and send him a recent bibliography about management of sever head trauma. Philippe Meyer MD>br> Anesthesiology, critical care and SAMU de PARIS Hopital des Enfants Malades Paris France
	Date: 11 Dec 96 18:58:09 EST From: Dr E Shearer [101366.3435@CompuServe.COM] Dr Griggs, I couldn't agree more. My main gripes were that some people seem to be advocating heavy sedation as an alternative to paralysis or not even sedating at all, merely intubating unaided and leaving the patient to fight on the ETT and there seems to be a misconception that muscle relaxants themselves can cause significant hypotension. Sure, DTC use to, but panc. or vec. do not (IPPV in an underfilled trauma patient certainly can). I did not intend to imply that the patients are inadequately sedated. As an anaesthetist I am paranoic about ensuring sedation and would always err on the side of over rather than under sedating. Euan Shearer Consultant in ICU Liverpool, England. 101366.3435@compuserve.com
	Date: 11 Dec 96 19:04:04 EST From: Dr E Shearer [101366.3435@CompuServe.COM] Dr Macartney I am glad to see that common sense prevails amongst British anaesthetists. Euan Shearer Consultant in ICU Liverpool England 101366.3435@compuserve.com
	Date: Thu, 12 Dec 1996 23:16:38 +1100 (EST) From: Shane Curran [scurran@tpgi.com.au] >Nick Macartney wrote: >I have sat and lurked on this subject, and can resist no longer. Until 2 >weeks ago, the scanner at this hospital was only operational >0900-1700 Mon-Fri. so is mine but mine is off site >As we all know most trauma is outside these hours, and seems to be >at midnight if you have to get up to respond. I would take the >view that if the GCS is less than 8 (maybe 9), the patient needs a >tube _before_ a scan, agreed 100% >even if done on site. Especially if done off site. The way we ran it was >simple. Do the GCS, and document it. Is there another way? >The ICU staff attend all trauma calls, >and they are in no doubt after one case how to do the score. The >adjective brutally comes to mind. I frequently demonstrate how to >do it. After doing>it, we give a general anaesthetic. No, we don't use >Alfentanil/Lignocaine to reduce the pressor response to intubation. please tell me that you give some drugs to intubate a patient with a GCS >3 It strikes me as barbaric to do anything else >I regard it as more important at trauma to be able to have >an escape path if you fail to intubate, and alfentanil might block it. Everyone who intubates anyone in an emergency sitauation should have at least 2 fallback positions in the case of a failed or difficulr intubation >Having intubated, we sedate and curarise. why not before with short acting agents? >patient is fully monitored. I take the view that they must be kept in an >ICU environment from that point. Arterial line, triple lumen central line, >aseptically inserted, urinary catheter etc. The mechanical ventilator is >attached, and a set of gasses checked, and then they make the trip >to another hospital. Curarising a patient will make a negligible/nil >difference in their blood pressure. After all, that is why he companies >go to such trouble. It is obvious that if the patient is awake, the >blood pressure will go up, but if the _doctor_ escorting the patient >is unable to manage this, they should not be doing it. >I do most transfers in this hospital myself, as the ICU consultant. >As for the neurology assessment at the other end, my view is that >CT is what is needed, with or without surgery/ICP bolts. I tend to >give a large dose of relaxant to stop suchstupidity as I sometimes >see from junior neurosurgeons agree with all of this Dr Shane Curran Staff Specialist Emergency Department Wagga Wagga Base Hospital Wagga Wagga NSW 2650 Australia
	Date: Thu, 12 Dec 1996 07:40:27 -0500 (EST) From: Gary Hecker RN [HeckerGS@UCBEH.SAN.UC.EDU] Dr. Fulton I am not familiar with the OSU system, but I believe that the flight program is based at your facility. If this is so then my qustion is do you have an integrated trauma team rounds or a interdiciplinary team meeting. If not then you need to start this up. It is important that delivers of each phase of care be incorporated into the process of planning interventions so that everyone's concerns are met. Granted if the patient arrives at the ER without paralytics on board waiting 2 minutes for the Neurosurgery resident to come down may not be a problem. But try managing a difficult compative patient while flying high up in the air in an egg beater . I did some work at Miami Valley for grad school and they have an excellent example of an integrated trauma program. My guess is that the OSU flight program functions through the Emergency Department. If this is so are we just seeing an extension of the usual tensions between ER doc's and surgeons. Gary Hecker RN, EMT Graduate Student University of Cincinnati College of Nursing & Health
	Date: Fri, 13 Dec 1996 10:57:49 -0000 From: Nick Macartney [macartn@ibm.net] My apologies for not stating what subconsciously I assumed. I always anaesthetise the patient before attacking with laryngoscopes and plastic. This would usually be Propofol (easier to draw up than Thio), and Sux, then as I said, sedate and curarise. If a junior intubates without, I offer to demonstrate on them what it is like to be intubated. My comment about alfentanil/lignocaine was just concerning the pressor response. From a lecture I was at last night, Remifentanyl sounds interesting. Dr NJD Macartney MBBS FRCA ICU, Chase Farm Hospital Enfield Middlesex EN2 8JL
	Date: Sun, 15 Dec 1996 23:40:25 +1100 (EST From: Shane Curran [scurran@tpgi.com.au] > My apologies for not stating what subconsciously I assumed. obviously on threads we need to assume the same as with junior staff i.e assume nothing! >I always anaesthetise the patient before attacking with laryngoscopes >and plastic. bravo! I'll be happy to be a head injury in your emergency departmnent >This would usually be Propofol (easier to draw up than Thio), and >Sux, then as I said, sedate and curarise. If a junior intubates >without, I offer to demonstrate on them what it is like to be intubated. none of my juniors are sufficiently good for them to be allowed to do this (a sorry statement on the availability of advanced airway training in junior staff in nsw)I'm happy if they can maintain an airway until more senior help arrives. Ask me next year and it will hopefully all be different glad to hear it was all a misunderstanding Shane Dr Shane Curran Staff Specialist Emergency Department Wagga Wagga Base Hospital Wagga Wagga NSW 2650 Australia