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Tue Jan 25 00:08:18 GMT 2005

No!!!!!!!

The head injured patient with a significant loss of consciousness but still with clenched teeth needs a proper induction of anaesthesia as much as if not more so than any other patient. This group of patients are likely to have a significant traumatic brain injury, but also may be in the category that will potentially do well with proper treatment (as opposed to the GCS 3 head injury patient with no responses, who is likely to do very badly no matter what you do). If you just give a bit of midazolam and a muscle relaxant you risk profound intracranial hypertensive as a consequence of your clumsy induction. The effects of midazolam are so unpredictable you cannot reliably use it as an induction drug.

The 'intermediate grade' head injury patient is one of those groups who really does need a skilled induction of anaesthesia, however you choose to do it, not a clumsy 'midazolam, sux, tube' sequence. The only other comparable group I can think of is the sick preeclamptic who likewise needs a really skilled induction and is an impending disaster if things are done without finesse.

Cheers, Ian

Ian Seppelt FANZCA FJFICM
Staff Specialist in Intensive Care Medicine
The Nepean Hospital, 
PO Box 63, Penrith NSW 2751
Clinical Lecturer, University of Sydney

>>> Jfried1202 at aol.com 01/25/05 08:20am >>>
cruel and unusual is a bit much for midazolam use!  I think the disagreement 
is because we are not specifying the level of consciousness of the patient 
needing RSI.  Many head injured patients already have a significant loss of 
consciousness but continue to have clenched teeth, the midazolam is more of a 
kindness act when what is really needed is muscle relaxation.  Obviously, if the 
patient is conscious and alert, midazolam alone would not be a good choice.  
Whatever drug one uses, a thiopental, propofol, they both depress cardiovascular 
function and must be used with caution, does the risk outway the benefit, 
hence the popularity of etomidate.
JAF
CCM/Anesthesiologist
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