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Tue Dec 19 06:45:59 GMT 2006

Dr. Goyal,

The patient you describe "highly  irritable head injury, bleeding, no IV access" is a common problem, especially with intoxicated patients. There are some tricks that I have used successfully in this scenario, i.e., controlling a patient who may have a spinal or other injury that can be made worse but movement or whose diagnosis may be delayed. Many sedative/narcotic drugs can be given either intramuscularly or intrarectally that have sufficient speed of action to be useful in the patient you describe. Three of the IM drugs I've used include ketamine (4-5 mg/kg), midazolam (0.02 - 0.06 mg/kg), methohexital (2 - 4 mg/kg). Ketamine is controvesial in those who you think have increased intracranial pressure. But, in the patient you describe, increased ICP is not an immediate concern based upon his hyperalert state, so ketamine remains an option I would consider because of its rapid onset and predictability of effect. I use to use methohexital at Children's Hospital when I was a reside
nt in anesthesia. I'd mix it in a concentration of 50 mg/cc and give the kids 3.5 mg/kg IM. Unconsciousness would ensue within 5 minutes, they would continue to breath, and we'd cart the kids off to the OR where we'd start the IVs, paralyse, intubate, and put on gas. It was smooth. With adults, you may have to give 2 injections IM, one in each buttock, because of the necessary volume (4 - 5 cc). You must be prepared to manage the airway. Get your IV while he is sedated, then you have complete control and can complete your sedation, paralysis, and intubation. 

DB

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Highly Irritable Head Injury Patient