List Archives

Wed Aug 20 14:23:54 BST 2008

  Well said Garth.  Unfortunately here all we have is fentanyl/morphine and midazolam for assisting intubating.  You figure the ride into a Trauma center here is about 17 minutes.  Not worth calling the helo for that amount of time.  However they do obviously have all of the medications necessary to intubate.  Three choices for us on the ground here.  1) nasal/oral intubate, 2) BLS maneuvers, 3) use the medication's listed above.
  About a handful of ground paramedic services are allowed to use SUX in Massachusetts.  With fantastic outcomes.  The Fire department I used to work for in New Hampshire had SUX available in the truck.  A minimal of 2 paramedics must be on scene (who both have had to complete the required in service in order to use it)  New Hampshire has liberal pre hospital treatment protocols for the simple fact that longer transport times existed.  
  So in short I have used sux for trauma patients and i find it works well for most any situation.

  Anthony M. Caruso
  Paramedic/firefighter
  Town of Natick, Massachusetts.

> From: gmelnick at efn.org> To: trauma-list at trauma.org> Subject: Re: Etomidate and Trauma> Date: Tue, 19 Aug 2008 19:38:31 -0700> > A few comments from the prehospital side of things:> > I agree that the literature that's been presented here recently > suggests some serious concerns for the use of etomidate in terms of > adrenocortical suppression, and that needs to be addressed.> > However, I have to take issue with some of your other thoughts and > concerns...> > With a fast-acting paralytic onboard (e.g. sux) there shouldn't be any > problems secondary to etomidate in terms of compromising your airway > and losing control of your pt. Etomidate is one of the better agents > in terms of maintaining hemodynamic stability (though ketamine does > sound promising, but I haven't heard of it being used much prehospital > here in the western US). I have not had issues with ease of > administration -- our etomidate is packaged in preloads just like code > drugs and is very easy to administer.> > Finally, the sequence of drugs you propose below may be appropriate in > an ED environment, but is far too complex for a prehospital > environment, with only one or two ALS providers on most scenes, and > only 4-6 providers total. The folks whose airways we are controlling > are generally the ones with the most emergent need (versus the ones > who are intubated semi-electively in the ED) and so the simplest > sequence of drugs is best.> > Just a few thoughts from a humble paramedic...> > Garth> NREMTP, etc> > On Aug 19, 2008, at 1:17 AM, bensonblues at comcast.net wrote:> > > To the etomidate folks:> >> > I feel that etomidate has no real use in trauma. My reasons are:> >> > 1) Unpredictable myoclonic/hebiphrenic/catatonic reactions which can > > result in airway compromise or lack of patient control> > 2) Adrenocortical suppression (and although it is alleged, I use the > > Cheney 1% rule)> > 3) Expense (not yet an issue in the US, but if ObamaCare takes hold, > > budget-limited care...)> > 4) Ease of administration (40 mg in 20 cc solution in a glass > > ampule? Give me a break.)> > 4) Ketamine is the best brain eraser for the trauma victim, hands > > down.> >> > If I am to manage a trauma victim's airway in the ED, I do so in the > > following way:> >> > First, I shut off the frontal lobe with ketamine. This is the > > kindest thing I can do.> > Ketamine does not affect the brain stem (blood pressure, > > respiration), and it renders mammals perceptually decerebrate > > (dissociative anesthetic). Next, I wage a receptor war:> > a) an Opiod for mu, kappa, et. al. receptors: 1 - 4 mg hydromorph > > (always treat pain)> > b) a GABA drug: 1 - 4 mg lorazepam (to treat anxiety, sedate, > > prevent seizures, provide muscle relaxaion, interject amnesia)> > c) an H1 blocker: 25 - 50 mg`diphenhydramine (to mitigate any > > histamine-releasing reaction)> > d) an H2 blocker: 20 mg famotidine (to prevent me from getting a > > Curling's or Cushing's ulcer)> > e) a neuromuscular blocker: 10 - 20 mg vecuronium (if necessary, > > depending upon the situation).> >> > If I am not worried about hypovolemia, then I occasionally use > > propofol in the place of ketamine.> >> > After that (if the night is good), they should be the anesthetist's > > problem....> >> > Come on - argue with me. I need stimulation.> >> > DB> > --> > trauma-list : TRAUMA.ORG> > To change your settings or unsubscribe visit:> > http://www.trauma.org/index.php?/community/> > --> trauma-list : TRAUMA.ORG> To change your settings or unsubscribe visit:> http://www.trauma.org/index.php?
_________________________________________________________________
See what people are saying about Windows Live.  Check out featured posts.
http://www.windowslive.com/connect?ocid=TXT_TAGLM_WL_connect2_082008

List Archives

For your convenience, find the Trauma List Archive Below

Etomidate and Trauma