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Thu May 15 06:22:34 BST 2008

Robert,
this is what I never understood: the dictum in trauma is everyone < GCS 8 is intubated as they cannot protect their airway and they have a full stomach and they can aspirate.
What is it about the "post-ictal" state that makes us so sure we don't have to intubate these patients ?
The fact that they will wake up later ? How long is it safe to be comatose with no airway protection ?
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Please don't say you'd rather not touch them as then they can aspirate. Aspiration during RSI/CP should not be too frequent, right ? Ivan Hronek MD                                                                              
SFMC, Los Angeles, CA                                                
http://health.groups.yahoo.com/group/Anesthideas/                           Nobody cares if you can't dance well. Just get up and dance. Great dancers are not great because of their technique. They are great because of their passion. Martha Graham
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Confidentiality Notice: This transmission and any attached documents may be confidential and contain information protected by State and Federal Medical Privacy statutes and is legally privileged. They are intended for use only by the addressee. If you are not the intended recipient of this transmission, or an agent of the intended recipient, you are prohibited from reading, disclosing, printing, saving, copying, using, or otherwise disseminating any information contained in this transmission. If you received this transmission in error, please accept our apologies and notify me at  ivanhronek at yahoo.comand delete the entire message and its attachments. Thank you. Disclaimer: this message contains the personal views of the author. The author will not be responsible in any way for procedures or approaches perfomed in the way suggested in this note. 
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----- Original Message ----
From: "Patterson, Robert" <Rpatters at nemours.org>
To: Ivan Hronek <ivanhronek at yahoo.com>; ccm-l at ccm-l.org
Sent: Wednesday, May 14, 2008 10:03:00 PM
Subject: RE: [ccm-l] Intubation post GM seizure: when ?

I'm presuming an uncomplicated and resolved seizure of non-traumatic origin.  If a kid is breathing adequately and maintaining his / her own airway, I am as likely to induce aspiration with my RSI as I am to prevent it.  The altered mental status is generally transient.  This happens multiple times a year with febrile seizures or breakthrough seizures in kids with epilepsy.  If they meet criteria for respiratory failure, I intubate them; otherwise they are observed in a monitored setting (emergency department to step-down unit) until they wake up.  

-rob
Robert Patterson, MD, FAAP
Department of Pediatric Critical Care
Nemours Children's Clinic
Pensacola, Florida
rpatterson at nemours.org
850-473-4511 

________________________________
From: ccm-l-bounces at ccm-l.org [mailto:ccm-l-bounces at ccm-l.org] On Behalf Of Ivan Hronek
Sent: Wednesday, May 14, 2008 9:55 PM
To: ccm-l at ccm-l.org
Subject: [ccm-l] Intubation post GM seizure: when ?

Robert, let me ask you please:

so there's a kid that comes in post-seizure post-ictal (=not awake) with a full stomach and you don't intubate the kid ? You're not afraid of aspiration ? How come ?

 Ivan Hronek MD                                                                              
SFMC, Los Angeles, CA                                                
http://health.groups.yahoo.com/group/Anesthideas/                           Nobody cares if you can't dance well. Just get up and dance. Great dancers are not great because of their technique. They are great because of their passion. Martha Graham
________________________________

Confidentiality Notice: This transmission and any attached documents may be confidential and contain information protected by State and Federal Medical Privacy statutes and is legally privileged. They are intended for use only by the addressee. If you are not the intended recipient of this transmission, or an agent of the intended recipient, you are prohibited from reading, disclosing, printing, saving, copying, using, or otherwise disseminating any information contained in this transmission. If you received this transmission in error, please accept our apologies and notify me at  ivanhronek at yahoo.comand delete the entire message and its attachments. Thank you. Disclaimer: this message contains the personal views of the author. The author will not be responsible in any way for procedures or approaches perfomed in the way suggested in this note. 
________________________________

----- Original Message ----
From: "Patterson, Robert" <Rpatters at nemours.org>
To: Ivan Hronek <ivanhronek at yahoo.com>
Cc: ccm-l at ccm-l.org
Sent: Wednesday, May 14, 2008 7:35:41 PM
Subject: RE: [ccm-l] ETT post GM seizure: when ?

I would usually decide to intubate based on a clinical diagnosis of respiratory failure, potentially after a failed attempt at non-invasive mechanical ventilation since this tends to be self-limited.  I can not recall a time I intubated to prevent aspiration.

-rob
Robert Patterson, MD, FAAP
Department of Pediatric Critical Care
Nemours Children's Clinic
Pensacola, Florida
rpatterson at nemours.org
850-473-4511 

________________________________
From: ccm-l-bounces at ccm-l.org [mailto:ccm-l-bounces at ccm-l.org] On Behalf Of Ivan Hronek
Sent: Tuesday, May 13, 2008 8:03 PM
To: trauma-list at trauma.org
Cc: csen_international at csen.com; Anesthideas at yahoogroups.com; ccm-l at ccm-l.org
Subject: [ccm-l] ETT post GM seizure: when ?

Let's try and vote for the best answer to the following question (please b brief if poss.):

What should we go by in the "post-ictal" state after a GM seizure when deciding to intubate to prevent aspiration ? Time (how long) ? GCS ? Reaction to antiseizure drugs ? 6th sense ?
________________________________

Some pertinent literature:

Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed.:
 Preparation should be made for endotracheal intubation in case anticonvulsant drugs fail to terminate the seizure.

 http://www.merck.com/mmpe/sec16/ch214/ch214a.html
Ivan Hronek MD                                                                              
SFMC, Los Angeles, CA                                                
http://health.groups.yahoo.com/group/Anesthideas/                           
Winston Churchill                                                                                                
  An appeaser is one who feeds a crocodile, hoping it will eat him last.       
________________________________

Confidentiality Notice: This transmission and any attached documents may be confidential and contain information protected by State and Federal Medical Privacy statutes and is legally privileged. They are intended for use only by the addressee. If you are not the intended recipient of this transmission, or an agent of the intended recipient, you are prohibited from reading, disclosing, printing, saving, copying, using, or otherwise disseminating any information contained in this transmission. If you received this transmission in error, please accept our apologies and notify me at  ivanhronek at yahoo.comand delete the entire message and its attachments. Thank you. Disclaimer: this message contains the personal views of the author. The author will not be responsible in any way for procedures or approaches perfomed in the way suggested in this note. 
________________________________

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Intubation post GM seizure: when ?