Problem areas Sedation It is never appropriate to paralysis

1
Problem areas

• Sedation
• It is never appropriate to paralysis a patient
  before sedation
• Monitoring
• All patients need to be monitored at all times
  with our monitors
• Darting
• Treatment for hemodynamically significant
  pneumothorax
• RSI
• It's time to change to thiopental/ketamine
• Weight stop using pounds

2
12/2/08
L Johnson/J Saylor
9556940
Pt 54 M 150Kg Loc CCH Dx Resp
distress
Pt found at home with BS of 40 and respiratory
distress. Responded poorly to D50 narcan and
with respiratory failure. 1514 BP 177/106
HR60 RR16 GCS15 SAO297 Initially very
short of breath and foaming gt CPAP mask at 10 cm
with improvement. Stable during transport.
Questions Morphine or furosemide?
Arrive 1450 Depart 1513 Dest 1523
3
12/3/08
H West/J Gwinner
10640261
Pt with progressive SOB for 2 days gt ER gt BIPAP
and worsening gt intubated gt arrest 30 minutes
later. Morbid obesity, COPD, aspergillus, DM,
CHF. 1240 BP 124/94 HR127 RR16 GCSpara
SAO296 ETCO232 Pt on norepinephrine and
tapered during transport. Stable in route.
vent VT500 Rate16 PEEP5 FiO21.0 900 NS
PTA, 1200 in route. EBL 400 PTA, 100 in route
Pt 36 F 150KG Loc MRH Dx SOB
Questions blood loss? sedation? fluid
management?
Arrive 1222 Depart 1301 Dest 1316
4
12/5/08
G Vogel/R Hogan
9933549
Pt 85 M 100Kg Loc LRH Dx ped v car
Struck by car at 55 mph, open head injury, chest
crepitus, GCS3. 1820 BP75/40 HR52 RR16
GCS3 SAO2- RSI with etomidate 10mg,
succinylcholine 100 mg and intubated. 1830
BP60/40 HR47 RR12 GCSpara SAO299
ETCO225 right chest darted. Norepinephrine 2
mg/min, midazolam 4 mg, vecuronium 10 mg. O neg
blood. vent rate12 VT500 PEEP5 FiO21.0
Ppeak25 1930 BP123/83 HR96 RR16 GCSpara
SAO299 ETCO230 2.5 L NS PTA, 0.5L in route. 1
u RBC
Questions norepinephrine?
Arrive 1815 Depart 1921 Dest 1942
5
12/7/08
C Willis/J Jonas
583755
Ejected roll-over. Combative, poorly responsive,
CHI and abdominal puncture. 1209 BP129/80
HR116 RR20 GCS9 SAO299 RSI lidocaine
100mg, etomidate 16mg, succinylcholine 80mg. ET
tube dislodged during transfer gt emesis,
re-intubated. rocuronium 80 mg, midazolam 2mg,
fentanyl 100 mcg. 1255 BP147/90 HR140
RR14 GCSpara SAO299 ETCO239 1100 NS in
route
Pt 16 M 80Kg Loc scene Dx MVA
Questions Loss of ET tube - lessons?
Arrive 1209 Depart 1247 Dest 1304
6
12/10/08
C Willis/R Baker
12318138
Pt 76 F 70 Kg Loc LRH Dx ICH
Found unresponsive at home. 1315 BP 102/77
HR68 RR10 GCS7 SAO295 Intubated after
lidocaine 70mg, etomidate 20mg, succinylcholine
70mg 1330 BP 127/98 HR59 RR12 GCSpara
SAO2100 ETCO228 vecuronium 10 mg, midazolam 2
mg. Vent rate 12 VT 500 PEEP 5 Ppeak28
FiO2 1.0. Tidal volume adjusted to 450gt550.
Questions ETCO2 target? vecuronium vs
rocuronium blood sugar
Arrive 1311 Depart 1332 Dest 1359
7
C Willis/R Baker
12/10/08
11177662
Pt 71 F 100 Kg Loc AMC Dx unresponsive
Pt found down at home. Intubated prior to
arrival. 1537 BP 188/100 HR68 RR12
GCSpara SaO299 ETCO2 35 Rocuronium 100mg
stable in transport no auto BP.
Questions paralysis without sedation no BP 30
min diagnosis?
Arrive 1815 Depart 1837 Dest 1850
8
12/13/08
T Janney/J Elliot
17737333
Pt 82 M 800 Kg Loc scene Dx trauma
MVA pt with agonal respirations and weak pulse.
0736 BP- HR74 RR6 GCS3 SaO2- Pt
intubated after 80mg etomidate and 80 mg
succinylcholine. Cardiac arrest noted at end of
intubation. No response to resuscitation.
Questions 80 mg etomidate? monitoring before
intubation?
Arrive 0736 Depart 0759 Dest 0811
9
12/12/08
M Eagen/J Saylor
12320426
Pt 66 F 145 Kg Loc St Mary's Dx
bowel obstruction
Pt with incarcerated umbilical hernia. Worsened
in ICU pre-op gt intubated and transferred.
1625 BP 112/55 HR90 RR12 GCS10
SAO298 Pt sedated with propofol drip. Propofol
drip titrated during transport. BVM during
transport with ETCO2's in high 50's or low 60's.
Questions dosing propofol ETCO2's
Arrive 1615 Depart 1703 Dest 1714
10
propofol

• initial dose
• 0.3-0.6 mg/Kg/hr
• load 1 mg/Kg (0.3-1.0 mg/Kg)?
• titrate
• 0.3 mg/Kg/hr every 5-10 min
• consider reload small
• usual range
• 0.3-3.0 mg/Kg/hr
• synergy with other sedatives
• standard example
• bolus 30 mg
• start at 30 mg/hr
• titrate up by about 20 mg steps every 5 min
• give 10-20 mg bolus when upping infusion

Propofol a review of its use in intensive care
sedation in adults. McKeage K, et al, CNS Drugs.
200317235-72.
11
12/12/08
J Newman/H Seemann
12320680
Pt 78 F 110 Kg Loc scene Dx s/p
arrest
Chest pain at home gt EMS gt cardiac arrest.
Initially asystolic, after 15 min resus gt pulse
and BP. 0755 BP91/46 HR133 RR10
GCS3 SAO287 ETCO282 Pt stable in transport.
Lost cardiac activity but returned with further
resus. Transported by ground to St. John's
Lebanon.
Questions ground transport?
Arrive 0726 Depart 0800 Dest 0826
12
G Johnson/J Simons
12/21/08
12326840
Pt in cardiogenic shock on balloon pump with
transfer to Barnes. 0930 BP130/89 HR97
RR16 GCS15 SaO297 Stable during transport.
Pt 84 M 80 Kg Loc LRH Dx cardiogenic
shock
Questions
Arrive 0930 Depart 1005 Dest 1120
13
J Newman/R Hogan
12/21/08
12306971
Burns to face/airway. COPD on oxygen.
Respiratory distress. 2100 BP166/98 HR106
RR8 GCS9 SaO299 RSI with etomidate 20mg,
succinylcholine 100 mg. Followed with rocuronium
(2107), midazolam (2120), fentanyl.
Pt 66 M 100 Kg Loc scene Dx burns
Questions timing of sedation
Arrive 2056 Depart 2115 Dest 2147
14
G Vogel/H Seemann
12/12/08
12328109
Pt found down at home without heat. Intubated by
EMS. 1527 BP 115/96 HR60 RR12 GCS3 SaO2
- ETCO225 temp 77.3. glu73. to LRH
Pt 86 M 65 Kg Loc scene Dx hypothermia
Questions warming measures? sats?
Arrive 1525 Depart 1539 Dest 1556
15
Out of the cold management of hypothermia and
frostbite. Biem J, et al. CMAJ. 2003168305-11.
16
Out of the cold management of hypothermia and
frostbite. Biem J, et al. CMAJ. 2003168305-11.
17
Out of the cold management of hypothermia and
frostbite. Biem J, et al. CMAJ. 2003168305-11.
18
Out of the cold management of hypothermia and
frostbite. Biem J, et al. CMAJ. 2003168305-11.
19
T Janney/J Simmons
12/25/08
12307365
16 y/o ATV accident. Facial/head/oral trauma gt
seizure. 1622 BP 130/70 HR124 RR22 GCS5
SaO299 ETCO225 Pt intubated after lidocaine
70mg, etomidate 14mg, succinylcholine 70mg,
followed by midazolam, rocuronium,
fentanyl. 1636 BP 138/62 HR135 RR20
GCSpara SaO299 ETCO241 800 cc NS, stable
in transport.
Pt 16 F 70Kg Loc scene Dx trauma
Questions monitoring?
Arrive 1621 Depart 1637 Dest 1651
20
D Shive/J Jonas
12/25/08
4560370
Pt in MVC major intrusion. Head injury, chest
injury. 1033 BP 112/60 HR70 RR14 GCS11
SaO2 99 Deteriorating MS gt RSI etomidate 20mg,
succinylcholine 100mg. 1038 BP - HR90
RR12 GCSpara SaO2 99 ETCO221 Over
breathing, emesis in ET tube, vecuronium 10 mg,
midazolam 2mg. Ashen color gt re-intubate. 1041
BP - HR40 RR14 GCSpara SaO2-
ETCO235 Dart left chest, continue deterioration
gt asystole.
Pt 22 M 100 Kg Loc scene Dx trauma
Questions monitoring airway charting
Arrive 1032 Depart 1106 Dest 1111
21
J McCandless/D Rodden
12/29/08
12332441
Pt in MVA hit tree. Refused to provide
history. Head laceration, uncooperative,
combative, prior alcohol use. 1600 BP 130/90
HR82 RR14 GCS15 SaO2 100 Discussed with
medical control and EMS on scene gt ground
transport by EMS 2 mg midazolam.
Pt 30 M 100 Kg Loc scene Dx trauma
Questions Was this the right answer?
Arrive 1546 Depart Dest
EKG next page
22
H West/J Gwinner
12/29/08
9689401
Pt hit by car and run over by another car.
Significant injury right leg. 1857 BP 90/60
HR70 RR16 GCS14 SaO2 100 Pt treated with
fentanyl 50 mcg x 2. Transported without
incident. Right leg status?
Pt 36 M 100 Kg Loc scene Dx trauma
Questions classification? I/II
Arrive 1855 Depart 1902 Dest 1912
23
M Laas/B Burkhart
12/30/08
12332599
Awoke at 7am with chest pain radiating into jaw
and arm with SOB - feels like my other heart
attacks. 0835 BP 150/90 HR120 RR18
GCS15 SaO2 100 Pt treated with asa, lidocaine,
heparin, ntg, ms. Had defib fire x 2 at outside
hospital
Pt 47 M 150lbs Loc I70 Dx MI
Questions
Arrive 0826 Depart 0838 Dest 0858
EKG next page
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25
Blood transfusion - when?

• BLOOD TRANSFUSIONS
• Indications To outline the flight nursing care
  of the patient who may require immediate
  transfusion prior to or during air transport.
  Criteria for transfusion include hemodynamic
  instability unresponsive to a two-liter fluid
  bolus, subsequent to blunt or penetrating trauma
  or excessive nontraumatic blood loss and/or
  known acute decreases in hematocrit to less than
  30.
• Indications To outline the flight nursing care
  of the patient who may require immediate
  transfusion prior to or during air transport.
  Criteria for transfusion include hemodynamic
  instability subsequent to blunt or penetrating
  trauma or excessive nontraumatic blood loss
  and/or known acute decreases in hematocrit to
  less than 30.