Sir,
 I got some questions for you on trauma management, can you help me out?

Looking for info on when and when not to admin morphine.  I know it's a CNS depress, causes vasodilation, analgesic and decreases mycardial demand  (I have my drug cards from paramedic school).  My question is, would it be adminsitered for GSW's and trauma that is serious in nature, that is located on the main trunk of the body?  Or seeing how it is a cns depressant, would you keep it to fx's, sharpnel and gsw's to extremities.

Second ?:
Would you want to intubate a patient, that is has previously suffered an aneuryism and is having reoccuring problems from it?  Specifically, a soldier came ambulatory to our aid station, was not able to get out of hummvee, IV started by me, GCS was probably 10 or 11 when he arrived and went to 7 or 8 before heloed out. He took a J tube w/o gag reflex.  O2 NRB 15 Lpm.  PMH - had been intubated three times before for the same type of incident.

The problem that I understand with Anueryism (sp?) is that you have ICP. Intubating also causes ICP and so does using a BVM.  So at what point do you decide to intubate or run the risk of not intubating.

If decision to intubate is made (no lifepaks at our level) do you hope to have a sedative to facilitate  the intubation?  RSI is out of the question because of the lack of heart monitoring capabilities.  So do you attempt OI and hope for no gag reflex or if you have a sedative, do you sedate and OI?

The reason I am asking, good chance I will be called to go to NTC (FT. Irwin, CA) later this month.  I will be one of two medics.  This above soldier may be there as well, if he is,  I want to be be better prepared to treat him, if he goes down.

In the Guard, it's real hard to find someone to ask these kinds of ???? to.  Especially in TX.  My unit does not have a PA or Doc.  It's kinda screwy here, hell we don't even have any medical helo's assigned to this state at all.  This state is an armored division and we have no intergrated medical air assets.  Oh well.
The morphine ?? was just for FMI, just in case we get deployed.

Your assistance, would be greatly appreciated.

Pakrat
TXARNG - Medic
EMT (one semester left for Paramedic cert)
PHTLS, also.

btt

If anyone is reading this thread, besides me and you all run into drjarhead, let him know I was looking for him and needed to ask some questions regarding trauma management.

Thanks.

I teach both EM and FP.
You have Narcan right?
I will usually give MS if the patient is screaming or writhing.
You can never go wrong intubating a patient.ET and ventilation will decrease the ICP.

I am not a MD, but I worked in ICU's and CCU's as a nurse while in the army. Also ACLS, ATLS, and PALS. If I were stuck in this situation, then I would probably do the following.

I agree with the follow up by cpermd, intubation, especially if you have a j-tube in with no gag reflex isn't going to be a problem with ICP, as soon as it's all said and done. The even resps and the added O2 can do nothing but good, as long as you are properly managing them.

MS, as long as administered in a proper dosage can get enough to get your patient relaxed. And, like cpermd explained, have Narcan available. Do you have capabilities to monitor SAO2? That would be very instrumental with both of the problems you have mentioned.

[BD] Boy,am I a dumbass! Keep up the good work guys!( and Gals [;)] )

No Narcan but if we get deployed, you can bet, I will have Narcan.

No SAo2 monitoring capabilities.  Tried to get one on order that was in new condition but don't think it will happen.  Anyone got a spare laying around?

If this pt, needs to be tubed and still somewhat conscious and if I could get Versed, would this help lower ICP in a round about way? I know it will help with the OI and may even do him some good with the amniotic affect.

I want to greatly improve our pt care but the Guard is kinda slow to doing things like this.  This maybe too aggressive for them.

Sounds like cpermd answered your questions.

You describe either an abdominal aortic aneurysm or a dissecting aotic aneurysm. I suspect from the pt's history that this a aortic dissection. In such case you would want to get pt's BP down, anyway. Treating pain with morphine should not be a big issue anyway unless you are overdosing pt. Pts pain, if severe, would be a considerable liability as it will increase BP(leading to greater dissection) and ICP. ICP is not going to be a big deal under these circumstances-I suspect that you may be confusing this with a cerebral aneurysm("berry aneurysm"). In this case ICP would be an issue but patient who needs intubation, needs intubation. Remember your ABC's. First, airway. Second, breathing! Additionally a patient who needs pain control, needs pain control. Versed would be fine for pre-intubation but be cautious mixing with morphine as this will also decrease respiratory response synergistically with the morphine. Of course, once successfully intubated, this is not much of an issue. The nice thing about Versed is that it is short acting compared with other benzodiazepines.
I did re-read your post and you describe trauma in the main trunk of the body but then talk about your pt's Glasgow Coma Scale. Maybe you could specify which type of aneurysm you are talking about. Between myself and cpermd we could probably better answer your question.
FWIW, I doubt anyone with any of the above aneurysms would remain in the military. Just an aside.

Sir,
 I guess I confused you on my questions.  My patient is one topic and the pain management is another and not related to each other.
 The MS questions are just general in case of deployment.  What type of injuries would be best be treated with MS and what injuries would you not use MS?  I know MS lowers the BP and fluid boluses need to be ready in case BP goes too low.  But I didn't know if say, would MS be adviseable with say serious GSW's or trauma to the main trunk, affecting lungs, heart or any other major systems.
 My pt is probably on the way out but with our state, medical stuff with part time soldiers seems not to be a real priority and in general medical issues are low on the priority list.  As can be demonstated by lack of funding, low priority of training, lack of knowledge in resupply and a lack of aero medical support units.  Oh well, nothing I can do to change that but do my best for my soldiers to give them the best treatment and patient care, even if I have to steal.......er I mean requasition the supplies thats needed.[;)]
 This patient really got me thinking about our poor ability to treat and maintain in the field until we can evacuate or hand off to higher medical support.  This pt has been intubated, something like three times for this problem.  If we are confronted again with him and his medical condition, I want to be better prepared.  Maybe even do better for another pt in like situation or circumstances.  
 Sometimes, it really sucks not having a doc or PA to run things by.  So I got to come up with my info anywhere I can.
 Hope you guys don't mind.
 Thanks, for your help.


Pakrat - OUT!

treat pain as necessary. Treat shock, etc as necessary as well.

I still don't understand what type of aneurysm your patient has and the management differs with each. In fact, it differs substantially. Will be glad to help you out further if I can.

PS. Don't call me sir. Never was an occifer. drj or Kevin will be fine.

But I guess by your moniker that you are a doc?

Still not sure as to what type of anureysm he had.  All I know is that it was in the occiptial region.  When he came to our aid station, he had the back of his head wrapped in ice.  Don't know who did it.

From my understanding, earlier in the year, came home from church, collapsed in the floor.  Was transported by EMS.  According to what I was told, they are not sure the problem but they felt it was due to some type of anuerysim.  

When we flew him to Darnell at Ft. Hood, they could not find anything wrong but they did agree that something was not right and he did not need to be in the military.

According to his verbalized PMH, he stated that he has been tubed three times and transported by EMS for the exact same reason we flew him out.

That's about all I know.  With what we know, it looks like OI should have been done.  Past that I was  not sure if anything else I should have done.  Just wanted to cover my bases incase we have to respond to him again, or someone in like circumstances.

I appreciate you guys taking the time to square me away.

doesn't sound like an aneurysm, FWIW. Further, that would be easy enough to ID with imaging or arteriogram. Possibility of seizures which may be due to an identifiable anomaly or not. Without seeing the patient it does not sound as if intubation is required given the history you present. Circumstances may dictate otherwise, of course.

Am an MD in family practice. Currently work urgent care walk-in. Went in the Marines as enlisted at age 17. Ooh-fucking-rah.

As the head is crowning you want to......oh, never mind!

I appreciate it, Kevin.  Sorry about the confusion on your moniker, see what happens when we A-S-S-U........well we get the picture! [;)]

Thanks also to cpermd.

Guess this pt got to bugging me and wanting to know if there is anything we could have or should have done differant.

Thanks again.  Be safe!

ARDOC -
Wrong room!  The one down the hallway and to the left with the big ugly women who wieghts 400 lbs with her legs up in the stirrups...........
That Sir, will be YOUR, patient!