Prehospital and Retrieval Medicine – THE PHARM dedicated to the memory of Dr John Hinds

Inspiring discussion on Twitter (Minh Le Cong@rfdsdoc, Karim Brohi @karimbrohi and Peter Sherren@PBSherren)

The topic:

Your hypotensive blunt/penetrating trauma patient with associated severe TBI needs a vent. How do you set it and how you achive your physiological goals?

Is it possible to mantain eucapnia, avoiding hypercapnic insult to the brain, using low minute ventilation strategy and not depressing stroke volume with high intrathoracic pressure?

“Permissive hypoventilation” in a swine model of hemorrhagic shock.

Conclusions: Although permissive hypoventilation leads to respiratory acidosis, it results in less hemodynamic suppression and better perfusion of vital organs. In severely injured penetrating trauma patients, consideration should be given to immediate transportation without PPV.

But what if we have concomitant severe TBI? How can we avoid respiratory acidosis and hypercapnia (due to hypoventilation) and conseguent insult to the brain?

Is PEEP…

Following some discussion on who owns the airway (see the comments at the post Paralytic is the answer on EMPills Blog)

Have to admit: I’m an occasional intubator.

I manage something like 10 airways per month, all of them are “non conventional”, (no operating room, no chance to wake the patient, no chance to call an expert), and usually I have no time to evalute any of common indicators to predict difficult airway (time is often a rare issue in ground or air prehospital scenarios).

Half of the airway I manage are CRASH, half needs an RSI, so, shame on me, I’m also an occasional “paralytic agents user”.

So I desperatley need a plan

But lissen, I got one!

Dear collegue, wathever intubator you are, occasional or regular,  feel free to submit any comment on the plan and also fell free, if you think it’s useful, to use and…