5cc Anesthesia in a Stick - PowerPoint Presentation

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5cc Anesthesia in a Stick

Vecuronium 10mg/ml (1ml) IV

Paralytic (to complete RSI)

Rapid Sequence Intubation—6 Steps

Golden Hour TIVA Maintenance drip

50 cc Bag of 0.9% NS and + 60 gtt setMix in- 5cc Anesthesia in a Stick-Ketamine 50mg/ml (3ml or 150mg)Midazolam 5mg/ml (1ml or 5mg)Fentanyl 50mcg/ml (1ml or 50mcg)Infuse at 0.1 to 0.5ml/kg/h

5 Hour TIVA Maintenance Drip

Lido 1% 10mg/ml, Max-300mg(30ml), Lido 2% 20mg/ml, Max-300mg(30ml),Marcaine 0.25% Max-150mg (60ml), Kenalog 40mg/m (duration of action 2-3 weeks)Joint injections- Lido+Marcaine+Kenalog40mg/ml- amount is joint dependentRegional- Superficial cervical plexus block/ Axillary brachial plexus block/ Intravenous RA / Wrist block/ Digital nerve block/ Intercostal nerve block/ Saphenous nerve block/ Ankle block/ Femoral nerve block *Consult Ortho Surgeon before use

5ML Syringe

, 20gu 1.5” needle, Atomizer

Mix- Ketamine 50mg/ml (3ml or 150mg)Midazolam 5mg/ml (1ml or 5mg)Fentanyl 50mcg/ml (1ml or 50mcg)Each ml provides- Ketamine 30mg, Midazolam 1mg, Fentanyl 10mcgSedation- IM/IV/IN-2ml initial, titrate to nystagmus then 1ml PRN(Consider doubling dose for IM route)Induction for RSI- 5ml syringe then add Paralytic

250 cc Bag

of 0.9% NS + 60 gtt Mix in- Ketamine 50mg/ml (15ml or 750mg)Midazolam 5mg/ml (5ml or 25mg)Fentanyl 50mcg/ml (5ml or 250mcg)Infuse at 0.1 to 0.5ml/kg/h(if Vecuronium is added to maintenance bag, STOP 15min prior to end of surgery)

Local/ Regional Anesthesia

Mix-

TXA

(1gm) in

100cc NS

or LR-Give ASAP: <3hrs post injury if significant blood loss anticipated. Give 1stgm over 10min-Begin 2nd infusion of TXA infused over 8 hrs after Hextend or other fluid treatment

Tranexamic Acid (TXA)

If in hemorrhagic shock--Most to least preferred- Whole blood, plasma/RBCs/platelets 1:1:1, plasma/RBCs 1:1, reconstituted dried plasma or liquid plasma or thawed plasma or RBCs alone-Using the ABC score, if massive transfusion indicated, initiate FDP while drawing FWB.-If blood products are not available:-Hextend: 100 - 250ml boluses IV, NMT 1LLR/Plasma-Lyte: 250 - 500ml boluses IV, NMT 2L-Re-assess VS q 3 to 5 minUncontrolled Hemorrhage:Resusc. until: MAP ~65 (palpable radial pulses with good perfusion [warm hands, feet, CR < 2sec, UOP > 0.5cc/kg/hr, increased mental status] Controlled Hemorrhage:-Resusc. to normal physiologyTeleconsult ASAP-For CHI, keep SBP >=90mmHg) - Re-assess frequently to check for re-occurrence of shock. If shock recurs, repeat the fluid resuscitation as outlined above.

Fluid Resuscitation

Analgesia on the Battlefield

Mild to Moderate Pain-Casualty is still able to fight- TCCC Combat pill pack- Tylenol 650mg bilayer, 2 PO q 8 hrs- Meloxicam 15mg PO q.d.Moderate to Severe Pain- w/o hemorrhagic shock or resp. distress-Oral transmucosal Fentanyl citrate (OTFC) 800mcg,or IV Morphine 5mg IV/IO Moderate to Severe Pain- Unstable-- Ketamine 50mg IM/IN, or- Ketamine 20mg slow IV/IORepeat q. 20-30 minCheck AVPU and monitor ABC’sEnd Point is control of pain or development of nystagmus.

Naloxone 0.4mg IM/IN/IV for Opioids

Opioid Reversal Agent

Antibiotics

Recommended for all combat wounds--Moxifloxacin 400mg PO q.d.If unable to take PO-Ertapenem 1g IV/IM q.d.

Anti-emetic

Ondansetron 4mg ODT/IV/IO/IM q. 8 hrs PRN for NV- each 8-hr dose can be repeated in 15 min if nausea not improved. - DO NOT give >8mg q. 8 hr

Benzodiazepine/ Anxiolytic

Diazepam 10mg/2mlDose 2-20 mg IM/IVModerate Anxiety-2-5mg IV/IM, 2-4 times dailySevere Anxiety/ Muscle Spasm/ Seizures-5-10 mg IM/IVRepeat in 3-4 hrs PRNMidazolam 5mg/mlSeizures lasting > 5-10 min-5-10 mg initially IV>IMrepeated q. 10-15 min PRN to Max of 30mg

Head Injury

GCS, V/S, CN, periph nerve exam, MACESupplemental O2- SpO2>90%3% Hypertonic Saline250ml over 10 min then 50ml/hrElevate the casualties head 30 degreesHypervent 1 breath q. 3 sec during HTS adminMannitol- if hypertonic not available or used 0.25-1g/kg over<20 min then, 0.25g/kg q. 6 hrs

Dry sterile dressing, consider Hypothermia Prevention KitRule of Tens- 10ml/hr x TBSA for 40-80 kg pt for >15% TBSA, add,100ml/hr for each 10 kg > 80 kg to UOP 30-50ml/hr

Burns

Flumazenil

0.5mg/5ml

0.2 mg over 15-30 sec then q. 1 min up to 1mg maxConsider BVM assisted respirations for Midazolam OD; wears off in ~ <30 min

Benzo Reversal Agent

Penetrating

Eye Injury

Rapid visual acuityFox/ rigid eye shieldMoxifloxacin 400mg PO or Alt

1

.

Pre-oxygenate

with 100%

O

xygen

by mask.

2

.

Induction

agent: 5cc Syringe with

Ketamine

50mg/ml (3ml or 150mg)

Midazolam

5mg/ml (1ml or 5mg)

Fentanyl

50mcg/ml (1ml or 50mcg)

3. Muscle relaxant:

Entire Vial-

Vecuronium

10mg/ml IV

0.1mg/kg

, with an onset of 2-3

min

and duration of 30-40

min

4.

Cricoid pressure (maintain until ETT placement is confirmed).

5

. Laryngoscopy and

orotracheal

intubation (after

2 min).

6. Verify tube placement.

Consider nasogastric or

orogastric

tube placement after securing airway.