13. Anatomy Review
Vertebral body
•posterior portion forms part of
vertebral foramen
•increases in size from cervical to
sacral
•spinous process
•transverse process
Vertebral foramen
•opening for spinal cord
Intervertebral disk
•shock absorber (fibrocartilage)
31. Evidence to the Contrary
3 Pressure of about 355 mmmmHHgg wwiillll ssiiggnniiffiiccaannttllyy rreedduuccee
bblloooodd ffllooww tthhrroouugghh tthhee ccaappiillllaarryy bbeedd.. PPrreessssuurree
mmaappppiinngg sseennssoorrss rreevveeaalleedd tthhee hhiigghheesstt ttiissssuuee iinntteerrffaaccee
pprreessssuurreess aatt tthhee ssccaappuullaaee,, ssaaccrruumm,, aanndd hheeeellss..**
Pressure produced:
SSppiinnee bbooaarrdd == 114477 mmmmHHgg ((uunnppaaddddeedd)),, oorr 111155 ((ppaaddddeedd))
VVaaccuuuumm MMaattttrreessss == 3377 mmmmHHgg
*Cordell, Hollingsworth, Olinger, Stroman, Nelson. Pain and tissue-interface
pressures during spine-board immobilization. Ann Emerg Med, 1995.
32. Evidence to the Contrary
Time: The average rigid spine board time in a Level I
TTrraauummaa CCeenntteerr wwaass ddeetteerrmmiinneedd ttoo bbee 112200 mmiinnuutteess..11
Another study found an average of 64 minutes
((wwiitthhoouutt iimmaaggiinngg)),, oorr eexxcceeeeddiinngg 118800 mmiinnuutteess ((wwiitthh
iimmaaggiinngg))..
Time on a spine board exceeded 7 hours when
ttrraannssffeerr ttoo aa LLeevveell II TTrraauummaa CCeenntteerr ooccccuurrrreedd22
11BBaarrnneeyy,, CCoorrddeellll,, aanndd MMiilllleerr,, AAnnnn EEmmeerrgg MMeedd,, 11998899..
22CCoooonneeyy,, eett..aall..,, IInntt JJ EEmmeerrgg MMeeddiicciinnee,, 22001133,,
33. Evidence to the Contrary
One study of spinal cord iinnjjuurryy ffoouunndd tthhaatt aallll ppaattiieennttss
wwhhoo ddeevveellooppeedd uullcceerraattiioonnss rreeccaalllleedd nnoo aatttteemmppttss ttoo rroollll
tthheemm oorr rreemmoovvee tthhee bbooaarrdd iinn tthhee ffiirrsstt ttwwoo hhoouurrss aaffeerr
tthhee iinnjjuurryy..
By contrast, all patients who did not develop
uullcceerraattiioonnss hhaadd tthhee pprreessssuurree rreelliieevveedd wwiitthhiinn tthhee ffiirrsstt
ttwwoo hhoouurrss bbyy rreemmoovvaall ooff tthhee ssppiinnee bbooaarrdd..
34. Evidence to the Contrary
There has been ddeemmoonnssttrraatteedd aa ddiirreecctt rreellaattiioonnsshhiipp
bbeettwweeeenn ttiimmee dduurraattiioonn oonn tthhee ssppiinnee bbooaarrdd aanndd
ddeevveellooppmmeenntt ooff pprreessssuurree uullcceerrss wwiitthhiinn tthhee ffiirrsstt eeiigghhtt
ddaayyss ooff hhoossppiittaalliizzaattiioonn.. UUpp ttoo 3311%% ooff ttrraauummaa ppaattiieennttss
wwiillll ddeevveelloopp pprreessssuurree uullcceerrss aass tthhee rreessuulltt ooff
iimmmmoobbiilliizzaattiioonn oonn aa bbaacckkbbooaarrdd..
35. *Berg, et.al., Prehospital Emergency Care, 2010.
ssiiggnniiffiiccaanntt rreedduuccttiioonnss iinn llooccaalliizzeedd ttiissssuuee ooxxyyggeennaattiioonn
iinn hheeaalltthhyy ppaattiieennttss..
a A period as short ass 3300 mmiinnuutteess ccaann pprroodduuccee
Evidence to the Contrary
36. Device Attempts to Correct
Ehob Waffle Mattress Expansion
Control Overlay With Pump is ideal
for:- Pressure ulcer prevention-
Treatment through stage IV - Pain
management.
The Back Raft is a low-cost, inflatable
air mattress and spinal stabilization
device that improves patient comfort
and virtually eliminates the risk of
pressure sores and other secondary
injury during transport.
37. Evidence to the Contrary
b Restriction to movement byy LLSSSS aanndd ssttrraappss rreessuullttss iinn::
rreedduucceedd FFoorrcceedd VViittaall CCaappaacciittyy ((FFVVCC)),, tthhee mmaaxxiimmuumm
vvoolluummee eexxhhaalleedd aafftteerr ddeeeeppeesstt iinnssppiirraattiioonn,,
RReedduucceedd FFoorrcceedd EExxppiirraattoorryy VVoolluummee ((FFEEVV11))
RReedduucceedd FFoorrcceedd EExxppiirraattoorryy FFllooww ((FFEEFF))11
((OOvveerraallll rreedduuccttiioonnss ooff 1155--2200%%))
15. The results were replicated in children, ages 6-15.22
11BBaauueerr KKoowwaallsskkii,, AAnnnnaallss ooff EEmmeerrggeennccyy MMeeddiicciinnee,, 11998888..
22SScchhaaffeerrmmeeyyeerr,, eett..aall,, AAnnnnaallss ooff EEmmeerrggeennccyy MMeeddiicciinnee,, 11999911..
38. Result in the inability for adequate self ventilation…
rreessppiirraattoorryy ppaatthhoollooggyy
Additional reductions, based on patient’s underlying
tthhoorraacciicc iinnjjuurriieess
Reductions are accentuated iinn tthhee ffaaccee ooff aaiirrwwaayy oorr
Evidence to the Contrary
39. Cochrane Review of Immobilization
2009: UUnncceerrttaaiinn EEffffeeccttiivveenneessss
REVIEWER'S CONCLUSIONS:
We did not find any randomised controlled trials that met the inclusion
criteria.
The effect of spinal immobilisation on mortality, neurological injury,
spinal stability and adverse effects in trauma patients remains
uncertain.
Low prevalence-Immobilization of 50-100 people for every patient at
risk of SCI
40. Malaysia Military Study vs. EMS
vs 120 without immobilization vs.. 333344 @@ UUnniivv.. ooff NNeeww
MMeexxiiccoo ddiidd..
OOuuttccoommee:: LLiittttllee oorr nnoo eeffffeecctt oonn oouuttccoommee ooff bblluunntt ssppiinnaall
iinnjjuurryy
Hauswald, et. al. Out-of-hospital spinal immobilization: its effect on
neurologic injury. Acad Emerg Med. 1998 Mar;5(3):214-9.
41. Difficulties in ED exam (due to board)
Increased risk of soft tissue injury
Increases safety risk to providers (Work Comp)
AAddddiittiioonnaall TThhoouugghhttss::
Evidence to the Contrary
43. iinnvvoollvviinngg tthhee hheeaadd,, ssppiinnee oorr ttrruunnkk
other high impact, high force or high velocity conditions
confounding factors such as osteoporosis, extreme age
sports injury (with force or velocity)
• ****ssttaabbbbiinngg
• ****gguunn sshhoott
violent situations occurring near the spine
patient fall greater than 3 times the patient’’s height
high speed motor vehicle collision
PPoossiittiivvee MMOOII Þ SShhoouulldd RReeqquuiirree SSppiinnaall MMaannaaggeemmeenntt
Consider Mechanism ooff IInnjjuurryy KKiinneemmaattiiccss
SCI General Assessment
44. SCI General Assessment
Consider Mechanism ooff IInnjjuurryy KKiinneemmaattiiccss
NNeeggaattiivvee MMOOII Þ DDoo NNoott RReeqquuiirree SSppiinnee bbooaarrdd
force or impact does not suggest a potential spinal injury
• ddrrooppppeedd aa rroocckk oonn ffoooott
• ttwwiisstteedd aannkkllee wwhhiillee rruunnnniinngg
• iissoollaatteedd mmuussccuulloosskkeelleettaall iinnjjuurryy
• ssiimmppllee ffaallll ffrroomm ssttaannddiinngg ppoossiittiioonn
• llooww ssppeeeedd mmoottoorr vveehhiiccllee ccoolllliissiioonn
46. No difficulty in communication
No Distracting injuries
Understands Recalls events surrounding injury
No impairment (drugs, alcohol)
Cooperative
Brain injury also?
LLeevveell ooff CCoonnsscciioouussnneessss
Neurologic Status:
SCI General Assessment
47. PPrriiaappiissmm
pain (pinprick), sharp vs dull, symmetry
weakness, numbness, paresthesia
SSeennssaattiioonn ((PPoossiittiioonn aanndd PPaaiinn))
Foot plantar flexors (gas pedal) {S1,2}
““Hitchhike Hitchhike”” {T1}
Spread fingers of both hands and keep apart with force
Shrug shoulders
PPaallppaattee oovveerr eeaacchh ssppiinnoouuss pprroocceessss
MMoottoorr ffuunnccttiioonn
Assess FFuunnccttiioonn SSeennssaattiioonn
SCI General Assessment
48. Spinal Cord Injuries
PPrriimmaarryy IInnjjuurryy
ooccccuurrss aatt tthhee ttiimmee ooff iinnjjuurryy
mmaayy rreessuulltt iinn
cord compression
direct cord injury
interruption in cord
bblloooodd ssuuppppllyy
SSeeccoonnddaarryy IInnjjuurryy
ooccccuurrss aafftteerr iinniittiiaall iinnjjuurryy
mmaayy rreessuulltt ffrroomm
swelling/inflammation
ischemia
movement of body
ffrraaggmmeennttss
50. 50
Force Applied by EMS: 10 Newtons
Force Required for SCI: 6000 Newtons
Did EMS “Cause” the SCI?
51. Immobilization vs Motion Restriction
Rule: All or None? (collar, board, CID, tape, straps…)
CCaauuttiioonn wwiitthh ““ppaarrttiiaall”” ssppiinnee sspplliinnttiinngg??
Secure joint above and below?
TTrreeaatt tthhee ssppiinnee aass aa lloonngg bboonnee??
Traditional Treatment:
Stabilization of the spine begins in the initial assessment
PPrreevveenntt sseeccoonnddaarryy iinnjjuurryy
Primary Goal
Management of SCI
54. Tape along (even duct tape) is not enough
pillows, blankets, towels
curvature of the lower back is normal - fill it
ffiillll aallll tthhee vvooiiddss
especially during transport on board or in vehicle
MMaaiinnttaaiinnss aannaattoommiiccaall ppoossiittiioonn
LLiimmiittss mmoovveemmeenntt oonn bbooaarrdd
Don Don’t ’t forget the Padding
Management of SCI
55. Management of SCI
Securing to the Board (Historical)
SSttrraappss,, TTaappee,, CCrraavvaattss,, wwhhaatteevveerr
TToorrssoo ffiirrsstt
then legs and feet and head
EEvveenn ppaattiieennttss eexxttrriiccaatteedd wwiitthh aa KKEEDD aarree sseeccuurreedd ttoo
tthhee bbooaarrdd
60. CC--ccoollllaarr oorr hheeaadd iimmmmoobbiilliizzaattiioonn ddeevviiccee
C-spine hyperextension due to improperly applied
aapppplliieedd hheeaadd iimmmmoobbiilliizzaattiioonn ddeevviiccee
C-spine movement by inadequate or improperly
sshhiimm tthhee bbooddyy
Movement possible due to little or no padding to
Inadequate strapping allows excessive movement
oonn bbaacckkbbooaarrdd
Spine not supported due to improper positioning
IImmpprrooppeerrllyy ssiizzeedd CC--CCoollllaarr
Common Treatment Mistakes
(Spine board and collar)
61. • hhoorrssee ccoollllaarr
• bbllaannkkeett oorr ttoowweell rroollllss
Improvise with
Difficult to find a correctly sized rigid collar
Lots of voids to fill
Vacuum mattress
Short board underneath
Pad underneath
Elevate the entire torso if large occiput
PPeeddiiaattrriicc PPaattiieenntt CCoonnssiiddeerraattiioonnss
Management of SCI
62. no cardiac arrest
no interference in airway assessment or management
can perform spinal motion restriction with helmet on
no impending airway or breathing problems
good fit with little or no head movement within
Leave in place if:
ttoo aaiirrwwaayy aanndd vveennttiillaattiioonn
Removal should be limited to emergent need for access
Management of SCI
HHeellmmeetteedd PPaattiieennttss
63. aanndd ffoorr rreemmoovvaall
Various helmets create different problems for patient
bicycle) Recreational (motorcycle, bicycle)--prefer removal
Racing (motorcycle, car racer)- prefer removal
• SShhoouullddeerr ppaaddss aanndd hheellmmeett ggoo ttooggeetthheerr
Sports (football, hockey)
Types of Helmets
HHeellmmeetteedd PPaattiieennttss
Management of SCI
64. aanndd ffoorr rreemmoovvaall
Various helmets create different problems for patient
bicycle) Recreational (motorcycle, bicycle)--prefer removal
Racing (motorcycle, car racer)- prefer removal
• SShhoouullddeerr ppaaddss aanndd hheellmmeett ggoo ttooggeetthheerr
Sports (football, hockey)
Types of Helmets
HHeellmmeetteedd PPaattiieennttss
Management of SCI
65.
66.
67. “Clearing” Protocols
SSppiinnaall CClleeaarraannccee
CCuurrrreenntt PPrraaccttiiccee
FFiirrsstt iinniittiiaatteedd iinn MMaaiinnee
wwiitthh aa ssttaattee--wwiiddee pprroottooccooll
NNooww mmuucchh mmoorree ccoommmmoonn
iinn UUSS
AAsssseessss sscceennee aanndd MMOOII
AAsssseessss nneeuurroo ssttaattuuss
IImmmmoobbiilliizzee
Most MOIs
Prevent further injury
CYA
No 100% method to
rruullee oouutt iinn tthhee ffiieelldd
fear of litigation
devastating
ccoonnsseeqquueenncceess ppoossssiibbllee
68. Treat with Spinal Protection
Difficult to determine
Injury may or may not be possible
3. Uncertain Mechanism (Most Common)
No reasonable probability of spinal injury
2. Negative or Obviously Minimal Mechanism
High likelihood of spinal injury
Violent impact
1. Positive or Obvious Severe Mechanism
One ooff tthhrreeee ppaatthhss iiss cchhoosseenn::
When should the screening tool be used?
69. “Clearing” Protocols
o No significant MOI orr eevviiddeennccee ooff ssppiinnee iinnjjuurryy
NNoo nneecckk oorr bbaacckk ppaaiinn ((PPaallppaattee aallll))
NNoorrmmaall NNeeuurroo EExxaamm ((nnoo mmoottoorr//sseennssoorryy lloosssseess))
NNoorrmmaall LLeevveell ooff CCoonnsscciioouussnneessss
Adult Adult, , Reliable Patient w/o anxiety reaction or
““nnoorrmmaallllyy”” aabbnnoorrmmaall mmeennttaall ssttaattuuss
No ETOH or drugs
No language barriers
NNoo ddiissttrraaccttiinngg iinnjjuurriieess oorr ppeenneettrraattiinngg iinnjj nneeaarr ssppiinnee
73. Immobilization with a Backboard
SHOULD NOT be performed:
PENETRATING TRAUMA of the:
HHeeaadd
NNeecckk
TToorrssoo
AANNDD
No evidence of spinal injury
75. Position Statement:
EMS Spinal Precautions and the Use
of the Long Backboard
National Association ooff EEMMSS PPhhyyssiicciiaannss
AAmmeerriiccaann CCoolllleeggee ooff SSuurrggeeoonnss CCoommmmiitttteeee oonn
TTrraauummaa
22001133
78. Once We Decide to
Immobilize/Protect: HOW?
RRiiggiidd CCeerrvviiccaall CCoollllaarr
SSeeccuurreedd ffiirrmmllyy ttoo EEMMSS SSttrreettcchheerr
BBeesstt UUssee FFoorr::
Ambulatory patients at scene
Prolonged use, interfacility transfer
No other backboard indication
79. Stratify the Patients for Protection:
1. Uninjured: Ambulatory, no pain or complaint
ssttaatteedd,, oorr oonn eexxaamm
TTrreeaattmmeenntt:: NNoonnee rreeqquuiirreedd
2. MOI/Complaint
TTrreeaattmmeenntt:: CC CCoollllaarr,, ccoott ssttrraappss,, mmiinniimmaall mmoovvtt..
3. Severe MOI/LOC/Deficits
TTrreeaattmmeenntt:: CC CCoollllaarr//VVaaccuuuumm//……LLSSSS?? MMiinniimmaall mmoovvtt..
81. SPINAL PROTECTION
CARE
EMT AND PARAMEDIC
PROTOCOL DRAFT
Patients with blunt traumatic injuries with mechanism
concerning for spinal injury should be assessed for spinal
injury.
82. Have no midline back or neck pain or tenderness upon palpation.
injuries or severe pain)
No evidence of a distracting injury (fractures, major burns, crush
(numbness/weakness in an extremity)
No history of new/temporary neurological deficit
No evidence of intoxication (alcohol/drug) or altered mental status
Conscious, cooperative and able to communicate effectively
age 5 , 65
following conditions apply:
Patients may have all spinal immobilization omitted if ALL of the
NO spinal protection necessary
PROTOCOL DRAFT
SPINAL PROTECTION CARE
83. neck 45 degrees to either side of midline and if still no pain,
NO immobilization is indicated.
If ALL of the above criteria are met, have patient move their
There is no major mechanism for severe injury
NO spinal protection necessary
PROTOCOL DRAFT
SPINAL PROTECTION CARE
84. SPINAL PROTECTION CARE
PROTOCOL DRAFT
Spinal Protection measures indicated
If, after assessment, spinal protection is indicated: Spinal
protection consists of keeping the head, neck and spine
midline. The neck can be stabilized with a well-fitted cervical
collar, head blocks, blanket rolls or other immobilization
techniques. Patients who are already walking or standing
should be laid directly on the ambulance stretcher and secured
to the stretcher with seatbelts. Backboards and scoops are
designed and should only be used to extricate and move
patients.
85. SPINAL PROTECTION CARE
PROTOCOL DRAFT
Spinal Protection measures indicated
Once extricated and moved, patients should be taken off the
backboard or scoop stretcher if possible, and be placed directly
on the ambulance stretcher. It is acceptable to leave a patient on
a backboard for transport, but every effort should be made to
secure the patient to the stretcher and not the backboard.
Decisional patients have the right to refuse aspects of treatment
including spinal immobilization. If a patient refuses
immobilization after being informed of possible permanent
paralysis, do not immobilize them and document the patient’s
refusal in your medical record.
86. SPINAL PROTECTION CARE
PROTOCOL DRAFT
Patients with Penetrating Trauma
(Gunshot or stab to head, chest, or abdomen)
Patients with penetrating traumatic injuries should only be
immobilized if a focal neurological deficit is noted on physical
exam (although there is little evidence of benefit even in these
cases)
87. Trainers (Technical Colleges, Hospitals)
NNeeuurroossuurrggeeoonn))
Customers (ED Doctors, Trauma Surgeon,
CCoouunncciillss))
Industry Colleagues (Agency, Medical Directors,
Within (Individual Champion, Crew, Organization)
Stakeholder Discussions
Implementation of Change
88. Oversight and QA
Run Documentation (movement, neuro exam, etc)
In-Service for ED Nurses (Managers)
FFaacciilliittiieess,, TTrraauummaa CCoooorrddiinnaattoorrss ((DDaattaabbaassee))
Notification of Customers (EDs, Trauma Care
Training of Personnel (internal)
Protocol Development / Approval
Roll Out
Implementation of Change
90. WILL VIDEO KILL DIRECT
LARYNGOSCOPY?
CASE:
35 yo MCA victim, arrives combative (with/without spineboard), injury
to head (unhelmeted), along with multiple extremity fractures, and a firm
abdomen.
91. Salvage (NVA, Device change, Provider change, Bougee, surgical)
Preferred technique (VL, DL)
What is in your decision tree?
Do you use the DL or VL? (or NVA)
A decision is made to RSI/RSA the patient.
LARYNGOSCOPY?
WILL VIDEO KILL DIRECT
92. *Walls,et. al, National Emergency Airway Registry, 2011
RSI used in 2/3 of cases
87% of intubations are performed by ED Physicians*
Some quick facts:
LARYNGOSCOPY?
WILL VIDEO KILL DIRECT
93. *Yeatts, Dutton, Hu, et. al, J Trauma Acute Care Surg. 2013;75:212-9.
desaturation, first pass success
Secondary: Subgroup survival, duration of attempt,
Outcome: Mortality
VL (GlideScope) vs. DL
Trauma Patients at Baltimore Shock Trauma
survival; a randomized controlled trial.”
“Effects of video laryngoscopy on trauma patient
LARYNGOSCOPY?
WILL VIDEO KILL DIRECT
94. *Yeatts, Dutton, Hu, et. al, J Trauma Acute Care Surg. 2013;75:212-9.
randomized to VL group
A possible increased mortality for most severe CHI,
VL and DL had similar mortality
Conclusions:
LARYNGOSCOPY?
WILL VIDEO KILL DIRECT
95. *Baldino, Walsh, Peek, Clayton, Morristown Medical Center, NJ.
Overall Intubation Success (97-85%)
First Attempt Success (80 vs 79%) (Glidescope)
with Video-Assisted Laryngoscopy
Changes in Intubation Success Over the First Year
NAEMSP Poster Presentations:
LARYNGOSCOPY?
WILL VIDEO KILL DIRECT
96. *DiCroce, Lubin, Penn State Hershey Medical Center, Hershey, PA
Overall Intubation Success (96.6%). (VL=100%, DL=93.3%)
First Attempt Success (74.1%) n=56 (VL) and 60 (DL)
Study Period 2 years (C-Mac)
Rates During Critical Care Transport
The Impact of Video Laryngoscopy on Intubation Success
NAEMSP Poster Presentations:
LARYNGOSCOPY?
WILL VIDEO KILL DIRECT
97. *DiCroce, Lubin, Penn State Hershey Medical Center, Hershey, PA
Better view with VL.
No significant difference in number of attempts.
Success Rates During Critical Care Transport
The Impact of Video Laryngoscopy on Intubation
Conclusions
LARYNGOSCOPY?
WILL VIDEO KILL DIRECT
98. *Escott, et. al, Baylor College of Medicine/EMS Collaborative Research Group.
Concluded as least as safe and effective as DL in pre-hospital use
First Pass Rate 71% (VL) vs 65% (DL) (King Vision)
227 intubations by 153 paramedics. Mean DL experience = 9 years.
Four Month Run-in Period by Paramedics
Video vs. Direct Laryngoscopy: Multi-site Review of the
NAEMSP Poster Presentations
LARYNGOSCOPY?
WILL VIDEO KILL DIRECT
99. First Pass Success in both groups was 80%
Desaturation 80% was greater in VL group (50 vs 40 sec)
VL had increased time for placement (56 sec vs 40 sec)
Mortality in VL and DL groups was similar
Take Home Points for Consideration:
LARYNGOSCOPY?
WILL VIDEO KILL DIRECT
102. Out of hospital SFI rates from 25-87%
In an ED setting , first pass RSI 91%, SFI 84%.
If apparent relaxation occurs, proceed with intubation
ppaarraallyyttiicc
Sedative (midazolam, etomidate, ketamine), without a
SFI:
Sedation Facilitated Intubation(SFI)
103. ppaarraallyyttiicc)),, ffaaiilliinngg ttoo ooppttiimmiizzee llaarryynnggoossccooppyy
Sedative alone will not overcome muscle tone (like a
aabbiilliittyy ttoo pprrootteecctt aaiirrwwaayy
Critically ill or injured may become apneic, without
Variable effects of dosing in healthy vs ill patient
Problematic
Sedation Facilitated Intubation(SFI)
105. ssiittuuaattiioonn ttoo aa tteeaamm lleessss aabbllee ttoo ssuucccceeeedd??
Why do we legislate a potentially more dangerous
ooppttiioonn
Single advanced provider limited to SFI as an
ppaarraammeeddiiccss pprreesseenntt ffoorr uussee..
f Requirement foorr RRSSII / RRSSAA ttoo hhaavvee ttwwoo
Implications for Wisconsin EMS?
106. Wide safety margin (EMS dream)
Reduction in chronic pain? Fibromyalgia?
Suicide reduction? Anticonvulsant? Neuroprotective?
Administer IV, IM, and yes, IN…
Sedation, induction, asthma, pain
Incredibly versatile!
Some Passing Thoughts on Ketamine
107. Tachycardia and hypertension (transient)
Emergence and vomiting
Adverse Events: Rare and easily treatable
ssuurrrroouunnddiinnggss oorr ooff ppaaiinnffuull ssttiimmuullii
Develops trance-like state, patient in not aware of
NMDA antagonist in brain
Some Passing Thoughts on Ketamine
108. Some Passing Thoughts on Ketamine
Cautions: Tachycardic aanndd HHyyppeerrtteennssiivvee ppaattiieennttss
Layed to Rest:
NNOOTT CCOONNTTRRAAIINNDDIICCAATTEEDD IINN HHEEAADD IINNJJUURRYY
KKeettaammiinnee ddooeess NNOOTT iinnccrreeaassee IICCPP