An obtunded patient may not require anything at all for intubation.  All comatosed trauma patients are just intubated. Maybe a few squirts of laryngotracheal lignocaine spray.

Disoriented, unco-operative, Haemodynamically unstable patient - most trauma patients with head injury fall into this category

These patients are potential full stomach and require RSI with cricoid pressure
Intubation should be fast, smooth and safe - oral route i guess meets all these requirements

Good IV line with fluids flowing, emergency drugs and airway equipment, vasopressors diluted and ready,monitors
Pre-oxygenate - Bag mask ventilation if necessary
Induction choices - Fentanyl  2 mcg/kg + Midazolam 1 -2 mg
                           Ketamine  titrated 1- 2 mg/kg
                           Eomidate titrated

Most of these do not produce haemodynamic instability. Even if a little drop occurs can be manged with fluid boluses + vasopressors.
Remember in trauma patients ABC - airway & breathing has to be set right before circulatory hypotension is corrected

Relaxant - Low dose Suxa with RSI 0.5 mg /kg - recommended in unstable trauma patients (Ref: Miller 6th ed muscle relaxants).
Rocuronium may be an alternative


I think your worry although genuine, is not unmanageable. It is exactly the group of patients as described by you who go on ventilators. Sedation, Paralysis and IPPV is needed to salvage them as also to provide anaesthesia for trauma patients with life threatening emergencies. Loss of sympathetic tone should be anticipated and minimized and when it occurs can definitely be managed

regards

I will post the details later, but surprisingly the first gas used experimentally to produce anaesthesia was CO2 by Henry Hill Hickman
Well managed
Just goes to prove how and why ETCO2 monitoring is so important during anaesthesia
regs

Not necessary
Infact sanctity of intradermal tests to detect anaphylaxis /allergy has not been conclusively proven.
Negative test dose not imply that the patient may not develop anaphylaxis or allergy

Which scale are people following to maintain CVP
mm of Hg
or
cm of H2O

Why did i get this doubt?
In CVP guided fluid resuscitation there exists a rule
"5-2" rule if you are using CVP
or
"7 -3" rule if you are using PCWP.

Now in 2 CME's I find that authors have used different units. One has opted for mm of Hg and the other the latter

It is very important to know because a CVP of 5 cm of H2O = CVP of only 2 mm of Hg.
Using the wrong scale may definitely be misleading

The boundaries of various specialities is getting blurred with a lot of overlap. In the future we will have no options but to accept this scenario.
Imagine a non-anaesthetist Casualty or Emergency medical officer requiring to control a status epilepticus or gain urgent airway in a trauma patient who is unco-operative. He might have to use sedatives, IV anaesthetics and relaxants in this patient. There is no rule that says only anaesthetists can intubate trachea.
On the flip side we are starting to use ultrasound for nerve blocks and CVC. TEE is also an adaptation of radiological devices. Imagine the radiologists claiming, since it is their area of expertise, only they can do blocks.
The list is endless
BIS monitor encroaches on EEG technicians job
CT surgeons may claim that IABP is their prerogative
Orthopods may want to do all intra-osseous routes
Chest people will lay claims over FOB use
and finally ENT surgeons way want to intubate

So I think we must be mentally prepared to accept this change
All we need to ensure is safety of the patient.
So just being an anesthetist, need not necessarily make you a safe person. If it were so, there would be no anaesthesia related casualities...........
........inadequately educated and trained people exist in all specialities including anaes.
lets educate all of them for the safety of the patient

While performing a ET intubation for a GA as per scientific recommendation, i follow pre-oxygenation and demonstration of adequate mask fit and ventilation after inducing anaesthesia prior to administration of relaxants.
So here is an scenario that is not uncommonly encountered
50 kg, ASA 1, Modified Mallampati Score 1, No other positive predictors of difficult airway or difficult mask ventialtion, No aspiration risk, scheduled for GA / CV.
IV line, monitors
Pre-oxygenated
Fentanyl 100mcg + Glyco 0.2 mg + Xylocard 50 mg + Thiopentone 250 mg

Mask ventilation failed
Jaw thrust and 2 person mask ventilation failed
Appropriate oropharyngeal airway in place  - mask ventilation failed

Saturation are holding due to adequate pre-oxygenation
time elapsed 3 mins

What should one do next. Give suxa as planned or do a laryngoscopy and intubate minus relaxants, try ventilation with LMA

thanks for all the input
regs

MISERY ACQUAINTS A MAN WITH STRANGE BEDFELLOWS
by Malcolm Fisher (World Medicine October 1976)

Surgeons and anaesthetist have a curious sadomasochistic relationship.
Roland and Oliver, Laurel and Hardy, Tristan and Isolde, Lillee and
Thompson have been dissected, analysed and lauded. The equally
temptuous relationship between surgeon and anaesthetist is less
lauded, and sometimes less laudable.

The love-hate aspects of the relationship are governed by two
historical truths: without surgeons, anaesthetists would be unemployed
(hence the diversification into intensive care, pain clinics,
hyperalimentation, and the like), and, because all surgical progress
has been made possible by anaesthesia, without anaesthetists, most
patients would rather keep their gallbladders, prepuces, and ugly noses.

As surgery has progressed and become more horrendous the function of
the anaesthetist has changed from providing good operating conditions
for the surgeon to saving the patient from the surgeon. As one cynic
put it: "They will do brain transplant one day, just as soon as I can
work out which bit to wake up".

I got my first insight into this unique relationship when I changed
from being a surgical resident to being an anaesthetic resident. On my
first day I learned the basics from someone who, while unknown in
scientific circles, is regarded highly in the antipodes as an
anaesthetic philosopher. In my first five minutes he taught me the
three fundamentals of anaesthesia.

* "Always check the oxygen supply."
* "Always identify the patient and the operation."
* "Hate all surgeons and hate the slow bastards most."

I was a little taken aback but I soon learnt that these rules, like
many other things he told me, were essential for survival. On my
second day, he initiated me into the inner circle which knows the
Cook's three laws of surgery:

* Surgery begets surgery.
* The adjustment of an operating light is an immediate signal for
the surgeon to place his head at the focal point.
* No substance is more opaque than a surgeon's head.

After three weeks I believed I had anaesthesia mastered, much so that
I asked a surgeon what the difference was between a three week
resident anaesthetic and a twenty year consultant anaesthetic.

"Very little," he informed me brutally. "the only major difference is
that when something goes wrong and a junior is anaesthetising, I know,
and when a consultant is anaesthetising I find out in the tea room
when it is all over."

I confronted the anaesthetic philosopher with this disturbing
information and learnt the next most important lesson.

* "Never tell the surgeon anything. There is nothing he can do and
he will only get in a flap."
* There were only four things he said to tell surgeon in time of
crisis.
* "Please get the retractor off the heart."
* "Could you stop a few bleeders and give me time to catch up."
* "Could you give cardiac massage."
* "You can stop now – he's dead."

I then went on and learned the complexities of the
surgeon-anaesthetist relationship. I heard of the famous Jones
technique of anaesthesia where the anaesthetist stands at the foot of
the table and tells the surgeon how to operate while the surgeon's
assistant hold the patient on the table. I learned that fitness for
anaesthesia was a meaningless term; anyone who could lie down was fit,
but fitness for surgery was a different matter entirely.

Fitness for surgery can be decided over the telephone by asking who
the surgeon is, where the patient is going after, and what the
operation is. All the pre-operative examination tells you is how and when.

I learned to understand the prima donna complexities of the surgeon
and to recognise when the operation was not going well.

* All surgeons follow the same procedure.
* Adjust retractors
* Reposition assistants
* Make bigger hole
* Change sides
* Order multiple light adjustments
* Ask for more relaxation
* Curse scrub nurse, resident, registrar, health commission,
government, anaesthetist, and deity
* Remove alternative organ and close.

Over a few further years I learned the two other important things that
every anaesthetist must know.
Surgical textbooks always list causes of excessive bleeding during
surgery.
They include incompatible blood transfusion, massive transfusion, poor
position, halothane, ether, patient too light, patient too deep,
hypoxia, hypercarbia, straining, and so on.
They never mention scalpels, tearing vessels or swabbing away clots.

In fact when a surgeon glares " Can you do anything about the
bleeding?" the best reply is "Certainly, but who will mind the patient
while I scrub?"

There is also a list of great surgical lies which every anaesthetist
will recognise.

* "Put him to sleep, I'll be down in five minutes."
* "He is old but he is fit."
* "You will like her, she's and old dear."
* "I haven't cross matched blood, we don't need any."
* "Don't put a tube down, it's just a quick snatch."
* "I'm just going to open, have a look, and close her."
* "She will die if I do nothing."
* "I'll be finished in ten minutes."

Surgeons appreciate a reciprocal number of anaesthetics lies as they
appreciate the law that fitness for surgery is universally
proportional to time of day.

And let surgeons beware when they hear:

* "The blood pressure is 123/72."
* "The patients is maximally relaxed and won't breathe for a week
if I give any more."
* "It's not cyanosis, it's just the bloody lighting."
* "Don't go away, it will be two minute turn around."

The subliminal implication of the lies must be appreciated by both
members of the relationship if they are to function in the best
interest of the patient, and perhaps the greatest advantage of the
lengthening postgraduate courses is to give fledgling surgeons and
anaesthetists time to appreciate the idiosyncrasies of the other.

As another cynic said: " Anaesthesia is the half asleep watching the
half awake being half murdered by the half-witted."
Only the other day when my colleague in the next theatre was
complaining bitterly: "What can I do about my mother-in-law?" the
surgeon withdrew his head from the thorax and snapped: " Why not give
her one of your anaesthetics?"

Totally agreed with you frontie

There is a concept called MODIFIED RSI
if you can adequately mask ventilate
induce  give NDP relaxant like vec / atra . ventilate for 3 mins and intubate
Accepted technique provided you can ventilate and maintain cricoid pressure for 3 mins

RATIONALE
ASA guidelines for failed intubation in obstetric GA
If failed intubation, check mask ventilation. If possible then proceed to add N2O + inhalational . Continue anaes with mask ventilation and cricoid pressure and proceed with surgery
So the key is not quick intubation but airway protection and adequate ventilation

Between Atra and Vec not much difference but remember that Atra can undergo Hoffman degradation and VEc is totally hepatic dependant
Also vec has active metabolite 6 desacetyl vec with 25% activity of parent compound. Atra has no active metabolites
So why not just use the theorotically safe option

To tell you the truth at a govt hospital for renal transplant recepient I have used Pancuronium and Pentazocaine because nothing else was available. We even extubated the patient. But that does not make it the right thing to do and if you get into trouble with MLC it will be easier to defend the theorotically right drug over the wrong one

Dont be too sure
We still dont know what anaes can do
Also there is a wide inter-individual variation in response

I had a GA for uretereroscopic removal of calculus

Got a GA

premed - Alprazolam 0.5 + Ranitidine 150  PO

Pethidine 50 + glyco 0.2 Im

Fent 50 mcg + Xylo 50 mg
Thio 250 mg + Suxa 100 mg
8.5 mmCOETT
N2O +  O2+ Halothane 0.5 %
IPPV with Vecuronium 5 + 0.5
Reversal Neo 2.5 + Glyco 0.5

Uneventful peri-op period

I am not exaggerating -  I had initially diplopia for 3 days and then difficulty in focussing near small objects for 15 days.
I panicked and had an entire ophthalmic evaluation. All normal

After 15 days things became better and now all is normal

Any explanation for this bizzaire experience. Eye symptoms have been reported in international literature including ION
but nothing like this

In anaesthesia I strongly beleive there is a lot we still dont know

Anaes as a medical science is still in its infantile stage of existence

Thio is OK

No suxa  - cholinesterases are produced by liver which in this case is diseased

Non difficult airway - Atracurium or cis atra , No Vec  because it has hepatic metabolism and hence prolonged action

Difficult airway - Between Suxa with risk or Rocuronium

Narcotics - Fentanyl

Needs RSI

Watch for hypoglycaemia, Coagulopathy, Hepatorenal syndrome, Hypothermia

Mannitol 0.25 mg / kg

Post - op ventilation on standby

Epidural for post -op analgesia - guarded - coagulopathy

In response to Dr.yogens observations

Hypertension and tachycardia usually occurs soon after inflation because the acute increase in Intra-abdominal pressures produces a great increase in catecholamines thus producing these effects.  I normally dont try to treat these increases unless they really go out of hand in a patient with risk of target organ damage

Most of the time we tend to hyperventilate our patients so hypercarbia is an extremely rare occurence unless there is some other major problem. Infact we see mostly hypocarbia and normocarbia all the time.
Hypercarbia due to absorption of CO2 from peritoneal absorption is most common to occur 30 to 45 minutes post -operatively and to be honest at that point of time none of us are looking at ETCO2.

Just a case report
We tried this technique of saline infusion - gravitational flow to identify space

Once space is identified the NS infusion is removed and catheter threaded. During this time the saline flows back through the catheter and scarily could also be CSF tap due to the advancing catheter
So you need a definitve methid to tell the difference between the two

One of our resident assumed the back flow to be NS, and  as usual proceeded to dose the patient. He ended up with a total spinal with patient in cardiovascular collapse and apnoea

I fully agree with Dr. Vaz's statistics
But  LOR air syringe still survives as a technique.
Also air deposited into epidural space can form pockets around nerve roots and prevent LA from coming in contact with it thus producing patchy blocks.

I use Lor air syringe and what technique you train in and gain experience with you are comfortable performing
Hope all the youngsters switch to LOR saline

we pay so much of attention to intubation response but even extubation can produce the same response. Infact post-extubation hypertension affects almost 90% of all patients, thankfully they are self limited. But in a patient at risk to severe hypertension or arrhythmia it may be a good idea to obtund this response. Amongst the various modalities avaliable Lignocard is probabaly the one with the safest risk benefit ratio (other choices would be narcotics, deep extubation, vasodilators, beta blockers)
I fully agree that this can delay recovery and arousal but by how many minutes. Maximum between 5 to 10 minutes. I am sure we can wait for this time with the patient under our supervision. This the average time one has to wait if he does a deep plane extubation with any agent except sevoflurane.
Also xylocard decreases risk of laryngospasm and brochospasm due to stimulation under light planes
We do not use xylocard on all cases but in a patient at risk of adverse CVS or RS complications during the peri-extubation period we use it at 1 - 1.5 mg / kg. After evidence of neuromuscular recovery of diaphragm, We give xylocard before suctioning pharynx and then reverse. Roughly within 5 to 7 mins the patient is recovered enough for extubation.
Lignocard does not block the extubation response completely but helps attenuate the problems related to it
regs

A significant number of consultants  are using Dopamine infusion to maintain BP during intra-operative period under CNB including High spinals (T2-4) , Thoracic epidurals or CSE techniques
So any patient coming for an laprotomy or trauma surgery both elective and emergent get a Dopamine infusion started followed by the CNB technique of choice.
Ephedrine and fluids do not play a main role in their management protocol
They claim that all you need to do is maintain BP irrespective of the drug used
I wonder what will be the outcomes in light of the uncorrected volume status,tachycardia and other problems that inotropes produce.

IS this technique scientifically acceptable supported by evidence.
Will the outcomes be affected by this technique

Dr Yogen
I wonder why you opted for a spinal in a patient who was already under GA. What surgery can be better performed under Ga + spinal than GA alone

Purist may not approve of a spinal in the prone position. What if you have a total or high spinal needing resuscitation and intubation

On the other hand the Taylor's approach to SAB through the L5S1 space has also been defined in the prone position