Podcast Episode 33: TIVA: Another Look at Pre-Hospital Analgesia and Sedation

Rick Hines has spent the last 20+ years in service to his country much of it deployed to combat zones and other unstable, austere environments and is dedicated to improving SOF Medicine.  He made it a point to spend a fair amount of time with surgical teams when possible and has gained quite a bit of real world knowledge that we hope to pass on to a wider audience here. Continue reading “Podcast Episode 33: TIVA: Another Look at Pre-Hospital Analgesia and Sedation”

Podcast Episode 20: TBI Round Table and Case Discussion

This podcast is a follow up from our last post on managing traumatic brain injuries in austere environments.  We included a scenario discussion with David, Jamie, Daryl, Jay, Doug and I with much needed answers to some frequently asked questions. Continue reading “Podcast Episode 20: TBI Round Table and Case Discussion”

Podcast Episode 16: Sedation

Being able to calm and sedate patient in operational or prolonged field care situations may be a valuable skill.  Here are our thoughts on sedating your patients when patient comfort and safety are an issue?

Glasgow Comma Scale

Get your GCS before sedating you patient so that you can track trends later during your sedation wake-ups/holidays.


GCS Cheat sheet


If you are doing sedation it is highly recommended that you prepare by going through the MSMAID acronym detailed in a previous post and podcast.  This will ensure you have the minimum equipment, drugs and personnel required for the job.

MSMAID Post and Podcast

MSMAID Handout

Circle of Awareness

This is the same circle of awareness from last episode.  Once you have your MSMAID plan for anesthesia you should monitor your patient and level of sedation using the circle of awareness ever 5 minutes until they have been off of anesthetic agents for an hour.  Anytime you are giving drugs that can alter the patient’s respiration rate or hemodynamics you should have someone at the head of the patient monitoring the components of the circle of awareness.  If you are using a push dose or bolus you should know how long the onset for the drug is and check the circle accordingly.  It will keep you out of trouble.

  • Sedation level (RASS)
  • Airway Patency (Including ventilator if being used)
  • Breathing Rate
  • Circulation Rate
  • Report Patient Status to the Surgical Team
  • Record on Anesthesia Form 517
  • Tasks

Richmond Agitation and Sedation Scale(RASS)

The Richmond Agitation and Sedation Scale is a standard scale used to quantify a patient’s level of consciousness.  Tracking a RASS is another way to trend a patients condition while sedated.  Hang this, along with the GCS card, next to your patient bed in your aid station for easy reference.




Doug’s Basic ICU Neuro Exam for a lightly sedated and Intubated or Criced patient:

Check Motor Cortex: Can the patient wiggle all toes and fingers or give the thumbs up

Check Frontal , Temporal and Occipital Lobes: check that both pupils are equal, reactive and accommodating with a pen light

Check Deep Brain Reflexes: Illicit a cough by suctioning the airway down to the carina with a sterile suction catheter like the Ballard inline suction

Check Brain Stem: Is the patient breathing spontaneously?  If ventilated are they breathing more than the set rate.

Along with a GCS score, this exam will tell you in simple terms if the geographic areas of the brain are intact.  It’s extra information in the case that you call

Take our sedation quiz and see if you are prepared to sedate your patient…

Further Reading

A protocol of no sedation for critically ill patients receiving mechanical ventilation

SLEAP paper


Case Discussion #1: GSW w/TQ

Indiginous force

Just as a rehearsal of a tactical operation will prepare the operator to better deal with contingencies, discussing and talking through realistic, hypothetical, medical scenarios will give the medic a good idea to how he might respond should a similar situation arise in real life. We encourage participation in the discussion by all levels of medic, nurse and provider. Constructively thinking through worst-case illness and injuries, through multiple perspectives, will open the eyes of those on the other side of the wire, no matter which side that may be. If you Continue reading “Case Discussion #1: GSW w/TQ”