Neurogenic pulmonary edema

[Gurby]

Thanks so much for sharing your experience, Nova - I didn't realize how dire of a mistake CPAP would be for this patient. I've often thought of decreased level of consciousness as sort of a relative contraindication (are they protecting their airway?), but that's usually in the context of a slam-dunk CHF/COPD patient who is still somewhat responsive just exhausted. Given that this patient had rapid onset of symptoms without obvious acute cardiac changes, no history of CHF, no peripheral edema, satting 99% on a NRB.... I suppose alarm bells should be ringing that something else is up here.

I'm going to be a lot more suspicious of CVA in the future, and a lot more cautious about CPAP in altered patients.

 

[Nova1300]

I meant sedation for the purpose of getting muscle relaxation and ease down the heavy work of breathing, while taking over ventilations. But I guess that would be tricky under these circumstances.

You could and should do all of those things. But you should do them once the airway is secured with a tube. Your logic is sound. The order is off.

 

[medicaltransient]

Good scenario, thanks for the education. I think I would have chased the AMS a little more. Hypoxia is east to fix with a BVM and a good seal. I would definitely look for a reason not to give Lasix and I don't think it would have been hard to find. I would want to get a last known well and a CO2 value. I have seen AMS caused by increased CO2. RSI would be a good idea if it was in favor physically and geographically. Good case.

 

[Carlos Danger]

I think it's important to address this. Remi is correct- mechanically these patients are usually just obstructing. Especially as our population get fat. So in theory, a little positive pressure is all they would need.

BUT... these brain injured patients like to vomit. There is something very emetogenic about free blood in the brain parenchyma or subarachnoid space. They vomit, without warning, and it tends to be copious and I'm actually gagging a little thinking about it so I'm going to stop.

But, that is why I would never use non-invasive ventilation in this group. They need an endotrachral tube, a well-inflated cuff, and an OG on suction.

You are correct. Any way you cut it, a GCS 3 with pulmonary edema is a perfect storm of indications for RSI. I was responding more to the specific comment that I quoted than to the original scenario. Even if emesis weren't a concern, it's not really practical to track-breathe in a moving ambulance.

Personally, while I am not 100% against prehospital RSI, I have a very conservative view of it because I think in many cases it introduces as much risk as it mitigates, and that any time a patient is breathing adequately, good positioning and close monitoring may be a better choice. So my comments on these scenarios come from that perspective.

 

[harold1981]

But is this patient really breathing adequately? He is not hypoxic now, but taken the work that he has to do for it, how long is it going to last? I would say that despite the sats this is an unstable patient with inadequate breathing, who is compensating, but will soon face exhaustion.

 

[Nova1300]

But is this patient really breathing adequately? He is not hypoxic now, but taken the work that he has to do for it, how long is it going to last? I would say that despite the sats this is an unstable patient with inadequate breathing, who is compensating, but will soon face exhaustion.

Don't get me wrong, I would intubate this patient as soon as possible. But, if you don't have the equipment to do it safely in the field, I would do my best to maintain until I got to an ER. There may come a point where you need to ventilate this patient, though usually a gentle jaw thrust and a non-rebreather will do. If you truly have to ventilate to save the patient's life, all bets are off. They have likely already aspirated and you need to do what is necessary to maintain oxygenation. I would just do my best to not apply any positive pressure to this patient's ventilations unless absolutely necessary. At least half of that air will end up in the gut and you will only be blowing more secretions into the lung.

 

[Carlos Danger]

But is this patient really breathing adequately? He is not hypoxic now, but taken the work that he has to do for it, how long is it going to last? I would say that despite the sats this is an unstable patient with inadequate breathing, who is compensating, but will soon face exhaustion.

Again, I was talking in more general terms, not necessarily about this specific scenario.

 

[NYBLS]

RSI has been mentioned quite a bit but this patient MAY be able to be intubated without it. Keep suction close, set up for first pass success and have the post intubation sedation of your choice ready to go.

 

[TXmed]

Post Intubation sedation might not be necessary with a GCS of 3, just because you Intubate them doesn't mean you need to take away there breathing. Over sedation amd long acting paralytics contribute to longer Intubation times and pneumonia. I just keep them sedated enough just to be comfortable

 

[Carlos Danger]

Post Intubation sedation might not be necessary with a GCS of 3, just because you Intubate them doesn't mean you need to take away there breathing. Over sedation amd long acting paralytics contribute to longer Intubation times and pneumonia. I just keep them sedated enough just to be comfortable

To my knowledge, there is no evidence that use of NMB in the prehospital phase has any detrimental impact on outcomes. I think there is some old stuff out there about large prehospital doses of midazolam affecting outcomes, but it's really tough to draw a causal link between some paralytic or versed use in the ambulance and poor outcomes days or weeks later.

 

[chaz90]

I get very nervous about intubating live patients who I'm "pretty sure" don't have a gag reflex without sedatives or paralytics.

Honestly, most of the time, if I'm intubating a patient with a pulse and respiratory effort, I'm going to go all the way and maximize my intubating conditions with drugs. I have no desire to end up deep in an airway with a suddenly vomiting and critically ill patient that still needs airway control.

In for a penny, in for a pound right?