# Crashing airway patient



## Rialaigh (Jan 2, 2017)

Dispatch comes out for "breathing problems". Notes state 52 year old female. Address is in a not great area of town. You have a 6 minute response time. No other notes in the CAD, you are on a double medic truck and you also have QRV back up coming to you about 1 minute behind you and fire responders as well.

Upon arrival you are in a poorly lit trailer park, patients husband is yelling from the porch. You can see from the ambulance patient is sitting on porch of trailer holding onto the rail. Initially patient appears in severe respiratory distress, husband states "she is having trouble breathing", no other information available. 

Go...


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## NomadicMedic (Jan 2, 2017)

History, All vital signs, including end tidal nasal capnography, skin, work of breathing.
Medication list from in the house. (You KNOW there is one, because ...trailer park.)

Depending on the distress, assist with a BVM, but I can't go down a treatment route til I know what the story is.


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## StCEMT (Jan 2, 2017)

Everything DE said...


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## NomadicMedic (Jan 2, 2017)

StCEMT said:


> Everything DE said...



I go on this exact call once a week. Southern Georgia = land of sketchy trailer parks.


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## StCEMT (Jan 2, 2017)

DEmedic said:


> I go on this exact call once a week. Southern Georgia = land of sketchy trailer parks.


How long did it take you to meet a Joe Dirt look alike?


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## NomadicMedic (Jan 2, 2017)

StCEMT said:


> How long did it take you to meet a Joe Dirt look alike?



First week. No joke.


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## StCEMT (Jan 2, 2017)

DEmedic said:


> First week. No joke.


That is awesome. I really hope he had a Skynryrd shirt to go with.


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## cprted (Jan 2, 2017)

DE's post + Lung sounds? Respiratory pattern? 

When did this start? Sudden onset or gradually getting worse? Any associated pain (chest or otherwise)?


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## PotatoMedic (Jan 2, 2017)

Patient on gurney and back of rig.  CPAP if able.  Lung sounds med list/med box or bag.  Sample.  IV cardiac monitor.  Meds dependent on findings.  Start doing math for RSI.


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## NomadicMedic (Jan 2, 2017)

FireWA1 said:


> Patient on gurney and back of rig.  CPAP if able.  Lung sounds med list/med box or bag.  Sample.  IV cardiac monitor.  Meds dependent on findings.  Start doing math for RSI.



You shouldn't even thing about going that far until you hear what the story is.

 Imagine this is the continuation of the scenario,  When you walk onto the porch you see that the patient is in significant distress, gasping for breath, with shallow respirations around 50 per minute. There's a strong odor of alcohol and cigarette smoke about her person. She appears to be disheveled and unkempt. The trailer is in a similar state.  The husband/boyfriend, clad only in a wife beater, boxer shorts and a smoldering Marboro red keeps screaming "she can't breathe you muthafukkas do something!"

Does she still get schlepped to the truck, CPAP and RSI math?

As your partner gets an end tidal CO2 cannula on the patient and the rest of the gear, you see sinus tachycardia at 130, SpO2 of 100% and end tidal of 19 with a flat expiratory plateau.

Still want CPAP?

As you start to work on de escalation and figuring out what the actual fck is going on, the husband shouts out, "man, her brother just got arrested for murder!"

Don't jump until you know what you're jumping into.


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## VentMonkey (Jan 2, 2017)

I realize there's no other info provided by _family/ bystanders_ on scene, but what's this patients GCS on arrival?

Will they be able to tolerate CPAP? Can they be successfully oxygenated and ventilated with less invasive measures (CPAP--->BVM) before electing to utilize RSI? 

A blood glucose and pupillary check will also be good to know before a straight away to aggressively managing their airway. 

Obviously, as others have mentioned breath sounds and RA waveform pleth SPO2 and ETCO2 monitoring are excellent supplemental diagnostic guides in this patient population.

Given you're scenario, it sounds like impending respiratory failure, but again, a bit more info with our (your) measures once we (you) arrive will tell us how aggressively we need to manage their airway. Also, the ETA to our closest ED, and do we even have the ability to perform RSI here?


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## VentMonkey (Jan 2, 2017)

DEmedic said:


> You shouldn't even thing about going that far until you hear what the story is.
> 
> Imagine this is the continuation of the scenario,  When you walk onto the porch you see that the patient is in significant distress, gasping for breath, with shallow respirations around 50 per minute. There's a strong odor of alcohol and cigarette smoke about her person. She appears to be disheveled and unkempt. The trailer is in a similar state.  The husband/boyfriend, clad only in a wife beater, boxer shorts and a smoldering Marboro red keeps screaming "she can't breathe you muthafukkas do something!"
> 
> ...


Bah! Ya' beat me to the punch...


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## NomadicMedic (Jan 2, 2017)

...Let's see what the OP has planned for this one.


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## Handsome Robb (Jan 2, 2017)

My vote is to crich. 


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## StCEMT (Jan 2, 2017)

Handsome Robb said:


> My vote is to crich.
> 
> 
> Sent from my iPhone using Tapatalk


Like this?


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## VentMonkey (Jan 2, 2017)

Handsome Robb said:


> My vote is to crich.
> 
> 
> Sent from my iPhone using Tapatalk





StCEMT said:


> Like this?


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## PotatoMedic (Jan 2, 2017)

True I went down the respiratory route feet first before getting further info.  But I do think doing drug math for an RSI when I put someone on CPAP is a good idea.  Do I expect to do it? No, but I will start developing a plan if the CPAP does not improve or stabilize the patient.


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## PotatoMedic (Jan 2, 2017)

StCEMT said:


> Like this?


Use a micro drip for peds!


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## DrParasite (Jan 2, 2017)

FireWA1 said:


> Patient on gurney and back of rig.  CPAP if able.  Lung sounds med list/med box or bag.  Sample.  IV cardiac monitor.  Meds dependent on findings.  Start doing math for RSI.


honestly,this is my line of thinking too.

you meet me outside, meaning you walked all the way to the front door, another few steps to my cot probably isn't going to kill you.  If you look sick, you might actually be sick, and even if not, odds are you going to the hospital with me, so I might as well take you into my office where I have all my equipment within arms reach.  Also gives me the ability to leave the scene quickly and have some privacy if needed.

Assess the patient and treat as indicated based on findings.  But yes, I'm getting her into the back of my truck as soon as I can, since she has met me on the porch.


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## ERDoc (Jan 3, 2017)

You guys are clearly missing a straight forward case of respiratory anthrax.

Hard to say what to do until we have a little more info.  The pt sounds sick but we need to get some more info.


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## Alan L Serve (Jan 3, 2017)

This patient is in need of homeopathy. And crystals. Lots of chinese herbal crystals. That should fix them right up.


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## Tigger (Jan 3, 2017)

I don't know what we are going to do in the ambulance, but that's where we are going. Do not like doing things on trailer park porches, just never seems to work out.


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## Carlos Danger (Jan 3, 2017)

StCEMT said:


> Like this?


Right through the posterior of the trachea.


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## StCEMT (Jan 3, 2017)

Remi said:


> Right through the posterior of the trachea.


Yea not my first choice....Or really one I want at all, but it actually is very similar to what I was taught to do these types of airways on.


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## Carlos Danger (Jan 3, 2017)

StCEMT said:


> Yea not my first choice....Or really one I want at all, but it actually is very similar to what I was taught to do these types of airways on.



Except those devices all have the sharp penetrator removed after insertion, unlike the drip chamber spike.


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## StCEMT (Jan 3, 2017)

Remi said:


> Except those devices all have the sharp penetrator removed after insertion, unlike the drip chamber spike.


Among other things. Never got to see it actually used, but I did like the gist of the design in theory.


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## Rialaigh (Jan 3, 2017)

DEmedic said:


> History, All vital signs, including end tidal nasal capnography, skin, work of breathing.
> Medication list from in the house. (You KNOW there is one, because ...trailer park.)
> 
> Depending on the distress, assist with a BVM, but I can't go down a treatment route til I know what the story is.



Heart rate palpated at wrist  between 120-140. Patient is pouring sweat. Labored shallow breathing 30-40 times a minute and regular. Pulse ox doesn't register a reading, no blood pressure obtained at this time. Husband is yelling at you to help, patient can't speak. no other information.Patient is sitting with her legs off the porch slumped over the bottom railing.



cprted said:


> DE's post + Lung sounds? Respiratory pattern?
> 
> When did this start? Sudden onset or gradually getting worse? Any associated pain (chest or otherwise)?



Patient sounds very wet from a mile away, you notice sputum coming from  patients mouth and nose. Unknown on when it started or whether it was gradual. Patient is not answering questions and husband is just saying to help repeatedly. 





Are you moving this patient, attempting any interventions in place prior to movement? next step?


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## VentMonkey (Jan 3, 2017)

Rialaigh said:


> Heart rate palpated at wrist  between 120-140. Patient is pouring sweat. Labored shallow breathing 30-40 times a minute and regular. Pulse ox doesn't register a reading, no blood pressure obtained at this time. Husband is yelling at you to help, patient can't speak. no other information.Patient is sitting with her legs off the porch slumped over the bottom railing.
> 
> 
> 
> ...


Gently remind (of have the QRV medic) remind the husband yelling gets us nowhere. Moving on. Yes, clear whatever secretions we can ASAP with portable suction, load the patient onto the gurneypreferably in a semi-sitting position. 

Dry the patient off some, try and get an accurate reading in regards to her SPO2. "Wer from a mile away" is indicative of either pneumonia, and/ or aspiration at some point, but without knowing an exact down time in the face of a frantic husband, separte them by moving to the MICU.

In the unit, continue to suction adequately watching for worsening hypoxia. I still want a BGL and pupillary check before moving onto intubation. 

I imagine the patient tolerates an NPA, how about an OPA?


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## DrParasite (Jan 3, 2017)

still moving the patient into the truck, suction as needed, CPAP if possible, but I have a hunch this patient is going to get tubed


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## VentMonkey (Jan 3, 2017)

Yes, and I can certainly understand some one wanting to be a bit more aggressive with this patient given the newly revealed airway compromise issues.

I'm just not biting yet. I think at this point good oxygenation and ventilation can suffice until I get an IV, my patients pupils thrown at me (doesn't sound narcotic-induced given the rapid shallow breathing), and a blood sugar. 

I am going out on a limb and saying any care I render will be better than the care she was found to be under, or lacking.


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## StCEMT (Jan 3, 2017)

Calm the husband, him being frantic isn't helping me get the answers I want from him. Move her to the truck. Suction as needed. Try to clean her up and get a better O2 reading, palp a quick pressure, have partner hook her up to the monitor. If she needs an NPA, that and a NRB. Get the CPAP set up. Start an IV. History from the husband, she has one...and whatever he knows about whats currently going on. Get meds and airway stuff out and within reach.


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## NomadicMedic (Jan 3, 2017)

Hahahah. Okay, now we can do the RSI math. 

I want to see actual vitals and capnography. CPAP sounds like a good place to start, but I don't know if she can support CPAP with her level of consciousness and if she's hypotensive, it's also a no go.


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## VentMonkey (Jan 3, 2017)

Yep, vittles would be great. Maybe it's my cynicism kicking in, but I'm not doing anything else until I know the OP isn't going to pull the ol' bait and switch.

In real life, it's pretty clear where I, and others stand.


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## Rialaigh (Jan 4, 2017)

Patient moved to stretcher rapidly, unable to hold any weight and has difficulty holding head up. CPAP placed on patient immediately however patient is non-compliant with CPAP and unable to tolerate. Pulse-Ox shows 30-40% with no decent waveform. 4 Lead monitor placed on patient showing sinus tach at 130-150. Blood pressure unobtainable.

Patient clearly worse off from 2 minutes ago after moving the patient


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## VentMonkey (Jan 4, 2017)

Rialaigh said:


> Patient moved to stretcher rapidly, unable to hold any weight and has difficulty holding head up. CPAP placed on patient immediately however patient is non-compliant with CPAP and unable to tolerate. Pulse-Ox shows 30-40% with no decent waveform. *4 Lead monitor placed on patient showing sinus tach at 130-150. Blood pressure unobtainable*.
> 
> Patient clearly worse off from 2 minutes ago after moving the patient


Uh, enter (or prepare to) cardiac arrest algorithm? OP, where are you going with this?

Clearly they need aggressive airway management, and most likely a whole lot more.


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## Rialaigh (Jan 4, 2017)

Patient arrested on us 1 minute into transport 8 minutes after we arrived at scene. Patient was combative immediately after placement into ambulance, we had difficulty assisting ventilations with a BVM due to combative hypoxic state. IV access was unobtainable until just after her arrest. I'm not sure we could have gotten RSI drugs up in time even if we had been able to establish an IV or IO prior to her arrest. We attempted CPAP prior to placing her in the ambulance as we were moving to stretcher and that was a massive failure. Post arrest we started CPR, placed an OPA, and continued to bag. King airway was worthless due to amount of nice pink frothy sputum coming up, and ET tube was not placed due to being 1 minute into a 4 minute transport. IO was established and Epi given (for what thats worth....). BVM with OPA and suction was pretty much useless too.


Basically trying to figure out if leaving her on the porch would have been a better initial plan as we began to try and CPAP her instead of the movement to stretcher. Event with us carrying her to stretcher she was clearly worse off after that 20 second transfer. Also trying to figure out going forward on patients that are in a peri respiratory failure or peri-arrest state should I just stay on scene until the airway is managed effectively in some form prior to transport. Once the patient got combative we "fought" with her and placed restraints over a ~3 minute period while attempting to bag her and assist ventilation which was obviously ineffective. I think the arrest was probably inevitable, however I am wondering about maximizing the chances of proper airway placement and getting her back after a very short downtime. I contemplated 5mg of versed IM while she was hypoxic and combative in the minutes before arrest (we don't carry ativan). Also kicked around the idea of 250mg of Ketamine IM.

I don't think I did anything wrong or poorly, that said, I had 4 medics on scene and other trained responders and it felt like we couldn't accomplish anything. Any insight on peri-arrest management of the combative hypoxic patient....?


My thought behind the Versed or Ketamine is if the arrest is inevitable this might make it happen a tiny bit sooner, however it might make the airway remotely manageble in the minute or two before arrest and give us a jump on airway management, it also might give us a couple more minutes prior to arrest since the patient would not be exerting all the effort to fight us. Not sure how it would affect the chances of ROSC post arrest if at all but I think it is worth consideration


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## VentMonkey (Jan 4, 2017)

Rialaigh said:


> Patient arrested on us 1 minute into transport 8 minutes after we arrived at scene. Patient was combative immediately after placement into ambulance, we had difficulty assisting ventilations with a BVM due to combative hypoxic state. IV access was unobtainable until just after her arrest. I'm not sure we could have gotten RSI drugs up in time even if we had been able to establish an IV or IO prior to her arrest. We attempted CPAP prior to placing her in the ambulance as we were moving to stretcher and that was a massive failure. Post arrest we started CPR, placed an OPA, and continued to bag. King airway was worthless due to amount of nice pink frothy sputum coming up, and ET tube was not placed due to being 1 minute into a 4 minute transport. IO was established and Epi given (for what thats worth....). BVM with OPA and suction was pretty much useless too.
> 
> 
> Basically trying to figure out if leaving her on the porch would have been a better initial plan as we began to try and CPAP her instead of the movement to stretcher. Event with us carrying her to stretcher she was clearly worse off after that 20 second transfer. Also trying to figure out going forward on patients that are in a peri respiratory failure or peri-arrest state should I just stay on scene until the airway is managed effectively in some form prior to transport. Once the patient got combative we "fought" with her and placed restraints over a ~3 minute period while attempting to bag her and assist ventilation which was obviously ineffective. I think the arrest was probably inevitable, however I am wondering about maximizing the chances of proper airway placement and getting her back after a very short downtime. I contemplated 5mg of versed IM while she was hypoxic and combative in the minutes before arrest (we don't carry ativan). Also kicked around the idea of 250mg of Ketamine IM.
> ...


Doesn't sound like you did, sometimes people just die, and we happen to be there when they do. And sometimes it isn't an uneventful death.

I had a very well like and well respected instructor once tell me, sometimes all you can you is step back and let them do what they're going to do, you can't stop it. Lay them somewhere flat and safe, do your best with what they'll allow you to, and once they're done fighting (they're dying, basically CTD) you treat them to the best of your ability.

I wouldn't have done much different than you based on your description. Perhaps and IO and tube enroute/ time permitting unless called on scene. Good luck with that spouse it sounded like, and with all jokes aside, he had he reasons and rights for being distraught.

"Impending doom" isn't just felt by the patient.


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## StCEMT (Jan 4, 2017)

Take my newbie perspective for what its worth. Based on what you gave this would probably be my plan. IV-->IO-->Ketamine-->Intubate-->Transport-->Reassess and ???

Probably would have tried the Ketamine to get some sedation to facilitate ventilations just to avoid fighting the patient, but you got a **** show thrown your way for sure. I can't really say much, I haven't seen this type of patient in 6+ months and I wasn't the one having to call the shots at the time. The only reason I say I would intubate before leaving is I don't have the experience to be comfortable doing one moving. If I think its highly likely its gonna happen on the way and I get that "oh ****" feeling when I see them, I will take the extra 90 seconds to do it from the start. That's just my $0.02 and I am by no means set in the belief that this is the one and only way.

@VentMonkey. I don't remember who here has done it, but is this patient not what yall would say is a better fit for DSI?


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## Rialaigh (Jan 4, 2017)

VentMonkey said:


> Doesn't sound like you did, sometimes people just die, and we happen to be there when they do. And sometimes it isn't an uneventful death.
> 
> I had a very well like and well respected instructor once tell me, sometimes all you can you is step back and let them do what they're going to do, you can't stop it. Lay them somewhere flat and safe, do your best with what they'll allow you to, and once they're done fighting (they're dying, basically CTD) you treat them to the best of your ability.
> 
> ...




Any thoughts on IM sedation in this patient early on when hypoxic agitation is immediately recognized?


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## VentMonkey (Jan 4, 2017)

No palpable BP, and an agitated patient (most likely from hypoxia) sounds an awful lot like a peri-arrest/ impending doom patient.

If so, there's no real logical reason to draw up any meds to treat something you can't fix, pre-death. Again, if it was me based on what the OP described, I am laying them on a flat surface somewhere and going to wait until they're treatable.

This sounds like a perfect case/ example of knowing when to do something vs. when not to. As the OP stated, the patient coded once placed in the unit. I am guessing they were already coding, and just didn't go down easily.
Not much many (I know) would for that.


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## VentMonkey (Jan 4, 2017)

Rialaigh said:


> Any thoughts on IM sedation in this patient early on when hypoxic agitation is immediately recognized?


An NRB at 15 lpm as tolerated is probably your best bet, seriously. Ref. my above post, but oftentimes even in a non-code agitated patient, placing them on an NRB at 15 lpm while drawing up your sedative is severely lacking.

This simple measure alone can do wonders to correct hypoxia, but again, I doubt in this case a sedative, or even DSI was indicated.

Anytime a patient has no palpable pulse in a setting even with all the drugs, EBM, and trends in medicine, it typically means they're dying/ dead...in my experience.


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## StCEMT (Jan 4, 2017)

I got a few steps I am curious about then, help me understand here. Get your sedative to get good preoxygenation before intubation. Palpable pulse=palpable bp, which is probably ****, so maybe a push dose pressor to bump it since hypotension+intubation=no bueno. Maybe I just don't like fighting people whether hypoxic or just an ***.


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## Handsome Robb (Jan 4, 2017)

It sounds like decompensated heart failure. 

Personally I would probably have darted her with some ketamine to gain compliance and potentially reap the benefits of the transient boost in BP to buy us some time. She needs PPV but she needs to not be hypotensive before we do PPV because the increased intrathoracic pressure has the high potential of bottoming out her venous return when she's already hemodynamically compromised. 

Ketamine, NRB as high as I can get it (our regulators will do 25lpm) then gurney, truck, IO and then possibly an epi drip with push dose epi in the interim. She needs a vasopressor but she really needs inotropic support. Once that's in place we can do PPV, probably via BVM at this point.  

I don't know any services that carry it but she's a candidate for dobutamine.

Someone asked about DSI. This is a prime patient for DSI if we can get her out of her peri-arrest state. 
Had this patient not arrested and we attempted to RSI her in her hypoxic, hypotensive state you certainly will cause a peri-intubation arrest. 


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## VentMonkey (Jan 4, 2017)

I think sometimes as newer providers we rush to try and throw the book at something without truly understanding what it is we're doing, an why.

We don't have DSI in our formulary, but even from what I know, and what's been given to us here by the OP, I personally don't think I would.

Decompensated heart failure? Perhaps, but at this point a diagnosis for me becomes irrelevant as again, they're crumping. If anything, aside from preparing for a code, all other presumable working diagnoses seem irreversible.

Being prepared to code this patient is probably what's going to make all the difference in this patients outcome. All the gimmicks and cool stuff we discuss can come later on...in the hospital.

I would caution newer providers to not over think things to point of ending up in left field when all that was needed were basic airway control techniques followed by entering an appropriate arrest sequence.

I can have a pharmacopoeia of tools, but what good is it if I am being way overzealous, and doing more harm than good?


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## NomadicMedic (Jan 4, 2017)

I have to wonder if putting this patient on CPAP, on the porch, before moving her anywhere might have bought you some time. 

And I've also done the deal where a non compliant patient is held from behind, with the CPAP mask on, working to get that seal. (It's also a little easier to bag a patient with they have a CPAP mask on.) 

At SCEMS the CPAP was in one of the backpacks, you could deploy it quickly. We don't bring CPAP to the patient here, but perhaps we should be doing that sooner than later.


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## Handsome Robb (Jan 4, 2017)

VentMonkey said:


> I think sometimes as newer providers we rush to try and throw the book at something without truly understanding what it is we're doing, an why.
> 
> We don't have DSI in our formulary, but even from what I know, and what's been given to us here by the OP, I personally don't think I would.
> 
> ...



In all reality it sounds like the OP probably just showed up a few minutes too early to this one. May sound crass but it's probably the truth. 

While I agree I also partially disagree. While the arrest of this patient is pretty much inevitable and preparing to transition into cardiac arrest management is definitely the correct path I'd argue that aggressive peri-arrest management may not prevent this arrest or may very well set you up for success during the arrest. 

Doing DSI and seeing the reasons and evidence behind it I'd argue that this patient absolutely needs to be DSI'd instead of RSI'd. The hypotensive, hypoxic patients are the ones we're killing with our RSI attempts. 

DSI is delayed sequence intubation but I'd argue it's actually DSO, delayed sequence oxygenation, with a RSI trailer. The whole goal of DSI is to optimize hemodynamics, correct hypoxia and ensure a safe residual reserve to prevent peri-intubation hypoxia. It's not all about the intubation, it's about optimizing your patient so if you choose to intubate them you can intubate them safely. 


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## VentMonkey (Jan 4, 2017)

We have CPAP in our first-in bag on the helicopter, but with that, again a "non-palpable BP", and HR ~130-150 at what point are we calling this a code? I'm guessing said patient was also beyond PAP-ing. What's say y'all?


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## Handsome Robb (Jan 4, 2017)

VentMonkey said:


> We have CPAP in our first-in bag on the helicopter, but with that, again a "non-palpable BP", and HR ~130-150 at what point are we calling this a code? I'm guessing said patient was also beyond PAP-ing. What's say y'all?



100% agree. In her current state PPV will absolutely precipitate an arrest. 

I'd be hesitant to call it a code until her carotid is absent. Her combativeness indicates she still perfusing her brain, albeit not well. 

With that said who knows, compressions may help her. This is one case where epi during the arrest may be helpful, although probably not 1mg q3. I'd probably stretch it to q5. Although I usually always do that...


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## VentMonkey (Jan 4, 2017)

Handsome Robb said:


> I'd be hesitant to call it a code until her carotid is absent. Her combativeness indicates she still perfusing her brain, albeit not well. With that said who knows, compressions may help her...


I personally, am ok ordering up even a quick cycle of CPR/ CCR. Even in the face of a weak carotid, a non-palpable BP indicates that end-organ perfusion---to include the brain, heart, and kidneys---is inadequate. The hypoxia only further serves to confirm my suspicion.

Then again, I'm not in Tejás with all the nifty new-age medicine.


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## Handsome Robb (Jan 4, 2017)

VentMonkey said:


> I personally, am ok ordering up even a quick cycle of CPR/ CCR. Even in the face of a weak carotid, a non-palpable BP indicates that end-organ perfusion---to include the brain, heart, and kidneys---is inadequate. The hypoxia only further serves to confirm my suspicion.
> 
> Then again, I'm not in Tejás with all the nifty new-age medicine.



I don't think you'd be wrong with compressions, I just think that there's less traumatic ways we can try to boost end organ perfusion. I think my biggest qualm would be the fact that she's still semi-conscious. Completely unresponsive I'd be a lot more onboard with it. 

I'd personally shy away from CCR in her just due to my suspicion that her arrest is ultimately going to be a hypoxic arrest rather than cardiac etiology. Kinda a grey area though because the cardiovascular problems are causing the respiratory problems which, in my opinion, is the cause of the arrest. 


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## VentMonkey (Jan 4, 2017)

I don't recall seeing an actual GCS posted by the OP, but IIRC, there was mention of a RR in the 40-50 range? I'm venturing to guess that's quite the unconscious hypoventilator with one foot in the grave.

You're right about the gray area, @Handsome Robb. Either way, (and some may in fact think it is crass) this sounds like a case where "the reaper" was one step ahead.


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## StCEMT (Jan 4, 2017)

I know the reasons behind what I want to do, but I also understand it may not be the most effective path. Kinda following the 6 P's of life, prior planning prevents piss poor performance. This patient already has two strikes against her for being a safe intubation. If I couldn't fix those, I would likely disregard intubation for a different option and try to improve things for the doc to do it. Not only that, if we are planning for this patient to crash and to fall into an arrest algorhythm, eventually we gotta face reversible causes of which she already has two right out of the gate. Being aggressive with her felt like a way to get ahead of the curve and even if the arrest is inevitable, at least optimizing her hemodynamically to run it.


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## VentMonkey (Jan 4, 2017)

StCEMT said:


> Being aggressive with her felt like a way to get ahead of the curve and even if the arrest is inevitable, at least optimizing her hemodynamically to run it.


I think your (our) definition of "aggressive" is circumstantial. I have had this exact patient with a few interns. Perhaps it's because our scope and practice is so limited in my state, but following the basics of preventing what I could at each step in the call, arrest was the ultimate outcome.

One did not make past the ED's work up, the others regained ROSC either prior to ED arrival, and/ once we transferred care; no clue about their long-term survival to discharge though.


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## EpiEMS (Jan 4, 2017)

With a non-palpable BP, is CPAP even really in play here? My understanding is that CPAP is contraindicated for somebody like this who is barely coherent, not maintaining a great airway, and is profoundly hypotensive.

Why aren't we jumping to BVM at this point?


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## NomadicMedic (Jan 4, 2017)

I think vent summed it up. It's really a case of arrival on scene about 2 minutes too early. Not much to do here but work the code.


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## StCEMT (Jan 4, 2017)

VentMonkey said:


> I think your (our) definition of "aggressive" is circumstantial. I have had this exact patient with a few interns. Perhaps it's because our scope and practice is so limited in my state, but following the basics of preventing what I could at each step in the call, arrest was the ultimate outcome.
> 
> One did not make past the ED's work up, the others regained ROSC either prior to ED arrival, and/ once we transferred care; no clue about their long-term survival to discharge though.


Probably is. The last deteriorating cardiogenic shock pt I had many months ago went bipap--etomidate--vl intubation --versed--hospital, so my line of thinking comes from limited experiences and more of what I have learned here combined. 

I haven't had enough of them to know the turning point of this can be reversed or they are gonna crash in minutes, but it was stressed that day that these patients I need to work with a sense of urgency and not waste time doing what I need to do. I was still early in my program and rather useless, but it was a standout call as a learning point. Definitely one I don't want to be that useless or clueless on again.


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## CANMAN (Jan 5, 2017)

Handsome Robb said:


> It sounds like decompensated heart failure.
> 
> Personally I would probably have darted her with some ketamine to gain compliance and potentially reap the benefits of the transient boost in BP to buy us some time. She needs PPV but she needs to not be hypotensive before we do PPV because the increased intrathoracic pressure has the high potential of bottoming out her venous return when she's already hemodynamically compromised.
> 
> ...



My treatment plan would likely look something like this, aside from moving to the truck being in the first 5 things I am thinking about. Agree that something like 100mcg push dose epi could be helpful here right off the bat. Call me crazy old school and disagree if you would like, but I might have even thought about dropping a nasal ETT in the position the patient was found after an attempt at pre-oxygenating. CPAP is great, and we all know it can work wonders, but this lady sounds too far trending towards arrest for me to attempt to setup, have it not be tolerated, then be in a situation to pull out intubation gear anyway after a time delay. Before the days of CPAP this is the exact patient population that when they were in that amount of failure they would suck a nasal tube down with the quickness.  

Regardless of the neighborhood I am treating right as found before moving this patient at all. I get the thought process of moving, but as you already pointed out sometimes any amount of movement will put you worse off then you were pre-move. Call for LE if you're really that worried and treat the patient. You're there to treat a respiratory patient, not a person who has just been shot up in a drug deal gone bad. Bring initial treatment to the critically ill patient, not patient to treatment in my opinion.


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## StCEMT (Jan 5, 2017)

I like the nasal intubation idea. I never seemed to completely get the hang of it, so it's one I am not as comfortable with and need to brush up on.


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## CANMAN (Jan 6, 2017)

StCEMT said:


> I like the nasal intubation idea. I never seemed to completely get the hang of it, so it's one I am not as comfortable with and need to brush up on.



With the implementation of CPAP it is quickly becoming a lost skill, and some P programs aren't even teaching it anymore sadly. My part-time FD gig is without RSI, so it's something I still keep in my toolbox. We stock trigger tubes and BAAM's so it makes for a fairly easy procedure. In the super frothy CHF patient they go down pretty easily. Biggest concern is making sure you really jam the ETT adapter in there, as once it gets lubricated and frothy it can easily become disconnected and your tube starts to disappear lol. I normally cut a section of IV tubing, use the IV tubing to make a quick and tight clove hitch around the tube/adapter section, and then secure/tie it around the patient's head. The plastic against plastic does a really great job at securing the tube in place for transport.


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## StCEMT (Jan 6, 2017)

CANMAN said:


> With the implementation of CPAP it is quickly becoming a lost skill, and some P programs aren't even teaching it anymore sadly. My part-time FD gig is without RSI, so it's something I still keep in my toolbox. We stock trigger tubes and BAAM's so it makes for a fairly easy procedure. In the super frothy CHF patient they go down pretty easily. Biggest concern is making sure you really jam the ETT adapter in there, as once it gets lubricated and frothy it can easily become disconnected and your tube starts to disappear lol. I normally cut a section of IV tubing, use the IV tubing to make a quick and tight clove hitch around the tube/adapter section, and then secure/tie it around the patient's head. The plastic against plastic does a really great job at securing the tube in place for transport.


I was taught it, but compared to other airway things it wasn't emphasized as much. Not many adjuncts had ever done it themselves, so it was kinda one of those "learn it, but you probably wont use it" things. The BAAM is another thing that would be nice that I don't have, but I could make do with other things I have. I do really like that IV tubing idea, I will have to remember that one.


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## Jon82 (Jan 7, 2017)

Quick question.  Is a QRV a quick response vehicle?  I am new to the scene, I just passed the EMT-B NREMT, and am trying to understand as much as I can.  I searched for it and all I came up with was quick response vehicle.


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## VentMonkey (Jan 7, 2017)

Jon82 said:


> Quick question.  Is a QRV a quick response vehicle?  I am new to the scene, I just passed the EMT-B NREMT, and am trying to understand as much as I can.  I searched for it and all I came up with was quick response vehicle.


Yep.


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## Jon82 (Jan 7, 2017)

Thank you.


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## NomadicMedic (Jan 7, 2017)

A QRV is a non transport truck, usually has a single paramedic on board, along with all of the ALS gear that would be on an ambulance.


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## Jon82 (Jan 7, 2017)

DEmedic said:


> A QRV is a non transport truck, usually has a single paramedic on board, along with all of the ALS gear that would be on an ambulance.



That was my next question, but I wanted to see if I could find the answer on the web without derailing the thread.  Thanks for the answer!


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## NomadicMedic (Jan 7, 2017)

Here's a couple of examples. 

They can also be SUVs, but squad body trucks are sexier. 10/10 for Johnny and Roy factor. 










Jon82 said:


> That was my next question, but I wanted to see if I could find the answer on the web without derailing the thread.  Thanks for the answer!


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## StCEMT (Jan 7, 2017)

Sounds like it'd be a pretty sweet job to do for a bit.


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## VentMonkey (Jan 7, 2017)

StCEMT said:


> Sounds like it'd be a pretty sweet job to do for a bit.


Or at the end of one's paramedic career at the right QRV service. @DEmedic that L&M intercept truck sure is purrrtty.


Jon82 said:


> I wanted to see if I could find the answer on the web without derailing the thread.


Too late, thread derailed! There's no going back!!


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## StCEMT (Jan 7, 2017)

VentMonkey said:


> Or at the end of one's paramedic career at the right QRV service. @DEmedic that L&M intercept truck sure is purrrtty.
> 
> Too late, thread derailed! There's no going back!!


I always pictured a nice career ending place being a 1 call a day base where you can cook, sleep, and get paid to be moderately retired. QRV does sound nice though.....less lifting people who consider diet and exercise double fisting McDonalds....


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## Jon82 (Jan 7, 2017)

VentMonkey said:


> Or at the end of one's paramedic career at the right QRV service. @DEmedic that L&M intercept truck sure is purrrtty.
> 
> Too late, thread derailed! There's no going back!!



Show some shiny trucks and any thread is bound to get derailed.


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## TXmed (Jan 7, 2017)

I am kinda too lazy to read ALL the comments, has someone already suggested a PE as the etiology? i think this lady wouldve arrested anyways.


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## VentMonkey (Jan 7, 2017)

TXmed said:


> I am kinda too lazy to read ALL the comments, has someone already suggested a PE as the etiology? i think this lady wouldve arrested anyways.


Lol, no.


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## TXmed (Jan 7, 2017)

oh well, if its a respiratory arrest early epi helps, if its a witnessed cardiac arrest early epi helps, if it is a PE turned arrest early epi helps. 

i am a fan of the peri-arrest/pretty sure its an arrest period just starting CPR and ACLS. although ive never done the pericardial hump.


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## VentMonkey (Jan 7, 2017)

TXmed said:


> oh well, if its a respiratory arrest early epi helps, if its a witnessed cardiac arrest early epi helps, if it is a PE turned arrest early epi helps.
> 
> i am a fan of the peri-arrest/pretty sure its an arrest period just starting CPR and ACLS. although ive never done the *pericardial hump*.


Precordial thump? If so, done a handful of times, it never worked. A good buddy of mine did and had ROSC, though I have no clue of it was actually the thump converting the VF at the right time in the arrhythmia or other measures.


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## TXmed (Jan 7, 2017)

VentMonkey said:


> Precordial thump? If so, done a handful of times, it never worked. A good buddy of mine did and had ROSC, though I have no clue of it was actually the thump converting the VF at the right time in the arrhythmia or other measures.



precordial thump ? i guess thats why that ACLS instructor looked at me weird


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## StCEMT (Jan 8, 2017)

Call it the hulk smash next time. I've never seen it done, from what I read the results are iffy. Sometimes it converts, sometimes it doesn't, sometimes it converts to a crappy thing like asystole.


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## Carlos Danger (Jan 8, 2017)

I was a handful of years into my career but somehow had never even heard of the precordial thump. We were on short final at a cardiac referral center with a sick patient and he went into VF. Before I could get the defib paddles off the monitor (yeah, we still had paddles) my partner leaned across the cabin and whacked the guy on the chest. He converted (swear to god) instantly and I think I sat there dumbfounded with my mouth hanging open until we were on the pad.


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## cprted (Jan 8, 2017)

Precordial thump is still in our guidelines based on organizational culture and anecdotes. 

I've had one or two opportunities where I could have used it, but it was never drilled into me during training so I always instinctually reach for the "Charge" button instead of popping them in the chest.


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## E tank (Jan 9, 2017)

If it's a witnessed onset of v tach or fib, an immediate thump can be pretty successful...done it twice with success both times. Both times I was the only one that saw the rhythm and everyone in the room thought I'd lost my mind. I had to dig through the monitor strips for proof I wasn't nuts.


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## EpiEMS (Jan 9, 2017)

While the precordial thump isn't super well studied, the anecdotes are compelling. Then again, the plural of anecdote is not data.

I'd love a good study if anybody can point me to one.


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## VFlutter (Jan 9, 2017)

I have seen a precordial thump work once. The theory is sound, just like commotio cordis. I also like the idea of percussion pacing from the old school anesthesia literature. When I was a floor nurse I had a patient that kept going asystole on me and every time I did a sternal rub/thump his rhythm would pick back up and he would wake up for a few seconds then slow back down. Pretty cool and worked until the crash cart got there.


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## StCEMT (Jan 10, 2017)

So when going for the thump...aim for the sternum and hit as hard as you can?


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## VentMonkey (Jan 10, 2017)

StCEMT said:


> So when going for the thump...reach for the defib pads, and forego the thump.


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## PotatoMedic (Jan 10, 2017)

StCEMT said:


> So when going for the thump...aim for the sternum and hit as hard as you can?


I bet you could even call it a "sternal rub" to make it a bls procedure.


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## StCEMT (Jan 10, 2017)

But isn't that how its done on TV? Be all dramatic, shout "DONT YOU DIE ON ME" and then hit them and they magically come back? Hollywood would never lie.


FireWA1 said:


> I bet you could even call it a "sternal rub" to make it a bls procedure.


That's a damn good rub then.


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## VentMonkey (Jan 10, 2017)

This is essentially what I was taught in school. Placing your elbow over their navel area should "in theory" generate enough force for it to be effective.

I would agree with an above post regarding its application in perhaps a commotio cordis situation what with the "R on T phenomenon", etc. 

I am willing to bet on the handful of patients it had success on, they were at that rare part in the cardiac cycle, truly divine intervention.


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## bakertaylor28 (Jan 24, 2017)

Really, the way I see this is that, on arrival our major issue is respiratory. In my book, this is one of those situations where methodical comprehensive assessment takes the back seat for the moment and you treat symptomatically to get it on ice to try to avoid the code or at least delay it long enough to come up with a plan. Bottom line, off the top, you pretty well know this situation is probably going down hill, so RSI (perhaps with a king)  is your best strategy off the top. We don't really have the time to sit around considering CPAP as an option, and frankly we don't want to be jacking with a BVM either at this point. Bottom line the way I see this is stabilize an airway quickly as possible or deal with the impending code. (would rather avoid dealing with the straight out code). After having secured the airway, I would then be in favor of looking to the more standard assessments and figuring out potential causes.


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## Tigger (Jan 24, 2017)

bakertaylor28 said:


> Really, the way I see this is that, on arrival our major issue is respiratory. In my book, this is one of those situations where methodical comprehensive assessment takes the back seat for the moment and you treat symptomatically to get it on ice to try to avoid the code or at least delay it long enough to come up with a plan. Bottom line, off the top, you pretty well know this situation is probably going down hill, so RSI (perhaps with a king)  is your best strategy off the top. We don't really have the time to sit around considering CPAP as an option, and frankly we don't want to be jacking with a BVM either at this point. Bottom line the way I see this is stabilize an airway quickly as possible or deal with the impending code. (would rather avoid dealing with the straight out code). After having secured the airway, I would then be in favor of looking to the more standard assessments and figuring out potential causes.


This patient needs to be ventilated pretty much immediately. A BVM is going to be needed. And I am not sure I would RSI someone only to place a King tube. This patient needs positive pressure and while a King can do that, there are better options.


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## Handsome Robb (Jan 24, 2017)

bakertaylor28 said:


> Really, the way I see this is that, on arrival our major issue is respiratory. In my book, this is one of those situations where methodical comprehensive assessment takes the back seat for the moment and you treat symptomatically to get it on ice to try to avoid the code or at least delay it long enough to come up with a plan. Bottom line, off the top, you pretty well know this situation is probably going down hill, so RSI (perhaps with a king)  is your best strategy off the top. We don't really have the time to sit around considering CPAP as an option, and frankly we don't want to be jacking with a BVM either at this point. Bottom line the way I see this is stabilize an airway quickly as possible or deal with the impending code. (would rather avoid dealing with the straight out code). After having secured the airway, I would then be in favor of looking to the more standard assessments and figuring out potential causes.



You're going to precipitate an arrest in this patient by sedating and paralyzingly a profoundly hypoxic and hypotensive patient...


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## StCEMT (Jan 24, 2017)

If we were in a rush, my partner and I could have someone on CPAP in a matter seconds, our CPAP set up is pretty easy get ready. Compared to the alternative, I will spare a little time to oxygenate them and try to get their pressure up before intubating.


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## Tigger (Jan 24, 2017)

Handsome Robb said:


> You're going to precipitate an arrest in this patient by sedating and paralyzingly a profoundly hypoxic and hypotensive patient...
> 
> 
> Sent from my iPhone using Tapatalk


This is a good patient for push dose epi, but I don't think that's something most people are cognizant of.


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## bakertaylor28 (Jan 28, 2017)

Tigger said:


> This patient needs to be ventilated pretty much immediately. A BVM is going to be needed. And I am not sure I would RSI someone only to place a King tube. This patient needs positive pressure and while a King can do that, there are better options.



My reasoning behind not opting for the BVM is because I would expect to encounter significant resistance with a BVM with this type of situation, especially since we're probably going to assume that the most common underlying pathology is most likely going to involve significant edema, etc. in the upper airways essentially. Hence, causing me to immediately consider the ET / King / Combi. (where the king is probably going to be your fastest bet.) And I agree with the notion of the Epi.


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## VentMonkey (Jan 28, 2017)

bakertaylor28 said:


> My reasoning behind not opting for the BVM is because I would expect to encounter significant resistance with a BVM with this type of situation, especially since we're probably going to assume that the most common underlying pathology is most likely going to involve significant edema, etc. in the upper airways essentially. Hence, causing me to immediately consider the ET / King / Combi. (where the king is probably going to be your fastest bet.) And I agree with the notion of the Epi.


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## VFlutter (Jan 28, 2017)

This is why peri-intubation arrests are so common....  

Insert "This is why we can't have nice things!" Meme


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## Carlos Danger (Jan 29, 2017)

Handsome Robb said:


> You're going to precipitate an arrest in this patient by sedating and paralyzingly a profoundly hypoxic and hypotensive patient..



Sux --> tube --> apologize later.


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## Handsome Robb (Jan 29, 2017)

Remi said:


> Sux --> tube --> apologize later.



With an experienced competent clinician doing the airway absolutely. 


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## TransportJockey (Jan 29, 2017)

Handsome Robb said:


> With an experienced competent clinician doing the airway absolutely.
> 
> 
> Sent from my iPhone using Tapatalk


Not a fly by night technician?

Sent from my SM-N920P using Tapatalk


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## Tigger (Jan 29, 2017)

Remi said:


> Sux --> tube --> apologize later.


Incidentally our medical director now wants us to handle these sorts of "crash" airway patients with a slug of Ketamine (2mg/kg IV), tube, and then handle the rest.


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## bakertaylor28 (Jan 30, 2017)

Tigger said:


> Incidentally our medical director now wants us to handle these sorts of "crash" airway patients with a slug of Ketamine (2mg/kg IV), tube, and then handle the rest.



Assuming of course Ketamine isn't otherwise contraindicated is the real kicker. I could see Ketamine as an alternative to more orthodox RSI (and perhaps make things a bit smoother in some ways if your particularly adept with dropping an ET or a King) On the other hand, if your case involves the presence of barbs, major tranqs, benzos, alocohol, etc. The ketamine is probably going to end up potentiating CNS depressant effects which probably isn't the best situation in the world, but never the less probably the most manageable solution in the long haul.
This whole thing almost sounds like one of those mega-code scenarios where things are going to turn into a quite nasty situation regardless of how you really handle it - the question is really more of exactly how long its going to take for the crap to splatter off the fan blades.


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## Tigger (Jan 30, 2017)

bakertaylor28 said:


> Assuming of course Ketamine isn't otherwise contraindicated is the real kicker. I could see Ketamine as an alternative to more orthodox RSI (and perhaps make things a bit smoother in some ways if your particularly adept with dropping an ET or a King) On the other hand, if your case involves the presence of barbs, major tranqs, benzos, alocohol, etc. The ketamine is probably going to end up potentiating CNS depressant effects which probably isn't the best situation in the world, but never the less probably the most manageable solution in the long haul.
> This whole thing almost sounds like one of those mega-code scenarios where things are going to turn into a quite nasty situation regardless of how you really handle it - the question is really more of exactly how long its going to take for the crap to splatter off the fan blades.



I am not sure that Ketamine potentiates CNS depression.


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## TransportJockey (Jan 30, 2017)

It generally doesn't unless the patient has essentially run out of sympathetic compensation 

Sent from my SM-N920P using Tapatalk


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## StCEMT (Jan 30, 2017)

Tigger said:


> I am not sure that Ketamine potentiates CNS depression.


Not that I am aware of.

@Remi enlighten us please.


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## Handsome Robb (Jan 30, 2017)

bakertaylor28 said:


> Assuming of course Ketamine isn't otherwise contraindicated is the real kicker. I could see Ketamine as an alternative to more orthodox RSI (and perhaps make things a bit smoother in some ways if your particularly adept with dropping an ET or a King) On the other hand, if your case involves the presence of barbs, major tranqs, benzos, alocohol, etc. The ketamine is probably going to end up potentiating CNS depressant effects which probably isn't the best situation in the world, but never the less probably the most manageable solution in the long haul.
> This whole thing almost sounds like one of those mega-code scenarios where things are going to turn into a quite nasty situation regardless of how you really handle it - the question is really more of exactly how long its going to take for the crap to splatter off the fan blades.



Ketamine is probably one of the safer agents in those scenarios you described...


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## VentMonkey (Jan 30, 2017)

I vote we call a spade a spade, and quit feeding into this guy's whacky notions.


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## bakertaylor28 (Jan 31, 2017)

It is a well known side effect of Ketamine that it will potentiate the effects of alcohol, barbs, Opiates, anticholinergics, Quinazolinones, and Phenothiazines. See the following links, among other research on the topic:
http://www.dovepress.com/to-use-or-...llicit-ketamine-use-peer-reviewed-article-SAR
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2148758
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1852477
http://www.palliativecareguidelines.scot.nhs.uk/documents/Ketaminefinal.pdf


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## VFlutter (Jan 31, 2017)

bakertaylor28 said:


> It is a well known side effect of Ketamine that it will potentiate the effects of alcohol, barbs, Opiates, anticholinergics, Quinazolinones, and Phenothiazines. See the following links, among other research on the topic:
> http://www.dovepress.com/to-use-or-...llicit-ketamine-use-peer-reviewed-article-SAR
> https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2148758
> https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1852477
> http://www.palliativecareguidelines.scot.nhs.uk/documents/Ketaminefinal.pdf



The first article talks about Ketamine's use and side effects, the second article actually supports concurrent use with benzos to reduce issues with emergence, the third article just talks about how young adults are abusing ketamine, and the other link doesn't work. None of the articles talk about pharmacodynamics or Ketamine potentiating anything. Not sure what any of those were meant to prove?  And I am not sure how "well known" it is since many of the practitioners here have never heard it.


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## bakertaylor28 (Jan 31, 2017)

Chase said:


> The first article talks about Ketamine's use and side effects, the second article actually supports concurrent use with benzos to reduce issues with emergence, the third article just talks about how young adults are abusing ketamine, and the other link doesn't work. None of the articles talk about pharmacodynamics or Ketamine potentiating anything. Not sure what any of those were meant to prove?  And I am not sure how "well known" it is since many of the practitioners here have never heard it.



I must have grabbed the wrong links. I'm going to double check the source, I'm working on it.


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## bakertaylor28 (Jan 31, 2017)

This link however, is more on topic in the meantime, until I can re-locate correct references.

http://ketamine.com/ketamine-facts/the-dangerous-interaction-of-ketamine-and-alcohol/


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## Carlos Danger (Jan 31, 2017)

bakertaylor28 said:


> It is a well known side effect of Ketamine that it will potentiate the effects of alcohol, barbs, Opiates, anticholinergics, Quinazolinones, and Phenothiazines.



You'll find the same warnings about giving opioids concomitantly with those drugs as well. Not really sure what point you are trying to make.

FWIW, ketamine isn't a CNS depressant. It increases CNS activity.


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## VentMonkey (Jan 31, 2017)

VentMonkey said:


> *I vote we call a spade a spade, and quit feeding into this guy's whacky notions.*


quoted for re-emphasis.


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## bakertaylor28 (Jan 31, 2017)

Remi said:


> You'll find the same warnings about giving opioids concomitantly with those drugs as well. Not really sure what point you are trying to make.
> 
> FWIW, ketamine isn't a CNS depressant. It increases CNS activity.



The point I'm making is that there's a reason they saw fit to put the warnings there. Hence, something to be OTL for as a distinct possibility. NOT saying Its something I wouldn't do - because like I said, its the path to least resistance. Especially for those of us who hate having to deal with standard RSI in general and would rather avoid that approach to things. ( Considering the fact that most of us are not particularly adept with an ET and find ourselves using the King with these sorts of things.)


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## Carlos Danger (Jan 31, 2017)

bakertaylor28 said:


> The point I'm making is that there's a reason they saw fit to put the warnings there. Hence, something to be OTL for as a distinct possibility. NOT saying Its something I wouldn't do - because like I said, its the path to least resistance. Especially for those of us who hate having to deal with standard RSI in general and would rather avoid that approach to things. ( Considering the fact that most of us are not particularly adept with an ET and find ourselves using the King with these sorts of things.)


When you gain both a better understanding of pharmacology and more practical experience with airway management, then we can have this talk.


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## ERDoc (Jan 31, 2017)

Every medication has several hundred warnings.  With ketamine, when someone is having an emergence reaction, we use benzos.


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## VentMonkey (Jan 31, 2017)

ERDoc said:


> Every medication has several hundred warnings.  With ketamine, when someone is having an emergence reaction, we use benzos.


Doc, how common are these emergence phenomena with Ketamine in your experience, and how big of an issue that needs to be addressed is it typically?


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## ERDoc (Jan 31, 2017)

VentMonkey said:


> Doc, how common are these emergence phenomena with Ketamine in your experience, and how big of an issue that needs to be addressed is it typically?



In 14 years, I've seen it twice.  As for how big of an issue it is, it depends on how bad it is.  If it is just a little agitation and restlessness, turning down the lights and minimizing stimuli usually works.  The worst I've seen is someone screaming and thrashing.  This is usually for procedural sedations.  When you use it to intubate it's not a problem because they are going to be further medicated.


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## bakertaylor28 (Jan 31, 2017)

Remi said:


> When you gain both a better understanding of pharmacology and more practical experience with airway management, then we can have this talk.



And exactly how many of us have ET Intubation down as a precise skill? Not like we're doing it every day. (at least MOST of us anyways- you might be the exception.) Think about it- Otherwise we would have absolutely zero need for a King in the first place-- EVER. And the last time I checked the first rule of pharmacology is take heed to the known warnings.


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## bakertaylor28 (Jan 31, 2017)

Of course, then again, I'm not so sure I'm exactly comfortable neither with the sheer idea of giving a drug designed to tranq large cats to a human. It just doesn't sound like a good idea. (Sarcasm intended). :-D


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## LaAranda (Feb 8, 2017)

Chase said:


> I have seen a precordial thump work once. The theory is sound, just like commotio cordis. I also like the idea of percussion pacing from the old school anesthesia literature. When I was a floor nurse I had a patient that kept going asystole on me and every time I did a sternal rub/thump his rhythm would pick back up and he would wake up for a few seconds then slow back down. Pretty cool and worked until the crash cart got there.



Somehow I was picturing you rounding on the pt every 2 hours and finding him asystolic every time. Sternal rub, ask how his pain is, move on.


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