82 y/o female respiratory distress

[mycrofft]

You are dispatched for the above call, when you arrive at the house you find the fire department is arriving the same time as you. Upon entering the house and making patient contact you find the patient sitting up in the bed in severe respiratory distress. You quickly place the patient on 15L NRB and assess lung sounds. Diffuse coarse crackles are noted, no pedal edema, really no stethoscope is needed to hear these crackles. pt aaox3, gcs 15, difficulty speaking due to the distress.

PmHx: HTN
Medications: Metoprolol

After further questioning this is an acute onset of breathing difficulty with no previous lung or heart problems. No recent n/v/d, skin p/w/clammy. Vitals are obtained.

BP: 103/90
HR: 133 (wide complex) no pacemaker
SP02: 92% on 15L NRB

Pt is loaded on a stair chair for extrication and re-vitalized

BP: 80/40 (still has good mentation)
HR: 140
SP02: 93% on 15L NRB

You have a 2 mile ride to the hospital, as you wonder what is going on with this patient.

What is going on and how would you proceed?

1. Dying
2. With a quickness.

OP, where are you?

 

[alabamatriathlete]

lmfao to above

 

[mycrofft]

I like your ideas of fentanyl and ketamine. I would probably use roc instead of sux so long as there's no predictors of a difficult airway. When given at the higher end of the dose range (1.2 mg/kg) it tends to have an onset similar to sux, but doesn't come with the risk of hyperkalemia.

If this patient gets RSI'd then likely we would need a pressor to support her BP.

You are 11,000 feet from the hospital.

 

[Handsome Robb]

You are 11,000 feet from the hospital.

I added the RSI question just to spark discussion. With that said even distance to the hospital isn't a good argument if the patient needs an airway right now. I'm a firm believer of providing care necessary to situate the patient for a successful transport in place. If that means spending a couple extra minutes establishing a patent airway and optimizing ventilation and oxygenation I don't see a problem with it but that's just me. More of the bring the ER to the patient rather than scoop 'em and run. Now if you're in the park across the street I might agree just to take them across the street.

Also, we're only 10, 560 ft from the hospital

 

[Handsome Robb]

I like your ideas of fentanyl and ketamine. I would probably use roc instead of sux so long as there's no predictors of a difficult airway. When given at the higher end of the dose range (1.2 mg/kg) it tends to have an onset similar to sux, but doesn't come with the risk of hyperkalemia.

If this patient gets RSI'd then likely we would need a pressor to support her BP.

I agree with that. I think it's going to come down to protocol and paralytic of choice at this point. I don't see any contraindications to any paralytics thus far, only reason I said succs was rapid onset in an emergent situation but this is also borderline elective since she is maintaining her own airway at this point.

 

[NightShiftMedic]

I agree with that. I think it's going to come down to protocol and paralytic of choice at this point. I don't see any contraindications to any paralytics thus far, only reason I said succs was rapid onset in an emergent situation but this is also borderline elective since she is maintaining her own airway at this point.

That makes sense. I think you could make good arguments either way.

 

[mycrofft]

I added the RSI question just to spark discussion. With that said even distance to the hospital isn't a good argument if the patient needs an airway right now. I'm a firm believer of providing care necessary to situate the patient for a successful transport in place. If that means spending a couple extra minutes establishing a patent airway and optimizing ventilation and oxygenation I don't see a problem with it but that's just me. More of the bring the ER to the patient rather than scoop 'em and run. Now if you're in the park across the street I might agree just to take them across the street.

Also, we're only 10, 560 ft from the hospital

I'm a pessimist. And if they're nautical miles, its 12,000 ft. :wacko:

Oxygenation is good, but delay due to placement of difficult case's airways (or unexperienced practitioners) isn't. I repeatedly wish that more can be done "on the move" (in the vehicle and enroute).

Isn't this a ripe scenario for the "I can do anything for you that an ER can" crowd?

 

[Handsome Robb]

I'm a pessimist. And if they're nautical miles, its 12,000 ft. :wacko:

Oxygenation is good, but delay due to placement of difficult case's airways (or unexperienced practitioners) isn't. I repeatedly wish that more can be done "on the move" (in the vehicle and enroute).

Isn't this a ripe scenario for the "I can do anything for you that an ER can" crowd?

It'd be cool if we could do these things safely and effectively on the move but we can't. I'm not sticking a laryngoscope blade in someone's mouth going code or non code down the street, that's just asking for trouble. If she's going to arrest before we get to the ER and I can correct the airway and breathing problem that's leading towards the arrest and support their circulation rather than end up doing CPR on them why wouldn't I?

The snatch and grab culture is really frustrating to me

 

[FLdoc2011]

I think it's a judgement call. Obviously in an respiratory arrest/code situation where getting an airway is crucial then yea, secure it and do whatever you need to there.

In something like this where ultimately they're probably going to end up intubated for impending respiratory failure but currently able to oxygenate then honestly they are probably better served intubated in a more controlled hospital/ER setting with more support and experience.

The peri-intubation period is an extremely dangerous time for the patient with a LOT that can go wrong and a lot of potential for decompensation immediately after intubation.

So if they can be supported for a short trip to a hospital I think that serves the patient better.

 

[Handsome Robb]

I think it's a judgement call. Obviously in an respiratory arrest/code situation where getting an airway is crucial then yea, secure it and do whatever you need to there.

In something like this where ultimately they're probably going to end up intubated for impending respiratory failure but currently able to oxygenate then honestly they are probably better served intubated in a more controlled hospital/ER setting with more support and experience.

The peri-intubation period is an extremely dangerous time for the patient with a LOT that can go wrong and a lot of potential for decompensation immediately after intubation.

So if they can be supported for a short trip to a hospital I think that serves the patient better.

I agree. But like you said there are situations where we need to 'stay and play.' This particular patient I do agree that she'd be better served by a quick trip rather than mucking around on scene. Just asked the RSI question to spark some more discussion.

 

[Carlos Danger]

I like your ideas of fentanyl and ketamine. I would probably use roc instead of sux so long as there's no predictors of a difficult airway. When given at the higher end of the dose range (1.2 mg/kg) it tends to have an onset similar to sux, but doesn't come with the risk of hyperkalemia.

If this patient gets RSI'd then likely we would need a pressor to support her BP.

Why fentanyl and ketamine? Why roc instead of sux? How likely is sux-induced hyperkalemia in this patient, given what was presented by the OP? What do predictors of a difficult airway have to do with anything? Which pressor would you use and how would you use it?

What do you need to be concerned about with using ketamine in a patient like this? What else could you use and what would your considerations be with those meds?

I think it's a judgement call. Obviously in an respiratory arrest/code situation where getting an airway is crucial then yea, secure it and do whatever you need to there.

In something like this where ultimately they're probably going to end up intubated for impending respiratory failure but currently able to oxygenate then honestly they are probably better served intubated in a more controlled hospital/ER setting with more support and experience.

The peri-intubation period is an extremely dangerous time for the patient with a LOT that can go wrong and a lot of potential for decompensation immediately after intubation.

So if they can be supported for a short trip to a hospital I think that serves the patient better.

This.

 

[mycrofft]

"Snatch and run culture" versus "stay and pay" culture.

Yes, I understand some stuff just isn't safely done on the roll and there are case where "stay and play" pays off in a stabilized pt. But it is frustrating when a case is a tossup as to whether running for definitive care or digging in and struggling to initiate stabilization will yield the better outcome.

We read about case after case where patients tossed into cop cars and raced to ER's survive and their peers expire at the scene in a pile of bloody 4X4's and discarded tubes and sharps. Sometimes it really is a coin toss. (And I know there are cop car expedites who arrive dead too, for sure).

I don't believe in these as "cultures" (no more than I believe in "hip-hop culture….urp), just two approaches which any practitioner needs to know how to weigh. When we don't either love or hate approaches, we greatly broaden our armamentarium.

 

[rhan101277]

I need to follow up on this patient but when we arrived she was placed on BiPAP and immediately began improving. Our protocols state that cpap is contraindicated due to increased intrathoracic pressure for bp's below 90. I did learn from this call though. I did not perform a 12 lead because I thought that time would be better used trying to get an IV in. If it was a STEMI there would be nothing I could do BUT it would be good to inform the hospital and it saves time. This patient was critical and I wanted to go. It was wide complex which made me pause, but p waves were present so I figure it was a block. Next time im going to do the 12 lead, I always do but with this call I didn't and opted just to get to the hospital faster.

 

[Handsome Robb]

What kind of settings did you use for the BiPAP if you don't mind me asking?

Always learn something every day. I had 12-leads on patients like this drilled into my head, I'd bet it was ugly.

 

[rhan101277]

What kind of settings did you use for the BiPAP if you don't mind me asking?

Always learn something every day. I had 12-leads on patients like this drilled into my head, I'd bet it was ugly.

Don't know about the BiPAP settings this was done at the ER. We only have CPAP, we need to get BiPAP prehospital though.

 

[mycrofft]

I need to follow up on this patient but when we arrived she was placed on BiPAP and immediately began improving. Our protocols state that cpap is contraindicated due to increased intrathoracic pressure for bp's below 90. I did learn from this call though. I did not perform a 12 lead because I thought that time would be better used trying to get an IV in. If it was a STEMI there would be nothing I could do BUT it would be good to inform the hospital and it saves time. This patient was critical and I wanted to go. It was wide complex which made me pause, but p waves were present so I figure it was a block. Next time im going to do the 12 lead, I always do but with this call I didn't and opted just to get to the hospital faster.

In this sort of case where decision is demanded quickly, would it help to try to ask yourself what would the receiving hospital prefer to see coming in the door, a patient along with an IV or an EKG or ???* I don't know in this case, just asking for thoughts on process .


*Yes, "OR a pulse". Assume that.

 

[Handsome Robb]

In this sort of case where decision is demanded quickly, would it help to try to ask yourself what would the receiving hospital prefer to see coming in the door, a patient along with an IV or an EKG or ???* I don't know in this case, just asking for thoughts on process .


*Yes, "OR a pulse". Assume that.

It's going to depend on the situation. If they need an emergent airway and you come in with a 12-lead but no line you're gonna get whomped on but say they're doing decently probably want a 12-lead.

 

[mycrofft]

And then some nurse will yell at you.
I hate it when we have to yell at innocent EMTs.

 

[Handsome Robb]

And then some nurse will yell at you.
I hate it when we have to yell at innocent EMTs.

It's pretty rare that we get hollered at by nurses here. We've got a pretty tight knit team and they know if they're rude to us we can make their lives a living hell and visa versa so we all get along pretty well.

Helps when it's a small enough region that you're on a first name basis with nearly every ERRN and ERP.

 

[mycrofft]

It's pretty rare that we get hollered at by nurses here. We've got a pretty tight knit team and they know if they're rude to us we can make their lives a living hell and visa versa so we all get along pretty well.

Helps when it's a small enough region that you're on a first name basis with nearly every ERRN and ERP.

Roger that!