Bariatrics Pt.! What would you do?

[Mrmackay82]

Scenario, 53 female, dispatched for SOB, on arrival Pt 600-700 lbs., CHF with rales bilateral SaO2 45% on personal bipap at 1lpm. P-120 sinus tach R-32 BP- 190/100. Hx. CHF, htn, diabetic. BGL-110. Small room with narrow hallways, rural county with one additional unit(emt & paramedic), volunteer first responders, any additional resources more than one hour response.

This is the initial scene. Backup unit 10 minutes out volunteers(aka lift assist 15+ minutes out).

I'm curious what your initial treatment, plan of action would be. I will advise what my plan and outcome would be after the Monday morning quarterbacking has begun.

Ps. Pt could have weighed up to 900 lbs for all I know. I'm being conservative as once you get to that level it's hard to determine!

 

[ah2388]

Nitrates/CPAP for Tx, if pt unable to be extricated via stretcher/ambulation, you'd have to consider extrication through a window if necessary. Most homes in my experience have large windows in the bathroom/living area.

Get on the radio, request all the help you think you'll need.

If you find yourself unable to perform the above, youre going to need to consider extrication through the structure itself, which opens up a whole can of worms id rather not even begin to get into.

-adam

 

[Shishkabob]

Cpap/Nitro/Enalapril

If that doesn't relieve symptoms in 5ish minutes, it's time to RSI. Once RSI'd, you have all the time in the world to figure out how to move them.

 

[Cawolf86]

This is my initial plan-
-Sit her high-fowler's
-NTG 0.8mg w/ repeat dosing based on BP and response to Tx
-CPAP titrated to relief
-Contact dispatch for FD with tools for poss extrication through wall or down the hall
-IV TKO

I would basically attempt to stablize the suspected CHF exacerbation and wait for help. There is no way that we can move this patient without the proper equipment and I don't want to get me or my EMT hurt.

 

[ah2388]

Cpap/Nitro/Enalapril

If that doesn't relieve symptoms in 5ish minutes, it's time to RSI. Once RSI'd, you have all the time in the world to figure out how to move them.

I'm not saying that RSI doesn't have a place in this pt's future, but what about this pt's condition leads you down that path at THIS point?

I'm not being hostile by any means when I say this, but this sounds like a poor treatment plan in THIS situation with THIS pt.

Sounds like an absolute disaster waiting to happen in a situation where it may not be indicated.

 

[ah2388]

I suppose I may answer my own question with this question butttttt..

what is the pt's mental status, the pt's current dyspnea, how far off is it from baseline(sort of irrelevant)

-Adam

 

[Shishkabob]

I'm not saying that RSI doesn't have a place in this pt's future, but what about this pt's condition leads you down that path at THIS point?

I'm not being hostile by any means when I say this, but this sounds like a poor treatment plan in THIS situation with THIS pt.

Sounds like an absolute disaster waiting to happen in a situation where it may not be indicated.

How is RSI not indicated in this situation after CPAP/Nitro/Enalapril have failed? What else is left aside from taking definitive control of the airway?



Aside from NTI*

 

[ah2388]

i find it hard to justify tubing a pt who is C, A&Ox4 c/o of resp. distress, who may oftentimes be short of breath due to generalized poor health.

I think it's poor practice to be buying vent days for these pt's, diminishing there already diminished quality of life, perhaps by leaps and bounds.

This is all obviously going to be based on assessment skills and what not, just not sure RSI is indicated here with the information we have.

If the pt is showing mental status changes and is losing the ability to protect there own airway, then I think obviously we have to take over it ourselves, but keep in mind that this is potentially a disasterous airway situation, and failure to plan for failure could make that worse.

As they say, I ain't skurred to do what needs doin, but dont you have a couple more questions before immediately jumping down that road.

 

[Aidey]

Scenario, 53 female, dispatched for SOB, on arrival Pt 600-700 lbs., CHF with rales bilateral SaO2 45% on personal bipap at 1lpm. P-120 sinus tach R-32 BP- 190/100. Hx. CHF, htn, diabetic. BGL-110. Small room with narrow hallways, rural county with one additional unit(emt & paramedic), volunteer first responders, any additional resources more than one hour response.

Are you sure that isn't a typo? Neither the LP 12 or 15 will read below 50%.

 

[Handsome Robb]

Call for the additional unit and vollies and tell them to bring the truck since this is more than likely going to be an extrication as ah2388 said. I'd advise dispatch of the situation and the size of your patient, sometimes you can get 2 extra hands sometimes you get 10 from a volunteer squad, so worst case scenario you may need that mutual aid. Its part of the scene size up as well.

Like mostly everyone else said, CPAP, NTG, I might consider furosemide if the NTG doesn't reduce the rales and for the reason that it has a slower onset but a longer duration for what seems to be a long transport time.

If you can't get the edema under control and the SpO2 up she's going to need airway control, so get your kit ready.

 

[Shishkabob]

I'm not saying ETI is the first step to go to, and didn't even claim as much, but if you've done everything else you could have done (Again, CPAP/Nitro/Enalapril) you need to do something for oxygenation of the patient. A 58% sat, if correct, is not a sat that is to be tolerated for any length of time. (Granted we don't know the EtCO2 on this patient either, which is going to be another determining factor in how quickly you move on to the next step.) But just because the numbers look good, or the patient is awake and "alert", is not reason to not do RSI. Infact, if you just looked at the numbers for my last RSI, you'd think I was crazy for doing it, but it had to be done.




I'm not one to take RSI lightly. Scares the bejeezus out of me. I shook more than Japan in an earthquake on my first RSI. However, as you stated, I will do what needs to be done.





Keep in mind I'm also part of a rural service with an extended transport... so we tend to be a lot more aggressive with airway control than someone who has a 5 minute transport.

 

[ah2388]

What is to say that the Sa02 feature is not functioning properly etc.

The point I am attempting to make is that we need to combine assessment and diagnostic tools to make decisions.

Is this pt's RR due to anxiety?

Then, is the anxiety secondary to hypoxia? Is it due to being self conscious of the exact challenge we are faced with as far as extrication? Is it due to other factors? All signs are pointing to this being a CHF exacerbation, probably related to the sympathetic nervous system freaking out because of some fluid backup in the lungs. These pt's generally respond well to NTG and CPAP. I agree that this pt is boogered if interventions are unsuccesful due to prolonged extrication time/pt's generalized health.


I would argue with you at length that if clinical assessment does not indicate RSI, and utilization of assessment tools does not indicate RSI, then RSI is not indicated.

I also work for a busy rural 911 service, we have transport times ranging from 10 minutes-1 hour. With that being said, RSI is rarely performed, especially with CPAP/Tridil and SL NTG being used. Non Invasive PPV is a hell of a tool.

 

[Aidey]

I would argue with you at length that if clinical assessment does not indicate RSI, and utilization of assessment tools does not indicate RSI, then RSI is not indicated.

Yet. You are forgetting the word yet. Planning ahead is not a bad thing. Steps 1-6 might work, and RSI won't be needed, but if you get to step 5 and nothing is working it is a lot better to have step 7 planned in advance rather than doing it on the fly.

There are plenty of patients whose vital signs don't indicate the need for RSI right then, but that does not mean they aren't going to decompensate.

 

[ah2388]

Yet. You are forgetting the word yet. Planning ahead is not a bad thing. Steps 1-6 might work, and RSI won't be needed, but if you get to step 5 and nothing is working it is a lot better to have step 7 planned in advance rather than doing it on the fly.

There are plenty of patients whose vital signs don't indicate the need for RSI right then, but that does not mean they aren't going to decompensate.

Of course, however in this scenario, it was stated that "If that doesnt work after 5 or so minutes then its time for RSI" or something to that effect.

It is reasonable to state that if this pt does not get better, they will get worse, but when it becomes evident that airway control is mandated, would you prefer a team of airway guru's paged from the bowels of the hospital (OR/Anesthesia), or a paramedic who may intubate real tissue 4 times a year?

Think about it from the patients perspective.

 

[Aidey]

Considering that in Linuss' area the bowels of that hospital are an hour away, and the patient is 700+lbs, I think the paramedic is as good as it is going to get.

 

[Shishkabob]

would you prefer a team of airway guru's paged from the bowels of the hospital (OR/Anesthesia), or a paramedic who may intubate real tissue 4 times a year?

Of course I'd prefer being in a place with alot more help, and when I was actually in a station that gave me the ability to be at the hospital in 10 minutes, I deferred 2 RSIs until we got the the ER. Had respiratory waiting for us, and both were RSId pretty darn quick.

Think about it from the patients perspective.

You mean "Oh God I can't breathe, I wish they would do something besides stare at me for 45 minutes?"


Like I said, I am in a place where my average transport is 45+ minutes to anything that can be considered a hospital. My patients don't have the luxury of waiting at times, which is why I have the tools, medications and (aggressive) guidelines that I have.

 

[Handsome Robb]

The thing about this is. You don't have a bunch of airway gurus to page from the bowels of this pt's house. Unless you want to activate an aircrew to fly to you then ride back in your bus cause they can't fit the patient in the chopper. But thats being unrealistic. I don't know what system your in but here for my internship, we are required to get 6 field tubes in 4 months to pass...and last year my school had 100% pass rate. You do the math.

If the patient is dying, I don't think they are going to nitpick about who tubes them to save their life.

 

[ah2388]

The thing about this is. You don't have a bunch of airway gurus to page from the bowels of this pt's house. Unless you want to activate an aircrew to fly to you then ride back in your bus cause they can't fit the patient in the chopper. But thats being unrealistic. I don't know what system your in but here for my internship, we are required to get 6 field tubes in 4 months to pass...and last year my school had 100% pass rate. You do the math.

If the patient is dying, I don't think they are going to nitpick about who tubes them to save their life.

This is obvious, and I have never advocated for deferring this procedure if it's indicated.

Linuss, you're adding things to this scenario that were not initially presented. I will presume that is in an effort to justify your decision making, it appears you are unwilling to consider that we simply don't have enough information to determine whether or not RSI is necessary for this pt at this time.

Additionally, our services sound a lot alike, I am not at all impressed by your "rural" transport time's, nor your "aggressive" guidelines, we are both fortunate enough to work for services that have both.

The bizarre thing about this discussion, is that I am mostly advocating that we need more information about this pt in order to make our decision in the best interest of the pt.

NVRob, again, it is clear that we do not have anesthesia on scene with us, and it is somewhat unreasonable to request a flight crew for a pt who isnt going to be flown(although not unheard of.) I am advocating with the limited information provided, that we consider non invasive positive pressure ventilation, whether with CPAP or BVM, as a bridge to RSI by a team of trained clinicians in an "ideal" environment. If the presentation of this pt does not allow for us to lollygag, and instead forces us to take definitive control of the airway, then of course that is what we will do.


With the information provided, as I'm not sure I'm buying into the saO2 finding(would use etco2) beyond the pt's respiratory rate, what other findings in the scenario as presented lead you to believe that this pt requires RSI after "5 minutes without dramatic improvement" What about 5 minutes without decompensation? Then what?

Anyway, I suppose I'm ranting without any real purpose, truly, we are saying the same thing. Just trying to get everyone to open there minds and justify the reasoning for this procedure as it is certainly not without consequence.

 

[Shishkabob]

Linuss, you're adding things to this scenario that were not initially presented. I will presume that is in an effort to justify your decision making, it appears you are unwilling to consider that we simply don't have enough information to determine whether or not RSI is necessary for this pt at this time.

If you REALLY want to go down the road of "not enough information for treatment", then you will have to redact your statement of

Nitrates/CPAP
-adam

 

[ah2388]

i suppose youre right, I was assuming the pt is sick, which ironically enough is exactly what I am advocating that we don't do now.

Congrats, you owned me.

Now prove me wrong, I issue that only as a challenge, if you can legitimize your argument as I believe I have mine, then I think it would be an opportunity to learn, certainly I would take it as such.