1. Tired of seeing ads? Click here to register today and the ads go away. It's completely FREE, too!
    Dismiss Notice
  2. Can't find what you're looking for? Use the search bar in the upper right corner.
    Dismiss Notice

Crashing airway patient

Discussion in 'Scenarios' started by Rialaigh, Jan 2, 2017.

  1. VentMonkey

    VentMonkey Forum Deputy Chief Premium Member

    2,081
    1,439
    113
    Education:
    Paramedic
    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.
     
  2. StCEMT

    StCEMT Forum Deputy Chief

    1,083
    593
    113
    Education:
    Paramedic
    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 ***. :p
     
  3. Handsome Robb

    Handsome Robb Youngin' Premium Member

    9,463
    914
    113
    Education:
    Paramedic
    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.


    Sent from my iPhone using Tapatalk
     
    CANMAN likes this.
  4. VentMonkey

    VentMonkey Forum Deputy Chief Premium Member

    2,081
    1,439
    113
    Education:
    Paramedic
    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?
     
    FireWA1 likes this.
  5. DEmedic

    DEmedic Baaaa!

    9,127
    3,416
    113
    Education:
    Paramedic
    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.
     
    CANMAN and VentMonkey like this.
  6. Handsome Robb

    Handsome Robb Youngin' Premium Member

    9,463
    914
    113
    Education:
    Paramedic
    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.


    Sent from my iPhone using Tapatalk
     
    VentMonkey likes this.
  7. VentMonkey

    VentMonkey Forum Deputy Chief Premium Member

    2,081
    1,439
    113
    Education:
    Paramedic
    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?
     
  8. Handsome Robb

    Handsome Robb Youngin' Premium Member

    9,463
    914
    113
    Education:
    Paramedic
    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...


    Sent from my iPhone using Tapatalk
     
  9. VentMonkey

    VentMonkey Forum Deputy Chief Premium Member

    2,081
    1,439
    113
    Education:
    Paramedic
    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;).
     
  10. Handsome Robb

    Handsome Robb Youngin' Premium Member

    9,463
    914
    113
    Education:
    Paramedic
    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.


    Sent from my iPhone using Tapatalk
     
  11. VentMonkey

    VentMonkey Forum Deputy Chief Premium Member

    2,081
    1,439
    113
    Education:
    Paramedic
    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.
     
  12. StCEMT

    StCEMT Forum Deputy Chief

    1,083
    593
    113
    Education:
    Paramedic
    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.
     
  13. VentMonkey

    VentMonkey Forum Deputy Chief Premium Member

    2,081
    1,439
    113
    Education:
    Paramedic
    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.
     
  14. EpiEMS

    EpiEMS Forum Deputy Chief

    2,069
    382
    83
    Education:
    EMT
    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?
     
    VentMonkey likes this.
  15. DEmedic

    DEmedic Baaaa!

    9,127
    3,416
    113
    Education:
    Paramedic
    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.
     
  16. StCEMT

    StCEMT Forum Deputy Chief

    1,083
    593
    113
    Education:
    Paramedic
    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.
     
  17. CANMAN

    CANMAN Forum Captain

    448
    180
    43
    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.
     
    StCEMT, VentMonkey and DEmedic like this.
  18. StCEMT

    StCEMT Forum Deputy Chief

    1,083
    593
    113
    Education:
    Paramedic
    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.
     
  19. CANMAN

    CANMAN Forum Captain

    448
    180
    43
    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.
     
  20. StCEMT

    StCEMT Forum Deputy Chief

    1,083
    593
    113
    Education:
    Paramedic
    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.
     
    CANMAN likes this.

Share This Page