Crashing airway patient

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.
 
StCEMT said:
So when going for the thump...aim for the sternum and hit as hard as you can?
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I bet you could even call it a "sternal rub" to make it a bls procedure.
 
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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.
 
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.
 
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.
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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.
 
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.
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You're going to precipitate an arrest in this patient by sedating and paralyzingly a profoundly hypoxic and hypotensive patient...


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


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This is a good patient for push dose epi, but I don't think that's something most people are cognizant of.
 
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.
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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.
 
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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This is why peri-intubation arrests are so common....

Insert "This is why we can't have nice things!" Meme
 
Remi said:
Sux --> tube --> apologize later.
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With an experienced competent clinician doing the airway absolutely.


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Handsome Robb said:
With an experienced competent clinician doing the airway absolutely.


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Not a fly by night technician?

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Remi said:
Sux --> tube --> apologize later.
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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.
 
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.
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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.
 
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.
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I am not sure that Ketamine potentiates CNS depression.
 
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