Crashing airway patient

This patient is in need of homeopathy. And crystals. Lots of chinese herbal crystals. That should fix them right up.
 
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.
 
StCEMT said:
Like this?
CLIC-EM+BVM+Spike+Cric.jpg
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Right through the posterior of the trachea.
 
Remi said:
Right through the posterior of the trachea.
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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.
image.jpg
 
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.
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Except those devices all have the sharp penetrator removed after insertion, unlike the drip chamber spike.
 
Remi said:
Except those devices all have the sharp penetrator removed after insertion, unlike the drip chamber spike.
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Among other things. Never got to see it actually used, but I did like the gist of the design in theory.
 
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.
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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)?
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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?
 
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.



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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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?
 
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
 
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.
 
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.
 
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.
 
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.
 
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
 
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
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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.
 
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
 
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.

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....?
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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.
 
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?
 
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.

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