What I'm getting at though is can you wait for it to work to fix the oxygenation or does the SpO2 sitting at 75 warrant more rapid and direct management via intubation.
In my anecdotal experience, unless there is major airway destruction or obstruction, a patient can be ventilated without a tube. As one of my anesthesia preceptors repeats ad nauseam, “Nobody ever died from not having a piece of plastic in their throat.” I also like to be psotioned for success, I would rather "know" I can ventilate than "think" I could get the tube. But certainly I would assess that before moving and if I liked how it looked I would intubate prior to transport.
I feel that the scenario is inherently flawed in that you begin transport before the process of working through the problem which is just silly.
You said it perfectly.
I am naturally assuming that the intubation would occur before transport (you guys intubate while racing along L/S?)
Tubing before transport is most certainly best practice. Especially when there are more hands than just your MFR to help. On occasion during longer transports I have had to tube medical patients in moving truck. (Tilting the stretcher head to 30 degrees helps a lot.) While moving, by yourself, and the real problem of lack of space, it is quite challenging. I wouldn’t make a habit of it.
I agree about the CPAP, if we're still worried about airway control (which at least I am), then CPAP is not the way to go. I'm all for addressing the the route cause of the problem as I mentioned earlier, but the dramatic increase in VT altered my thinking. Is it appropriate to be pushing catecholamines into a person who has a quickly worsening problem with VT? Its not rhetorical, I'm actually asking, whats the relationship there?
With 2 hands, an NPA, and a bag I can control almost any anyway.
Dobutamine is indicated in cardiogenic shock. Outside the hospital I have never had it. But along the same lines, dopamine will work almost as good. If you look at my earlier statement, it depends on the nature of the heart failure. If you are looking at a condition caused by something such as unstable angina, you first have hypoxia that causes arrhythmia. If you have mechanical failure which causes arrhythmia, you have arrhythmia with hypoxia secondary to it.
A 67 y/o male (almost certain to have hypertension) subsequent left heart failure, possibly right as well, depending on the time of onset, with most likely a CABG from his scar in this scenario, and despite the med list, most likely on Beta blockade and/or ace inhibitors, his ability to compensate is reduced if not taken away completely, It is my thinking his “faint” s3 sound was caused by myocardial failure. As well, if you became short of breath while driving, I would think most people would try to brake before crashing into a tree as a natural reaction. His condition had to be nearly instantly incapacitating for the events to unfold as they did. Even with unstable angina, people generally are aware they are worsening. I have noticed it is in late stage heart failure people suddenly lose consciousness. They can be talking to you then out, without finishing the sentence as a baseline. In such a case you need the increased contractility. Other than epi or norepi, (which might be too potent for this and not to mention I would have to mix an epi drip.) I couldn’t think of anything else I had on a truck that would do that. The Dopamine receptors in central circulation cause vasodilatation so that would also increase myocardial blood supply in diastole. The effects would be fast enough to be practical, as it is a drip you can simply shut if off if it is not working and do something else in a few minutes as the catecholamine has significantly lower half life than amiodarone. That way if you have to switch from one to the other you have less what I call “mad scientist effect” of having multiple active drugs in the mix. As well there is a Beta blockade effect of Ami on the SA and AV nodes, but I can’t tell you how significant it is.
I also opted out of using Ami as it is indicated for a stable VT. Which this patient is ceetainly not stable by mental status or BP. I am not one of those “you’re going to kill the person” if you don’t follow the exact cookbook types, so I can see where starting with ami might help also.
