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I'd like to give some narcan
Oral board guy: patient is now in florid pulmonary edema, next step
I'd like to give some narcan
This thread is a good example of how the real world differs from the boards. For the padawans lurking here who are studying for orals, just keep in mind that in an AFOI situation (which inevitably will be on the exam) if you say 'I'd give a bit of prop or fentanyl' the next words out of the examiner's mouth will be 'pt is now obstructing/desatting/apneic, how would you like to proceed?'
If your plan for a stem is AFOI then stick to a truly awake plan. If they push you (pt is freaking out, pt is a kid), start with reassurance and additional excellent topicalization, and only then proceed to medications that minimally suppress respiratory drive I.e. Dex, ketamine, volatile.
Volatile would be the absolutely last thing I would do if performing an AFOI.
There is absolutely nothing wrong with titrating fentanyl - predictable sedation that is easily titrated, can be reversed and also can help with cough reflex.
IRL, I'm also not that big a fan of vapor for spontaneously breathing intubation, but vapor is a tried and true answer for securing the airway in tamponade, mediastinal mass, etc
TrachOral board guy: patient is now in florid pulmonary edema, next step
Oral board guy: patient is now in florid pulmonary edema, next step
Neither of which the patient has😵
Supine afoi? Do you like pain? That sounds horrendous lolIve done them both supine and sitting. But I figured it would be good to have them in position if you needed to try something else.
if you say 'I'd give a bit of prop or fentanyl' the next words out of the examiner's mouth will be 'pt is now obstructing/desatting/apneic, how would you like to proceed?'
If your plan for a stem is AFOI then stick to a truly awake plan.
Supine afoi? Do you like pain? That sounds horrendous lol
I guess different strokes eh
Agree and disagree.
If you said I'd give a 'bit ' of anything you're in soup for sure.
But if you say you'd give titrated sedation with whatever to RAS 0, or sedate with an infusion of whatever with the appropriate infusion rates ready if they ask, all while spont vent with rr monitored then you're golden.
If they obstruct a bit then ask nurse for jaw thrust/stimulate, halt infusion that should be fine too...
It's fairly common. Doesn't mean you have to abandon and go straight to front of neck or anything
If an exam expects you do do a fully awake afoi without any sedation then screw that. It's a bad exam. Completely not in keeping with the real world. I don't think that examiners think that way... I hope they don't anyway. If they do they should be sacked. And probably haven't given an anesthetic themselves in years
we do 99% of our AFOI supine. only sitting if they can't lie down without dying
we do 99% of our AFOI supine. only sitting if they can't lie down without dying
Anyone do them lateral?
Supine afoi? Do you like pain? That sounds horrendous lol
I guess different strokes eh
I do a lot of things that I don't necessarily think are ideal
Why did you need to do this case at midnight? Airway obstruction?Had one of my toughest airways this year. Bad, bad, neck-oral-pharynegal cancer super duper crap your pants badness. Mouth opening was a few millimeters. Literally no possibility of glidescope or AFO through the mouth. Only way in was nasal or trach.
Of course... this was at midnight on a Tuesday.
Was able to get my Nasal FO, but should have just trached him from the get go.
Dude had minimal work up and ended up on my lap in the middle of the night. Did the case, but transferred him to Stanford where he received a face half-ectomy and then died 3 months later from his disease. AW cases can be ball busters and come in unexpectedly sometimes.
Why did you need to do this case at midnight? Airway obstruction?
Ah - same thing happens doing a prone mask case 🙂No, always prone. Keeps the tongue outta the way.