er intubations

Started by m32b
Get help with your application

Use all the free resources available to you from SDN: articles, guides, expert advising, forums discussions, and school research.

Browse articles Compare schools My application plan Read Interview Feedback
Practice for interviews Ask an Advisor
M

m32b

m42b
20+ Year Member
working a shift in the er yesterday when a patient needing intubation came in...i tried (m3), my resident tried and then my staff tried: no luck...the patient wasn't looking so good at this point and we were preparing to do a surgical airway...luckily an anesthesiologist was in the department preoping a patient when we called him over...guy heard our story and went over to the er airway cart and pulled out this device called a lighted stylette...made getting the airway look soo easy....the thing is basically a five inch handle with flexible stylette an endotracheal tube slides onto...there's a light source at the tip of the stylette...the guy said the thing is a lifesaver and er physicians should know how to use it...he also said something about laryngeal masks and how they were a bridge until someone with more airway experience shows up.

any er people ever use these things (lighted stylettes and laryngeal masks)
 
Yes, I have used both, and I'm only a med student. I didn't use them in the ER but I know we have them down there. Why didn't the ED attending do the intubation?

C
 
You're right, anyone in the ED (or anyone in need of an emergent airway) should be able to provide some form of an airway, be it a definitive airway (ETT) or something to ventilate hte patient with (LMA). I'm *relatievely* proficient at the Miller/Macs, have done a Bullard or two, and have used an airway exchange catheter ONCE. I still need to learn the "intubating LMA" but know how to use the LMA (they're so easy). Have read about but never seen the lighted stylet.

Had an intubation two months ago, big big big big fat guy with no no no no neck... I had tried with a Mac blade twice... his epiglottis looked like a folded over taco (much like a Taco Bell Meximelt... yum yum), totally impossible to see his cords. Tried to intubate, but no go. Gave it to my attending, he tried three times. Unable. Atleast we coudl ventilate the guy. Anywho, gave it to one of our paramedics, who intubated him with relative ease. Thank heavens for paramedics.

Q, DO
 
Tough intubations are a pain in the butt, but I prefer to learn good tube techniques rather than crike or do funky lighted stylets, retrograde intubations, LMAs, etc.

Lots of cricoid pressure if necessary, try using a smaller tube, make sure you have adequate suction, make sure you have a good inflexible stylet (essential, often overlooked). I've never actually seen a tube missed in our ER, and we tube some funky patients several times a day. I once thought I missed a tube because funky white stuff came up after I inserted it, so I pulled out and tubed again. Turns out I was in both times, and that white stuff was pus from the lungs...

If you have sufficent preoxygenation (gentle bagging) then you have lots of time, at least 5 minutes, which is ages in intubation time.
 
5 Minutes? I know this sounds rude so here goes! Hold your breath for that long. 0h, I am sorry, it can't be done. This is not medicine, it is a barbaric, self centered, egotistical thing poor providers do to say that they did not have to go back in. One (1) minute is all that you should be in someone's air way between ventilation.

As for going from intubation to surgical airways, this is again irresponsible. I hate to use this card but I have been in EMS for a decade and I have always had a rescue airway device. I have no idea who would let a student intubate and not know about alternative options. I have to go on a medic call now but want to see what others think.
 
YOU ABSOLUTELY HAVE 3-5 MINUTES IF THE PATIENT IS PROPERLY PRE-OXYGENATED! That is basic stuff.
No one should ever be taught (today) to think they have a single minute or to hold their breath for a minute while intubating. Any or all of Ron Walls, MD literature supports this...Rosen supports this.

While any difficult airway needs to be prepared for, sometimes they come as a surprise. I have seen plenty of missed attempts, but there must ALWAYS be a temporizing measure (whether that is an LMA or bag ventilation until the sux wears off) in the back of one's mind.
 
HNS said:
5 Minutes? I know this sounds rude so here goes! Hold your breath for that long. 0h, I am sorry, it can't be done. This is not medicine, it is a barbaric, self centered, egotistical thing poor providers do to say that they did not have to go back in. One (1) minute is all that you should be in someone's air way between ventilation.

As for going from intubation to surgical airways, this is again irresponsible. I hate to use this card but I have been in EMS for a decade and I have always had a rescue airway device. I have no idea who would let a student intubate and not know about alternative options. I have to go on a medic call now but want to see what others think.
Click to expand...

Sorry bro, you are going against the newest fad, something called "evidence-based medicine." Preoxygenating with a NRB for 5 minutes will allow ATLEAST 5 minutes (I've heard 8) before a patient starts to desaturate below 93% saO2. You'll find that most, if not all, of us here on SDN are huge pre-EMS proponents (some of having done it), and most EM residents support our EMS compatriots...

I will also quote "Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation" that (i'll paraphrase) often paramedics were not aware (i.e. did not report) of the incidence of bradycardia and desaturation during field intubations.

Ah!
Baraka AS et al. Preoxygenation. Comparison of maximal breathing and tidal volume breathing techniques. Anesthesiology 1999 Sep; 91:612-616.[Medline abstract][Download citation]

Benumof JL. Preoxygenation. Best method for both efficacy and efficiency? Anesthesiology 1999 Sep; 91:603-605.[Medline abstract][Download citation]

To paraphrase, 8 full VC breaths with 100% O2 allows apnea for 5 min (+/- .95 min). Preox allowed 3.73 min +/- .76 minutes.
Plenty o' time.

Far longer than 1 minute. Enough time, wayyyy enough time, for a medical student to get one or two shots before someone else comes in.

Q, DO
 
A few points:
-An adequately preoxygenated patient will be fine for 5+ minutes.
-A definitive airway is a balloon inflated in the trachea. Adjuncts such as LMA, combitube, ventilating stylet are ok for temp use while preparing another intervention but they are not adequate protection against aspiration. I will not let a patient travel in the ED with one of these.
-Lighted stylet, intubating LMA, gum bougie, fiberoptic scope are all great ways to achieve a definitive airway in tough patients.
-If you can't intubate and can't bag surgical airway is indicated period.
 
i think that the theory with the 5 min thing is that (with good preoxygenation: bagging -or- patient takes a reasonable number of large exagerated deep breaths if able) the FRC has been filled with close to 100% O2 instead of the usual 21%. this allows pulse oximetry to be maintained at >90% for several minutes without any ventilation. i have seen this many times during my anesthesiology rotation. keep in mind that for a pt with pulmonary dz, obesity, etc. that the FRC can be much less than for us relatively healthy people (think 35 yo female being intubated for an elective surgery vs the crashing copd or chf patient brought in with acute decompensation to the ED). i would think that if you know or suspect pulmonary dz, etc, that you would pay extra close attention to the pulse ox as you attempt to tube the pt so that you would have a clue as to when you have used up the FRC reserve O2. then, assuming you can ventilate them, bag the FRC back up and try again/try a new technique.

- later.
 
basementbeastie said:
i think that the theory with the 5 min thing is that (with good preoxygenation: bagging -or- patient takes a reasonable number of large exagerated deep breaths if able) the FRC has been filled with close to 100% O2 instead of the usual 21%. this allows pulse oximetry to be maintained at >90% for several minutes without any ventilation. i
Click to expand...

Yer right. Some people refer to it as "nitrogen washout," you are replacing the 70-80% Nitrogen with nearly 100% oxygen. Wheeeeeeeee! More oxygen!

Q, DO
 
HNS said:
5 Minutes? I know this sounds rude so here goes! Hold your breath for that long. 0h, I am sorry, it can't be done. This is not medicine, it is a barbaric, self centered, egotistical thing poor providers do to say that they did not have to go back in. One (1) minute is all that you should be in someone's air way between ventilation.

As for going from intubation to surgical airways, this is again irresponsible. I hate to use this card but I have been in EMS for a decade and I have always had a rescue airway device. I have no idea who would let a student intubate and not know about alternative options. I have to go on a medic call now but want to see what others think.
Click to expand...

As you might have already realized, you should shut your cake hole. Another case of premed/paragod syndrome!

Love a good beat down, specially when someone deserves it.
 
It is actually a fun math problem-- the numbers work out so nicely.

I wish I had all of the figures here, but if you take the O2 carrying capacity of the blood, the amount that can be transferred from the lungs (if filled with 100% 02), the stroke volume of the heart, (which translates to the needs of the tissue) and so on. I would like to show you all how pretty it works out, but I am way too lazy.

In any case, there is a pretty pretty math problem shows that you have 7.5 minutes (given a normal, 70 kg person).
 
There is an excellent slide illustrating the amount of time you have in various patient populations at http://www.theairwaysite.com/rsi_9.htm

I don't suggest you take 7 minutes before you start your attempt, but realize that you do not need to rush- which leads to errors.

It is also important to recognized that once the SpO2 starts to drop below ~90%, it drops fast...
 
OK, you had your fun. I was going to get on and post my appology until I spoke to a nunber of other EMS types. Thus far not a single person has heard of not velitlating a pt for such extended periods of time. If anythign BeriBeri has proved that the pt in question did not have the type of 7.5 minutes as he/she posted. How many of you read the first post? I am not sure you read the part about the NEED to intubate this pt. If the pt needed to be intubated then they did not have the advantage of a controlled hyperoxygenation as you keep reffering to. One of you mentioned preoxigenation with a NRB. If the pt is in dire need of intubation then a NRB is not going to work as the pt does not have either the ability to manage thier airway or they are not ventilating themselves appropriatly. Either way, the pt described is in the post is not going to be able to withstand the aforementioned 5-8 minute no ventilation time.

The only reason I even attempted to make the post was that the case appeared to be an EMS type incident as far as airway management. This is something I do know about. No, I am not a paragod. Never have been and never will be. As a medic though I do have the benefit of doing intubation with pts whom are VERY sick, all the time. If we are refering to god complexes it would appear that the only peron who posts riticule without basis is that of "blotto geltaco".

As to the issues of the resident and the attending I am surprised that nobody else thought to comment. How can anyone feel it is appropriate to allow someone, an M3 in this instance, to be allowed to intubate, the gold standard of airway management, without any education about rescue devices. This is covered in basic First Aid, why not in medical school? I am glad that the M3 was able to make the post he did, this is why this forum is here. He should not have been put in this position by the medical school.

Next let us look at the attending at a teaching facility. How can this obvious expert in thier field not know about alternate intubatiuon techniques. Again, an infatructure issue. How can this attending teach if they are not current on what is going on in the emergency medicine community in the harmark of care, airway management.

In conclusion I am NOT a physician. I AM starting medical school. What I have posted is mostly based upon the last decate I have spent in EMS, most as a paramedic. What you have posted has been extremly educational and I appriciate the knowege. I thank those who have been helpful and am glad that the forum still brings you out. As for those who feel that they have put me in my place, you are mistaken and correct. You have not put me in my place, those whom have offered information have. Again, thank you for setting me strait, but I am still not sure that the pt in the initial post is an example of this long time withuot ventilation.
 
The only reason I even attempted to make the post was that the case appeared to be an EMS type incident as far as airway management.
Click to expand...

Naw, they just said he needed intubating sooner rather than later. Anyways, the "5 minute" comment was made in regards to a patient who is bagged easily allowing you to accomplish nitrogen washout. It may or may not have applied to this patient. The 5 minute timeframe has been pretty well established at this point. This of course would not be an EMS approach as 1) your FIO2 may be sufficiently less than 100% in the field (and it may not), and 2) if you're thinking of intubating in the field then likely you don't have that much time anyway.

As to the issues of the resident and the attending I am surprised that nobody else thought to comment. How can anyone feel it is appropriate to allow someone, an M3 in this instance, to be allowed to intubate, the gold standard of airway management, without any education about rescue devices.
Click to expand...

Students have to learn sometime and it's always possible they haven't done all the background learning required by that time. If they were intubating alone then it would be a problem but in this case there was backup.

This is covered in basic First Aid
Click to expand...

Since when are combitubes/LMAs/lighted stylets covered in first aid? The first time I learned about them in a structured setting was ACLS.

Next let us look at the attending at a teaching facility. How can this obvious expert in thier field not know about alternate intubatiuon techniques.
Click to expand...

No one said he didn't know of alternative techniques, he didn't know of the lighted stylet.
 
hns: i had intended to be fairly clear about ideal versus non-ideal patients and/or situations with regard to the aforementioned ventilation/nitrogen washout (ie: consider what the FRC really is and watch the pulse ox constantly). i will try to do better next time. i agree with you about the apparent lack of skills in the attending!

(technically, the anesthesiologist said, "the thing is a lifesaver and er physicians should know how to use it". no mention of the ER attending saying that they did not know how to use it....although it is implied)
 
Have heard some people who actually use a 2 miller in the difficult intubations in those with no necks. Never actually used it, but may want to give it a shot if all else fails.
 
HNS, While you make fantastic points and are obviously proud of your EMT-P training (you should be)...welcome to the humbling experience of being in medical school. Try not to go head-to-head in person, because you will always lose (regardless of you are right or wrong).

As for this patient...yep they needed to be ventilated, they eventually needed a definitive airway. I think the point is that the ONE minute rule/holding your breath rule is nonsense and should go the way of rotating tourniquets. With proper pre-oxygenation (non rebreather etc), you should have 5 minutes for intubation and definitive airway placement. Earlier the better.
 
In fairness to HNS, the scenario described did not sound like someone you could spend 5-7 mins securing an airway as presumably they were in respiratory decompensation & was not someone who was going to be able to be preoxygenated and ventilate sufficiently to blunt the profound acidosis I'd be afraid of.


Just a comment on the lighted stylette's: I saw them used extensively in medical school by a bunch of CNRA's in the late 1990's , the MDA's were kind of skeptical as I remember. Those CRNA's were pretty proficient I thought. I've never seen one used since & most anesthesia residents/staff and CRNA's here I've asked have never seen or used one. I think two things that would make it not so good for use in emergency room is

1. if you start blindly banging around in a hurry in the post-pharynx you're going to create more edema

2. you need near total darkness to see the light transilluminate properly thru the trachea in many people, & that is how the technique for that device is described. This would seem to make it a not very good solution for the ED.

Has anyone used those combi-tube devices that you just shove in the back of the throat & don't require much thought to placement? I remember reading some papers on it in the trauma literature years ago but haven't seen one in use.
 
I've personally used the combitube 3 times on code blues that were unable to be intubated in the field. They were all successful and all patients were easily ventilated as evidenced by a good ETCO2 reading and chest rise.

Our protocol at my old medic service was 3 field attempts at intubation and then go to the combitube.

It's nice since it is blind placement and you really can't mess it up (theoretically).

The one thing about it that i don't like is that it is HUGE. you really have to lube it up and do a really big togue-jaw lift to open up the airway.

I've gotten one into a little old lady so i think they're pretty nice and user friendly.

later
 
HNS said:
I hate to use this card but I have been in EMS for a decade and ...
Click to expand...

Yeah, speaking as an ex-medic, don't play that card.

Frankly, if I never hear another medic justify their position with an appeal to seniority, I'll be glad. It seems like the old grizzled medics would whip out their years in EMS and start swinging it around every time they heard about something new.

Incidently, I was RSI certified back when I was on the rig. Sux and etomidate. Carried the Combi and the Melker cric-kit, JIC.
In the ED, we had a Difficult Airway Cart with ALL the toys: LMA, Fastrach, needle cric setup, a Bullard, a Bougie...
 
any of you former medics remember eoa's and inverse intubations?
the eoa/egta was a pain in the butt. I still use inverse technique sometimes on those with no neck.
 
emedpa said:
any of you former medics remember eoa's and inverse intubations?
the eoa/egta was a pain in the butt. I still use inverse technique sometimes on those with no neck.
Click to expand...


We still have eoa's at one of the stations I work at now. We keep them in an old dust covered box next to the LMA's. 🙂
 
I have worked in environments where the combitube was the go to backup device for EMS. I don't think they are a definitive airway but they are a good adjunct for getting to the more controlled setting in the ED. Because you're blowing up a balloon in the esophagus there is a chance of causing esophageal rupture.
 
emedpa said:
any of you former medics remember eoa's and inverse intubations?
Click to expand...

Sigh....count me in. As much as I hated that thing about intubating around the EGTA, it seems to have stuck with me.

Inverse intubation? Perhaps we have a nomenclature issue here but I've never heard of that one.

Thanks, BTW, for making me feel old again. That hasn't happened for, say, two days. 🙂

Take care,
Jeff
 
docB said:
I have worked in environments where the combitube was the go to backup device for EMS. I don't think they are a definitive airway but they are a good adjunct for getting to the more controlled setting in the ED. Because you're blowing up a balloon in the esophagus there is a chance of causing esophageal rupture.
Click to expand...

Not sure if its universal or not, but here at TGH, a "definitive airway" is a nasotracheal, ETT, or combitube.

Q, DO
 
jeff
inverse intubation = 2 person intubation technique. intubator #1 places straight blade in mouth in typical fashion. assistant straddles pt facing head(typically done on floor) and lifts straight up on handle of laryngoscope giving better leverage than 1 person can do with wrist alone(lifting, not prying....as always)
intubator #1 then gives his own crich pressure and passes tube. works really well with pts with no neck. used this technique a few weeks ago successfully on pt that could not be intubated by 2 other experienced folks. er doc had never seen it done before. I teach this technique to folks in my acls airway station.
 
HNS said:
If we are refering to god complexes it would appear that the only peron who posts riticule without basis is that of "blotto geltaco".
Click to expand...


Actually my "riticule" had a lot of basis to it. That point has been proven ad nauseum by others on this thread, many of whom are med studs or residents. Get over yourself. When you advance in your training you will see that there is more to medical training than life on the old meat wagon. There are plenty of us folk around here with many years of EMS cards to play. We all know out in the field that patients have one foot on the grave and another on a banana peel. Things can be very different in the hospital. Best wishes. God.
 
emedpa,

Thanks for the explanation. I'm trying to visualize that in my head. I'm getting a picture of two people occupying the same space at the patient's head so I must not fully understand the specifics (although the concept is pretty clear).

I've seen folks intubate patients, typically trauma patients, by stradling their head, "holding" c-spine with their knees, and leaning back. This never worked for me because I'm about as flexible as a 2X4 but this approach is probably part of what's clouding my picture of what you're describing.

Take care,
Jeff
 
Jeff- The 2 People Intubating Are Facing Each Other. #1 Is In The Nl Position To Intubate On The Floor And #2 Is Straddling Pts Chest Facing Intubator #1 And Lifting Straight Up. #1 Is Basically Looking Into The Groin Of # 2, But It Gets The Job Done.
 
OK, that did the trick. Perhaps it was the groin comment but I can see it clearly now. 🙂

Thanks and take care,
Jeff
 
you win. As it does not matter my rebuttal I loose.
 
inverse intubation....we had considered terming it 'tag team tubing'...but the inuendo was too much for the fire station!
 
emedpa said:
Jeff- The 2 People Intubating Are Facing Each Other. #1 Is In The Nl Position To Intubate On The Floor And #2 Is Straddling Pts Chest Facing Intubator #1 And Lifting Straight Up. #1 Is Basically Looking Into The Groin Of # 2, But It Gets The Job Done.
Click to expand...


Wow, did you manually capitalize every word?
 
clarification from original poster:

patient came in with an acute asthma/copd exacerbation....original pCO2 was high normal...after inhaled bronchodilators etc. and an hours time her pCO2 had risen significantly (44 to 68) and clinically it was obvious she was tiring...her pO2 was also trending down, but the change wasn't as significant...intubation was declared urgent at this point though...the airway was deemed not dificult by the er resident, therefore i (m3.9)was able to try(pt was a thin, 50 something chronic asthmatic/copd smoker who said that every spring with all of the pollen her pulmonary disease "flares up")....ketamine/sux by the resident and i stepped up...considering all things, the lady bagged pretty well and we preoxed for a good 2-3 minutes....well, then all the things discussed in the original post happened....interestingly enough no significant O2 desaturations occured...you would think with all of that airway manipulation be me, the resident, and the attending er and anesthesia staffs that she would have exhibited significant progression of bronchoconstriction, but that simply wasn't the case...the anesthesia staff made an interesting observation about the patient's "thyromental distance"....essentially this lady had no chin whatsoever...the anesthesia guy (even though he was pretty cool) then spoutted off about how this fact is a significant indicator to the degree of difficulty of gaining access to an airway and blah blah blah...it certainly seems that way to me now.
 
Two additional thought on this case.

Ketamine +Succ for asthma is a common intubation mix because of ketamines bronchodilatory effects. However, if you don't give glycopyrrolate or atropine first the pt will salivate so much you can't see to intubate. That might have been part of your problem.

Also, if they suddenly get easy to ventilate and oxygenate right after the ketamine and before the succs they may have been a case of vocal cord disfunction-a more psychiatric disease which typically goes away with good sedation. In fact more than once I've knocked down what appears to be a severe asthmatic with etomidate or ketamine, seen all their respiratory distress go away and ended up just letting them wake up without intubating them. We had one lady here in town get intubated 4 times in two weeks before everyone got wise to her vocal cord disfunction.

My favorite rescue device is the intubating LMA. Never tried a combitube
 
To jump back a few notches...

If you haven't seen pre-oxygenation therapy in action, head down to your local OR where you can measure ETO2. We usually wait until this is >85% or so before initiating induction.

I'm curious as to how often this is practical in the ED. In the OR we usually let patients breathe themselves into this range, and it takes several minutes. But if you begin to bag the patient, you've by definition lost your window at doing a true RSI. How many of your patients are at low-risk for aspiration? I was under the impression that most ED patients usually needed to be intubated relatively emergently, and were often intubated via true or modified RSI.
 
I've done the ketamine/sux combo to take advantage of the bronchodilation but I only use it on a select population. Because of the increase in ICP I generally don't hit my geriatric population with it. Most docs think you can't use ketamine in adults but that's not true. You just have to deal with the emergency phenomonon. If you're tubing and the pt will be on propofol or whatever it's not an issue. If you're doing con. sed. you can hit them with some versed to blunt the emergence.
Gator05 is correct. True RSI does not bag. You get an insufflated stomach and an unpleasent surprise when you insert the laryngoscope.
 
Gator05 said:
To jump back a few notches...

If you haven't seen pre-oxygenation therapy in action, head down to your local OR where you can measure ETO2. We usually wait until this is >85% or so before initiating induction.

I'm curious as to how often this is practical in the ED. In the OR we usually let patients breathe themselves into this range, and it takes several minutes. But if you begin to bag the patient, you've by definition lost your window at doing a true RSI. How many of your patients are at low-risk for aspiration? I was under the impression that most ED patients usually needed to be intubated relatively emergently, and were often intubated via true or modified RSI.
Click to expand...

I dont' do BVM to pre-oxygenate, but I'll just slap a NRB and put it at 15 L/min on them if i know they're going to be intubated (or especially before a conscious sedation procedure).

Q, DO
 
Wow, that really brings back memories EMEDPA.........inverse intubation.

never heard it called that, but have definately done it. Very fat guy with no neck and coding in bedroom years ago.

could NOT see anything.........so i straddled the guy on the floor (sounds bad doesn't it) and pulled like crazy and my partner passed the tube.

worked great. I also teach it during ACLS.

later
 
m32b:

a few things about your post don't make much sense....

1) somebody with increasing respiratory acidosis and a PCO2=60 is by no means an urgent or emergent intubation (especially if the PO2 isn't that bad). People don't die of respiratory acidosis in a sudden urgent way - it is a prolonged process... People do die of hypoxia - that makes an airway urgent (there are other things that make an airway urgent as well)

2) after ketamine/sux - you bagged for 2-3 minutes??? that doesn't make much sense - cause sux kicks-in in about 30-40 seconds - unless you were hoping to increase her FRC (something which should have been done prior to ketamine/sux).

3) if you could bag her "pretty well" then why did you guys even think of an emergent surgical airway.... just take the laryngoscope out, put in an oral airway and bag her.... and regroup

4) since you could bag her and your ER attending failed at the intubation - just wait for sux to wear off - wake her up and then have an airway "expert" assist in the proper induction/intubation of this patient

5) prior to intubation, you guys should assess the airway properly: first you say the ER resident deemed the airway to be easy - then you mention how the patient had no neck whatsoever!!!! that is a poor assessment of airway difficulty.

a few other thoughts (i realize you are still a med. stud. so take this as a few pointers) - there are other ways of managing severe COPD exacerbation before resorting to intubation. If the PO2 isn't that bad, then you can always try Heli-Ox w/ bronchodilators (due to lower viscosity you are able to get a better spread of the bronchodilators). If the patient will tolerate it, you can always try BiPAP (a means of delaying intubation)... etc...

HNS: agreed that in an emergent setting the airway may need to be secured - but if you are unable to secure the airway, then the proper next move is to attempt oxygenation w/ mask-ventilation, until the next attempt to secure the airway is made.... Your oxygen consumption is between 200-300cc/min, so if you fill somebody's FRC (close to 2000 cc in adult) w/ 100% oxygen then you have quite some time before you desaturate. However, this statement falls apart when the closing capacity of the airway is lower than the FRC.
 
tenesma

good points.

the things that sealed her fate were the degree of increase in CO2 over a relatively short period of time, but more importantly the lady was just tiring out...given the scenario, her pulmonologist wanted the lady intubated and sent to the micu....about the bagging, i thought that strange too...asked the attending yesterday why he did it: patient had been confirmed by two sources to not have eaten for two days (patient and daughter) and wanted to see if ketamine had any bronchodilatory effects (it did)....as far as no neck goes that wasn't quite right...she had a long thin neck, it's that she didn't have any chin...that was the problem.

as far as the patient is concerned, ended up having a pnuemonia that didn't show up on initial cxr (she did have a low grade fever and a slightly abnormal wbc# in the er which were attributed to the inflammatory flare-up associated with asthmacopd exacerbation)...after hydrating the patient it showed up the next day on subsequent cxr according to the pulmonologist....my first question was did the lady aspirate...he said highly unlikely considering the locale of the consolidation and the sputum culture results (taken in the er prior tointubation) (those two bits of info i don't know) and the plan is to extubate her today (5.15.04).

very cool case, probably one of the most interesting i've seen as a med student....someone did mention during the initial workup that she might have a pnuemonia (i think it was the er nurse initially caring for the patient, but a clear cxr nixed that idea)...maybe er is for me!
 
i stand corrected - you did say no chin whatsoever... still another indication for better airway evaluation.
 
Another thing you can try in an asthmatic is to give some Magnesium. I haven't had much success in COPDers (different disease) but it works in asthmatics sometimes.

Q, DO
 
I don't know about you, but every time I give someone mag they break out into a sweat and throw up. Am I pushing it too fast? When you're using Mag, you don't have time to pretreat with an antiemetic.

Anyone with similar experiences?
 
beyond all hope said:
I don't know about you, but every time I give someone mag they break out into a sweat and throw up. Am I pushing it too fast? When you're using Mag, you don't have time to pretreat with an antiemetic.

Anyone with similar experiences?
Click to expand...

Actually I haven't had any of my pateints have that sort of reaction. I give mag a lot to my headache patients, haven't ever had that problem (although in my headache cocktail I give benadryl, reglan, and mag, so they pretreat each other). 🙂

Q, DO
 
You must log in or register to reply here.