Fire during intubation

Discussion in 'Critical Care' started by Nephro critical care, Mar 2, 2017.

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  1. Nephro critical care

    Nephro critical care 2+ Year Member

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    So I have this patient with respiratory failure who I am preoxygenating with nasal cannula prior to RSI. I took the cannula off and intubated the patient and he developed ventricular fibrillation immediately afterwards. Code was called and the nurse shocked him. Patient came back to sinus rhythm with the shock but bang at the same time the patient's bedsheets caught fire. Nurses frantically tried to extinguish the fire and then I who was at the head of the bed picked up the sheets and shook them until the fire was extinguished. Turns out the nasal cannula were still on the bed blowing oxygen on the patient and the defibrillator paddles sparked a fire . No harm was done but I was thinking both the patient and me at the head of the bed would have easily been turned into blackened Jamaican Jerk chicken.

    Beware of nasal cannulas during defibrillation .
     
    Meowgical, tartesos, secants and 2 others like this.
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  3. FFP

    FFP Bored certified Gold Donor 7+ Year Member

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    Interesting. Worth a case report.
     
  4. BigRedBeta

    BigRedBeta Why am I in a handbasket? 7+ Year Member

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    As my wife said "well that's...shocking"
    Sorry that's terrible. Have heard of issues like this in the OR, but never with NC flow. What was the flow rate?
     
  5. Nephro critical care

    Nephro critical care 2+ Year Member

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    It was 15 liters i.e maxed out . When the person was defibrillated a spark shot out from the paddles towards the cannula but the cannula being not flammable did not catch fire . But the bed sheets had some nylon mixed in so they did.
     
  6. drmwvr

    drmwvr 7+ Year Member

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    Unrelated comment here, but why take them off for intubation? Might give some advantage in prolonging apneic oxygenation.

    Back on topic, we've switched to adhesive pads for just such issues.
     
  7. Nephro critical care

    Nephro critical care 2+ Year Member

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    I tend to take the cannulas off when I start bagging . The cannulas prevent a good seal . Some of this is probably dogma ground into me from training. My standard intubation RSI procedure in ICU is preoxygenate with cannulas ( which doesn't necessarily bring up sats in ARDS unless using bipap ) . Then give 2 mg of versed and then etomidate (0.4 mg / kg ) . After etomidate usually pt will tolerate oral airway . Then bag up rapidly to sats 95% or greater ad make sure they can be bagged. Bag for 2 -3 minutes but if you bag too long then pt's stomach will fill up with air and there is risk for vomiting. Then succinylcholine ( or roc if hyperkalemia or contraindications to sux ) and then tube 1 minute later. Works like a charm .

    Follow with propofol gtt and keep Levophed ready. If vent dysynchrony in 1st hour give rocuronium 1 dose after additional Versed, fentanyl , propofol . Invest in A -line at 1st sign of hypotension. 1st hour after intubation and rocuronium is golden time for procedures like central line , Aline and bronchoscopy.
     
    tartesos likes this.
  8. tartesos

    tartesos Medalaganario Gold Donor 5+ Year Member

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    Neat layout.
    Doesn't sound too rapid to me.

    And you forgot the #notmedicaladvice.



    Sent from my iPhone using SDN mobile app
     
  9. tartesos

    tartesos Medalaganario Gold Donor 5+ Year Member

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    At least a poster!


    Sent from my iPhone using SDN mobile app
     
  10. Nephro critical care

    Nephro critical care 2+ Year Member

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    It's not that rapid but I feel 5 minutes of preparation/ preoxygenation / or bagging to sats > 95 % is worth it if you can get an extra 3 minutes while you are getting the tube in on the 1st attempt. Invariably happens that if pts sats are 89 - 90% at the time of intubation attempt I will fumble with the glidoscope stylet in the back of the oropharynx and then nurse will inform me sats are 80% and I will have to pull out and restart bagging. And once you have given NMB it becomes harder to get sats up with bagging. By then I am getting Prinzematal's angina and it's not a nice feeling.
     
  11. SurfingDoctor

    SurfingDoctor "Hooray, I'm useful" 10+ Year Member

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    sb247 and FFP like this.
  12. Nephro critical care

    Nephro critical care 2+ Year Member

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    That's indeed true . I have had a good experience intubating ARDS / high oxygen requirements with 100% high flow at 60 L / min. Sats remained 90% despite not being an easy airway. Only problem is the cost as our hospital RT department would get upset if we used an Optiflow device just for intubation because it would be wasted afterwards.

    Also the fire that would have occurred with high flow oxygen from defibrillator paddles would be interesting . Probably the fire department would have to come to put it out.
     
  13. OTCAwesome

    OTCAwesome

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    In a true RSI you shouldn't be bagging the patient. Also after giving a paralytic, it should be easier to bag the patient, not harder
     
  14. Nephro critical care

    Nephro critical care 2+ Year Member

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    I guess my technique would be defined as a ' modified ' RSI intubation. ICU intubations are different from ED intubations in that usually the patient has been sick for some time so less likely to have a full stomach. That is unless they were getting tube feeds. They are also going to be more hypoxic so you will have less time to get the tube in so better have sats 99 % prior to 1st attempt.

    To me at least the big fat dudes become harder to bag once I give the sux. Their oropharynx just collapses .
     
  15. chocomorsel

    chocomorsel Senior Member 10+ Year Member

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    Maybe you are spending all your energy bagging a non paralyzed patient that by the time you are bagging them and they are relaxed, you muscles are fatigued. With proper technique, relaxant almost always helps with mask/bag ventilation.

    Also, with patients who are septic, sick ice, etc, they may not have per se a "full stomach" worth of food, but what about delayed gastric emptying and higher content of stomach acids, illeus than healthy patients? If you make a decision to RSI a patient, especially a septic patent (GI induced especially) put that pressure on the cricoid and go for the tube as soon as he/she defasciculates. Been there, done that, a whole bunch of green **** spewed out into the airway.
     
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