How would you incubate this patient?

[Impromptu]

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Cardioversion may prove difficult with the recent addition of digoxin. 12 hours of digoxin is unlikely to produce an overdose, but I would keep it in the back of my mind.

 

[debvz]

What's the indication for "incubation" here?

They're not dead unless they're warm and dead.

 

[dewer]

ketofol titrated
or alternatve mdazolam 1-2mg

 

[45408]

1. Preoxygenate with 100% O2
2. Priest at HOB which should be elevated[kind of like an exorcism]
3. R2 pads + whatever pressors are needed for BP maintenace
4. IV scop if conscious, otherwise nothing; even etomidate will tank the pressure[I don't think the 5 cc's of propofol is a very good idea, only 3cc's did MJ in]
5. DL with Mac 3 versus glidescope...
6. put tube thru cords
7. hope for the best
7. get ready with stick of levo or epi when bp crashes from PPV

In this situation, there really is no anesthesia like no anesthesia

What are R2 pads? The defibrillator/pacer pads?

And how often might you actually go with "no anesthesia" for an intubation? Our paramedics will obviously just intubate a comatose/unresponsive/dead patient in the field with no meds whatsoever, but do you ever just use paralytic?

 

[RxBoy]

but do you ever just use paralytic?

I did once during a floor code. Didn't know why the patient was so stiff.

Turns out he was in rigor mortis.

 

[Idiopathic]

i gave a guy sux once during a code because i couldnt open his mouth. the med resulted in no improvement in oral opening. reference the above post.

 

[deleted162650]

Any meds you give during a true code are just gonna sit in the pts arm, SVC, etc. wherever the tip of that IV is since the cardiac output from chest compressions is no where near adequate to actually circulate the drug to its sites of action

 

[rsgillmd]

Any meds you give during a true code are just gonna sit in the pts arm, SVC, etc. wherever the tip of that IV is since the cardiac output from chest compressions is no where near adequate to actually circulate the drug to its sites of action

That is why they say in ACLS that you should flush the meds with 20 ml volume and raise the arm after giving something through a peripheral IV. Not as good as a IJ or subclavian, but better than nothing.

 

[45408]

Any meds you give during a true code are just gonna sit in the pts arm, SVC, etc. wherever the tip of that IV is since the cardiac output from chest compressions is no where near adequate to actually circulate the drug to its sites of action

Depends what you mean by "true code." If they're in asystole and may have been that way for a while, then I'd agree. However, I've seen (and done) CPR on a patient with an a-line that showed a marked difference in SBP during chest compressions, and I find it hard to believe that they're not circulating enough to get around. Besides, why would ACLS include epi/vaso/atropine if they just "sit in their arm"?

 

[RxBoy]

Depends what you mean by "true code." If they're in asystole and may have been that way for a while, then I'd agree. However, I've seen (and done) CPR on a patient with an a-line that showed a marked difference in SBP during chest compressions, and I find it hard to believe that they're not circulating enough to get around. Besides, why would ACLS include epi/vaso/atropine if they just "sit in their arm"?

There is perfusion to tissues during compression as mentioned above, albeit greatly reduced. A great marker of optimal chest compressions is EtCO2. The perfusion is high enough to allow for gas exchange in alveoli. Also can fool you during confirmation of intubation with stat EtCO2. If chest compressions are inadequate, it won't change colors and you'll think you goosed it.

As for actual numbers:

"Cardiac output during closed cardiac massage is only approximately 25 to 30 percent of normal. [61 ] – [64 ] Standard CPR generates systolic blood pressures of 60 to 80 mmHg, but diastolic pressures are commonly less than 20 mmHg. [65 ] Mean carotid pressure is typically less than 40 mmHg, which produces cerebral blood flows of 10 to 15 percent of baseline. [65 ] Coronary blood flow is even more compromised, usually being only 1 to 5 percent of normal with standard CPR techniques. [66 ] – [68 ] "

 

[SouthSideSteve]

pent, sux, tube.

 

[deleted162650]

I think CO from chest compressions is adequate to circulate the gargantuan doses of vasoactive drugs given as part of ACLS to the heart and major vascular beds, but I don't think it is adequate to distribute sux or other NMB's to the NMJ's of interest within any clinically relevant time frame for intubation. If the patient is stiff from rigor mortis, they have been dead for 3-4H and should not be coded in the first place.

 

[deleted162650]

Not to mention paralytics will not help with rigor mortis stiffness as it occurs at the actin-myosin interface which is distal to the NMJ.

 

[Arch Guillotti]

The times I have done compressions on someone with an arterial line, a relatively adequate MAP was able to be maintained.

 

[Idiopathic]

I think CO from chest compressions is adequate to circulate the gargantuan doses of vasoactive drugs given as part of ACLS to the heart and major vascular beds, but I don't think it is adequate to distribute sux or other NMB's to the NMJ's of interest within any clinically relevant time frame for intubation. If the patient is stiff from rigor mortis, they have been dead for 3-4H and should not be coded in the first place.

yeah thanks, sometimes it take a few minutes to figure that out, when you are in the middle of things.

 

[45408]

I think CO from chest compressions is adequate to circulate the gargantuan doses of vasoactive drugs given as part of ACLS to the heart and major vascular beds, but I don't think it is adequate to distribute sux or other NMB's to the NMJ's of interest within any clinically relevant time frame for intubation.

Sure, that makes sense.

If the patient is stiff from rigor mortis, they have been dead for 3-4H and should not be coded in the first place.

And God help the nurse that didn't evaluate their patient for 3-4 hours...

 

[RxBoy]

And God help the nurse that didn't evaluate their patient for 3-4 hours...

They're called floor nurses. Vitals Qshift.

The worst I've seen was a patient that was admitted but somehow never added to the primary team's list for follow up. It took 3 days for the floor nurses to realize.

 

[45408]

They're called floor nurses. Vitals Qshift.

The worst I've seen was a patient that was admitted but somehow never added to the primary team's list for follow up. It took 3 days for the floor nurses to realize.

None of our floors do vitals Q shift, and someone (nurse or CNA) is supposed to assess the patient every hour. I'm sure what is supposed to happen and what happens aren't always the same...

 

[Idiopathic]

sometimes the roommates of VA inpatients alert the nurses that the patient has expired