moonbeam895

Shut up and drive. ~Rihanna 8)

[quote="Asysin2leads"So if you can scoop and run, treat w/ diesel" ??? Was there something I missed? With all due respect, I think you must have missed my whole post, except for the last sentence. Ref: Before you intubate..... We can agree to agree on this one. I think we're both saying the same thing, though we do have different ways of saying it. Bear with me. If someone with status asthmaticus has a sat of less than 94% on 40% NRB, decreased or absent breath sounds despite the chest moving up and down, maximal accessory muscle use, and altered mental status/is obtunded, then, by all means....intubate. It sounds like the original poster's patient had all or most of the things that score a "2" on the asthma scale and he probably did need to be intubated.....AGREED. But, if a patient can speak a partial sentence, is moving air at all, and there is any way that he can have kitchen sink therapy...O2, non-invasive PPV, bronchodilators, corticosteroids, mag, terbutaline, etc and get to definitive care pretty quickly, intubation should be avoided if at all possible. Transport rapidly instead, after you've gotten the drugs started. (My comment on solumedrol was that, once you had decided to intubate the pt, it would come after the fluids and intubation, since you won't see immediate benefits from it like you will the fluids or the Mag.Yes, definitely give it. It works....just later.) The reason I advised to TWD is due to the terribly increased morbidity/mortality for these patients once they are intubated. They frequently die from pnuemonia or other complications and never make it back off the vent. We see this in the intensive care setting, whereas EMS providers don't always see the long term outcome (or lack of it) for their patients. I'm sure you have your pt's best interests at heart and want to take the best care of them that you can. I have the utmost respect for our medics and EMTs. The original poster had a question about why her asthma patients kept coding after being intubated. Specifically speaking about the asthma patient, they have probably been sick for hours or days before they call you. They are tachypneic, which contributes to dehydration from rapid and prolonged exhalation, and they probably haven't been drinking fluids well. Typically, these patients are already very hypovolemic. Add this to the fact that they aren't moving air well... they have air trapping, mucous plugging and bronchospasm. With the intubation procedure, intrathoracic pressure suddenly increases with the pressure from mechanical ventilation, which leads to decreased venous return and decreased cardiac output. Add that to a bronchospasm, and you're in alligators up to your elbows. This leads to a bradycardic patient (not from vagal stim), who may not recover from the event. Bottom line: do the best for your pt. If you think this means intubation, so be it. It's your call. But, think about preload issues WHEN you intubate if you want your pt to make it to the hospital without CPR in progress. My 0.02 for what it's worth. Be safe.

Here is an excerpt from an article by Laura Ibsen, MD, which pretty much sums up what I was trying to say: Intubation and Mechanical Ventilation 1. Indications: There are no widely agreed upon guidelines for when asthmatics require intubation. Intubation and mechanical ventilation are difficult and dangerous for the asthmatic, hence are avoided if at all possible. The difficulty arises as to when it is or is not possible. Relative indications: 1. Apnea or “near apnea” 2. Diminished level of consciousness with inability to protect the airway. 3. Severe hypoxia despite supplemental O2 via 100% non-rebreather mask. Look also for evidence of impaired O2 delivery, i.e., presence or worsening of metabolic acidosis. 4. Consider at slightly earlier time if the patient needs to be transported to another facility. Intubation in the back of an ambulance is always suboptimal. This decision requires careful judgement. 2. Complications: Pneumothorax (high airway pressures needed), cardiovascular compromise or collapse (more deleterious cardiopulmonary interactions) aspiration during intubation, worsening bronchospasm (presence of foreign body in trachea) 3. Induction and intubation: The induction and intubation of the severe asthmatic during a severe exacerbation is particularly difficult to do safely. The patient usually must be considered to have a “full stomach,” is NOT a candidate for an “awake” intubation due to the intense bronchospasm that will occur if he/she is not adequately anesthetized, and will be difficult to bag-mask ventilate due to the high airway pressures required. In addition they are hypercapnic, usually hypoxic, usually dehydrated, and there are potentially detrimental cardiopulmonary interactions occurring (the blood pressure will fall with intubation). A rapid sequence induction is generally indicated. Medications should include: 1. Lidocaine (to blunt the bronchospastic response to intubation) 1.5 mg/kg. 2. Atropine 0.015 mg/kg 3. Sedation-a combination of midazolam(0.05-0.1 mg/kg) and ketamine (0.5-1.5 mg/kg). 4. Paralytic-succinylcholine (premedicate with defasciculating dose of pancuronium 0.01 mg/kg) 1.5-2 mg/kg, or rocuronium 1.2 mg/kg. If using succinylcholine, remember to give a long acting neuromuscular blocker immediately after intubation is achieved (risk of pneumothorax with positive pressure ventilation). 5. Two functioning large bore IVs are essential. Start a fluid bolus as you are readying for intubation--additional preload will be neccessary for adequate cardiac output after the patient is intubated.

Thanks for the feedback. To clarify: our Peds Intensivists recommend the fluid boluses as fast as you can push them...by hand before we intubate, AND as we are intubating. You're not just risking bottoming out the blood pressure if you don't do this, the patient will brady and code on you as the intrathoracic pressure changes with the procedure( as it sounds like happened with this case. ) We've seen it over and over with EMS bringing in pts to the PICU/ED, and it could go so much easier for the pt and the teams if they had this in their protocols. Agreed! If they need to be intubated, push boluses and DO IT. We try hard not to if it can be avoided because these pts are doomed to weeks of trying to wean off the ventilator and sometimes never make it off again. Each time they are intubated their risk of dying on the vent is increased about 50%. So in critical care, we'll try many other things to keep from having to intubate That being said, sometimes what will be...will be. We don't always treat with diesel, and I don't think that's what I said. A thousand pardons if that's how you perceived it.

Only thing I would add is a couple of rapid fluid boluses before you intubate. When you intubate an asthmatic, the sudden change in their intrathoracic pressure causes them to lose their preload and their BP will bottom out immediately. This is exactly why they code when you intubate them. Someone should be pushing fluids before and as you are placing the tube. The steroids won't kick in for about 4 hours, so I wouldn't bother with that until everything else is done. Aminophylline or terbutaline might help if you have those handy. We do everything we can to keep from having to intubate these pts, so if you can scoop and run, treat w/ diesel.

Does the Melatonin help?

From some of the info I've read: Next month, the International Agency for Research on Cancer, the cancer arm of the World Health Organization, will add overnight shift work as a probable carcinogen. The higher cancer rates don't prove working overnight can cause cancer. There may be other factors common among graveyard shift workers that raise their risk for cancer. However, scientists suspect that overnight work is dangerous because it disrupts the circadian rhythm, the body's biological clock. The hormone melatonin, which can suppress tumor development, is normally produced at night. Also, I'm double-whammied because it's also being researched and found that: People who work a mix of day and night shifts may face a greater risk of dying from heart disease than those who work fixed days or nights only. I work days and nights. I'm sure our exposure to diesel fumes, etc, doesn't help much either.

Yup...I've had those "micro-sleeps" on my way home from work many times. It's scary to think I can fall asleep while slapping my face, singing to the top of my lungs with the window down. Waking up at a stop light with someone blowing the horn behind me is a scary feeling. When we've worked 12 hours and get a late call, turning the shift into 15 or 16 hours I am definitely not safe to drive home. But, what do you do? Gotta be back at 1830. My guardian angel is worn out.

Best cartoon ever made was Bugs Bunny's "Kill da wabbit" Wish I could find it online. Bugs...he's da man.

Hi All, I'm from NC and do inter-facility children's transport. I found this site via a link in JEMS. I've enjoyed it so far. Especially the funny stuff. Be safe.