Depressed Man with Bad Luck

[DartmouthDave]

I agree with everything Paramagic said except for this...

The primary reason to my mind he's got a 30+ bpm RR is the fractured ribs and the resultant pain interfering with good respiratory effort. Which means he does indeed need to be intubated and have mechanical ventilation initiated. But not with long-term paralysis and not on SIMV. Controlling pain and meeting O2 demand will reduce his respiratory rate. The first will be accomplished via LARGE doses of sedation and analgesics. The second mechanical ventilation will take care of.

SIMV was (and still is) a weaning mode as developed. Weaning is not something we do much of in EMS, the reason it's a popular mode of transport ventilation is it's perceived as "safer" than A/C. However, SIMV (especially with pressure support) can deliver somewhat erratic ventilations to the point of becoming uncomfortable for the patient. In addition it may increase work of breathing, if the initial mandatory MV is inadequate the patient will now be trying to meet his O2 demands by breathing through the circuit. A/C is a better choice to reduce WOB, however requires closer monitoring, which shouldn't be an issue as your at bedside 100% of the time.

Long-term paralysis has been shown to worsen outcomes (I'll dig up the references today). It also hampers assessment. Usually the only time you see long-term paralysis indicated is with your more exotic vent modes (HFOV, inverse ratio). Asynchronous interface with the vent is usually a sign of inadequate sedation.

Hello,

"A/C is a better choice to reduce WOB, however requires closer monitoring, which shouldn't be an issue as your at bedside 100% of the time."

Good post. You are correct about the potential of mechanical ventilation increasing the work of breathing (WOB). In general, a ventilator is able to deliver three types of breaths. With A/C delivering the first two: Controlled & Assisted.

Controlled - the ventilator triggers the respiratory cycle and end it at a preset volume or pressure with the WOB removed by the ventilator.

Assisted - the patient triggers the vent and the ventilator 'assists' or finished the respiratory cycles with minimal WOB for the patinet.

Spontaneous - the patient starts and strops the respiratory cycle with the WOB depending upon the amount of pressure support provided.

Also, like usalsfyre noted, pain control is key. In some patients with pulmonary contusions and fractured ribs adequate pain control or blocks (epidurals, paravertebral, ects) are all that is needed to prevent respiratory failure and possible intubation as well.

Cheers

Edited March 24, 2011 by DartmouthDave

[HellsBells]

Here is a question for you: What do you think is causing the ugly looking EKG?

Based on the numerous PVC's, I'm gonna say my first 3 guess's are hypoxia, hypoxia, hypoxia.

You mentioned the pts in AFib @ 130-140, probably from hypovolemic shock rather than cardiogenic. However, do we know what caused him to fall asleep in the first place? Was he drunk, just sleepy, or was there another underlying cause? Was a 12 lead performed on this fellow?