mobey Posted December 23, 2011 Posted December 23, 2011 This is not a test, just looking for credible opinions. Obvioustlythere are a few things I would change. *Medication doses are non-negotiable* 78 Y/o COPD patient in bronchospasm. Grey looking, obvious distress. Home 02 at 4lt. Tripoding, 3 word sentences. Resp rate 34, BP160/90. HR120 SpO2 90% on NRB by first responders. EtC02 68 Been SOB for 5hrs Initial treatment *5mg salbutamol w/500mcg Atrovent *Dexamethasone 8mg IM *2gm MgS04 *500ml NaCl through 2 18G IV. No real improvement *Start 2nd Neb with same breathing treatment as before. *CPAP applied Reassess: After 5min of CPAP, pt improving. Color better, Sp02 97%, EtCo2 50. About this time the patient reaches up and breaks the CPAP port off (hard to explain.... if you request I'll explain) Anyway..... CPAP mask removed & Nebulizer re-applied. Reassess: (this is now 1min post removing CPAP) BP:160/108 HR170, Sp02 97%, EtC02 80, colour GREY. Pt lying head on pillow c/o fatigue. Noted decrease in Resp rate. Sedate Pt w/1.5mg/kg Ketamine and pass #7tube. Confirm via visualization, EtC02, auscultation. Ventilation difficult - Parilize with 1mg/kg Rocuronium. BTW: I have a 40min transport to nearest ER. Continue sedation with .5mg/kg ketamine, and paralysis with Roc. Ventilated EtCo2 50. Sp02 98. Colour pretty good. Stop in at local ER for more drugs, foley, blood gas, chest x-ray, and back on the road. Continue as before, as well as MDI ventolin q20min About 45min later, noticing the pt becoming hyper dynamic (tachycardia at 130, BP 140/96) obvioustly resedation attempted x2 but no effect. So I thought perhaps it was all the freaking ketamine he has been having all day! Started a Versed drip at 5mg/min after a 5mg Bolus. Fentanyl 100mcg PRN To b continued.... sorry gotta run
chbare Posted December 23, 2011 Posted December 23, 2011 Sounds reasonable. What were the results of the patient's gas and what did his lungs sound like? Also, did you manage to obtain history on this patient? What ventilator settings were you using?
Vorenus Posted December 23, 2011 Posted December 23, 2011 (edited) This is not a test, just looking for credible opinions. Obvioustlythere are a few things I would change. *Medication doses are non-negotiable* 78 Y/o COPD patient in bronchospasm. Grey looking, obvious distress. Home 02 at 4lt. Tripoding, 3 word sentences. Resp rate 34, BP160/90. HR120 SpO2 90% on NRB by first responders. EtC02 68 Been SOB for 5hrs Initial treatment *5mg salbutamol w/500mcg Atrovent *Dexamethasone 8mg IM *2gm MgS04 *500ml NaCl through 2 18G IV. No real improvement *Start 2nd Neb with same breathing treatment as before. *CPAP applied Reassess: After 5min of CPAP, pt improving. Color better, Sp02 97%, EtCo2 50. About this time the patient reaches up and breaks the CPAP port off (hard to explain.... if you request I'll explain) Anyway..... CPAP mask removed & Nebulizer re-applied. Reassess: (this is now 1min post removing CPAP) BP:160/108 HR170, Sp02 97%, EtC02 80, colour GREY. Pt lying head on pillow c/o fatigue. Noted decrease in Resp rate. Sedate Pt w/1.5mg/kg Ketamine and pass #7tube. Confirm via visualization, EtC02, auscultation. Ventilation difficult - Parilize with 1mg/kg Rocuronium. BTW: I have a 40min transport to nearest ER. Continue sedation with .5mg/kg ketamine, and paralysis with Roc. Ventilated EtCo2 50. Sp02 98. Colour pretty good. Stop in at local ER for more drugs, foley, blood gas, chest x-ray, and back on the road. Continue as before, as well as MDI ventolin q20min About 45min later, noticing the pt becoming hyper dynamic (tachycardia at 130, BP 140/96) obvioustly resedation attempted x2 but no effect. So I thought perhaps it was all the freaking ketamine he has been having all day! Started a Versed drip at 5mg/min after a 5mg Bolus. Fentanyl 100mcg PRN To b continued.... sorry gotta run I`d like to answer more, but I really need to go to bed. Just some things. I don`t see the constant need of Rocuronium here. Why didn`t you just sedate with Ket and Versed? First guess would go into the raw direction of pulmonary edema - regarding to the EtCo2 getting better after CPAP. How much PEEP did you apply? Edited December 23, 2011 by Vorenus
paramedicmike Posted December 23, 2011 Posted December 23, 2011 I'm not seeing anything here to raise any huge flags. I'm curious, too, about lung sounds. Would he have taken a second CPAP mask? Just wondering realizing that if he broke the first one a second one might not've done much good.
chbare Posted December 23, 2011 Posted December 23, 2011 (edited) He was more than likely headed toward intubation regardless. Let's make some assumptions and create broad boundary conditions based on a "normal" patient since we do not have labs. Using perfectly normal gasses as my starting point, I have the following: PaCO2 40, HCO3- 24, Ph 7.4. Using Henderson Hasselbalch: Ph = pKa + log ( HCO3-/ PaCo2*0.03) log of 24/1.2--> log 20 --> 1.3 The coefficient of pKa in this case is 6.1 and that will apply throughout the bodynasnallmthe (EDIT: as all the) buffering systems are in equilibrium. 6.1+1.3= 7.4 Hopefully, you can accept what I did above as quantative proof for what I am about to do next. So, we look at this patient and we have an ETCO2 of 68. Being conservative, I will assume a gradient of 5 to give me a PaCO2 of 73. Let's see what the pH was at initial contact: Using the quantative method above without changing the HCO3-, you get a pH of 7.14. This is clearly much lower than the common cutoff of around 7.25 when considering respiratory failure and intubation. However, we can play around and assume this patient has metabolic compensation. Let's be generous and increase the HCO3- to 30. This still gives us a pH of 7.24. Even with metabolic compensation, this patient would clearly be in trouble. While I am not exactly sure of the patient's gasses, what I did above works as a good first approximation. Edit: phucking iPhone and it's phucking predictive entry!!! Edited December 23, 2011 by chbare
DFIB Posted December 23, 2011 Posted December 23, 2011 (edited) I agee with everything cbare wrote! This is so obviously a thread for medics but I simply can't resist. Was his chest x-ray negative? Did he have Jugular Vein Distention? Was his trachea midline? What were his lung sounds? Edited December 23, 2011 by DFIB
tniuqs Posted December 23, 2011 Posted December 23, 2011 (edited) Ok the CPAP device, what type was it ? Second question .. so what PEEP level and did you put a flow diverter with PEEP on the BVM post intubation ? Edited December 23, 2011 by tniuqs
Kaisu Posted December 23, 2011 Posted December 23, 2011 OMG.. what a nightmare. The only comment I can make is possibly counteracting the hyperdynamic circulation problem with fluid. Your ETCO2 and SPO2 are pretty good (for this guy), Breathers are so often hypovolemic after at least 5 hours of increased work of breathing. Please forgive my simplistic approach... I know I don't know what you and chbare do, but this is what I would do if it was me.
DartmouthDave Posted December 23, 2011 Posted December 23, 2011 Hello, Looks good to me. Just one question: Why such a small tube? Cheers
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