Just Plain Ruff Posted March 15, 2012 Posted March 15, 2012 Well this lady seems to more than likely have had some sort of cerebrovascular incident since the nursing home fed her. I'd call for helo and have them meet us. I'm gonna tube her both to protect her airway and to increase my tube stats. So what is the difference between your Primary stroke center and your Major hospital with surgery???? I'd Like to know because there is a difference of only 15 minutes. Does the Primary stroke center do surgery or not???? 1
AnthonyM83 Posted March 15, 2012 Posted March 15, 2012 "I'm gonna tube her both to protect her airway and to increase my tube stats." - LOL, I just +1'ed you for that... I want to take a closer inspection of the throat and neck. I'm assuming the reaction to the OPA was pressure in the pharynx nerves interrupting brain stem function, though (and possibly food causing similar response). Does her oxygen sat improve with the nasal cannula? I'll move on to D. Pupils? Any sort of posturing? Also a quick head to toe exam. Signs of recent injury perhaps. Since she's on the cot, let's get her in the ambulance. I'd like to tube there and prevent further aspiration. I want to confirm the staff witnessed her go from normal to abnormal, so we can confirm the fibrinolytics window. Go to the stroke center. Try to find out why she's on prednisone (and confirm name of eye drops...they have some crazy meds in eye drop form these days). Once intubated she might also be a candidate for hyperventilation...but I'd contact medical control on this.
mobey Posted March 16, 2012 Author Posted March 16, 2012 Well this lady seems to more than likely have had some sort of cerebrovascular incident since the nursing home fed her. I knew that chicken didn't smell right I'd call for helo and have them meet us. Rationale? I'm gonna tube her both to protect her airway and to increase my tube stats. So what is the difference between your Primary stroke center and your Major hospital with surgery???? I'd Like to know because there is a difference of only 15 minutes. Does the Primary stroke center do surgery or not???? No. We have a unique system out here in the sticks. One of the nearby "health centres" staffed with GP's, has a head-only CT scanner. The scan is read by a neurologist in the city in live time, then the patient is placed in front of a camera hooked to a monitor in the city and the neurologist will assess using the smalltown GP as his "remote arms" "I'm gonna tube her both to protect her airway and to increase my tube stats." - LOL, I just +1'ed you for that... I want to take a closer inspection of the throat and neck. I'm assuming the reaction to the OPA was pressure in the pharynx nerves interrupting brain stem function, though (and possibly food causing similar response). No food bolus. That is what I chalked it up to as well Does her oxygen sat improve with the nasal cannula? Yes 97% I'll move on to D. Pupils? Any sort of posturing? Pupils small and non-reactive. Now decorticate posturing to deep painful stimuli Also a quick head to toe exam. Signs of recent injury perhaps. Notta Go to the stroke center. Rationale? Try to find out why she's on prednisone (and confirm name of eye drops...they have some crazy meds in eye drop form these days). You can ask her but I doubt she'll answer (Haha... being a dick, I know) As for the eye drops "We" left them in the appt. Hey I never said I was without flaw! Once intubated she might also be a candidate for hyperventilation...but I'd contact medical control on this. Welcome to my world... There will be no cell phone reception for about 15-20min, then you will have it for about 10min. Super cool to see you join in Anthony. What would ya'll like to use to intubate? Repeat vitals Bp 150/98 RR 24 deep, nonlaboured Sp02 97% BGL 5,4 (normal) HR 48
AnthonyM83 Posted March 16, 2012 Posted March 16, 2012 Agh, so I'm kinda lazy in finding the page where you gave the ETA's to the different receiving hospitals, but rationale is that she's showing signs of possible CVA. A stroke center would be more equipped to handle. One of the best things they have is experience and protocols set up to minimize delays. They tend to have a stroke team waiting at the door (I know, depends on the hospital), can get vitals and a quick stroke screen in a few minutes, followed by a CT in only a few more minutes, with neurologist consult pretty quickly. Speed and experience and equipment. What's her height and weight? Probably a Mac 4 or 3, and a 7.5? I'm picturing a not so large lady... I will say I'm going to take a moment to pause and think...I have a patient with adequate non-labored respirations, good saturations. While she lacks a gag reflex, if I tube her I'm now going to be trying to match respirations (no vent). Agh. BUT she also has a very high aspiration risk.... Just saying, it's something to think about...
Kiwiology Posted March 16, 2012 Posted March 16, 2012 I will intubate using a Mac 4, 7.0 cuffed tube, anaesthetise with fentanyl 1mcg/kg, ketamine 1.5mg/kg; paralyse with suxamethonium 1.5mg/kg and vecuronium 0,1mg/kg If her time to hospital was not so extended I would not intubate right now and see how the LMA went No hyperventilation from me; ventilate to maintain EtCO2 30-35mmHg
Vorenus Posted March 16, 2012 Posted March 16, 2012 I will intubate using a Mac 4, 7.0 cuffed tube, anaesthetise with fentanyl 1mcg/kg, ketamine 1.5mg/kg; paralyse with suxamethonium 1.5mg/kg and vecuronium 0,1mg/kg If her time to hospital was not so extended I would not intubate right now and see how the LMA went No hyperventilation from me; ventilate to maintain EtCO2 30-35mmHg Why would you want to use both?
Kiwiology Posted March 16, 2012 Posted March 16, 2012 Suxamethonium only has a short duration ~15 minutes or there about, vecuronium is a much longer acting neuromuscular blocker
Vorenus Posted March 16, 2012 Posted March 16, 2012 (edited) Suxamethonium only has a short duration ~15 minutes or there about, vecuronium is a much longer acting neuromuscular blocker Sure enough, but after having the tube in that throat, you don`t need the patient to be paralyzed anymore. You just need the paralytic agent to get through the vocal cords, it`s not needed for post-intubation anaesthesia. Edited March 16, 2012 by Vorenus
Kiwiology Posted March 16, 2012 Posted March 16, 2012 Kiwi, why do we need continued paralysis? To maintain the presence of the endotracheal tube post-intubation; using paralysis in combination with sedation is likely much safer than using sedation alone; and we'll be able to use a lower dose of sedation.
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