A simple fall goes wrong

[Kiwiology]

In the first instance I would like to sedate her a bit with some ketamine and see if she will tolerate passive oxygenation as opposed to completely anaesthetising and paralysing her because if we do that then we have to sit squeezing a bag mask for the next two hours until we get to the hospital (automated ventilators coming next year apparently) and also because it is a less invasive procedure.

She could be in CHF however if this were the case I would suspect significant worsening of her respiratory status and possibly either extravascular edema or the production of a lot of pink frothy sputum or both because if we have given her four litres of fluid it would have horrendously expanded her extravascular fluid and it would either end up in the interstitium or alveoli

[mobey]

Kiwi, you are very close to my way of thinking... not quite, but close.

I agree that RSI is indicated, however let me repaint this picture for you:

You have an extremely hypoxic (Spo2 77%, blue, diaphoretic, confused), Obeise patient who is combative.

IF you choose to just slam a bunch of meds & RSI this patient, there is a HUGE risk of an inability to bag with a mask to preoxygenate (Think sleep apnea).

So the decision becomes: 1) Accept the risk of intubation without preoxygenation and quickly intubate

2) Find a way to preoxygenate her

3) Find a way to oxygenate her without intubating

4) Assume fetal position in corner of ambulance and wait for her to code (ACLS is easy)

[Kiwiology]

Before we begin, some premedication sounds good, of me, with valiumz, amitriptiline, prozac and these little blue pills the Doctor put me on as well

I just saw this as I was out the door to work, I will have a think about it and post later from teh medicalphone ....

[Kiwiology]

Man what a bitch this situation is, fo realz, I reckon we need to oxygenate her without the need for intubation, now that can be either sedating her and using a bag mask with PEEP and passive ventilation or using an LMA.

She is likely to be a very difficult intubation so if we do need to tube her then we need to pre oxygenate her by sedating her with some ketamine say 0.5 mg/kg, a tight fitting bag mask with PEEP of 10 or 15 and a nasal cannula set to 15 lpm then intubating her using a bougie, which we should be using as standard anyway oh and lots of anterior laryngeal pressure.

[Arctickat]

My backup tube would be a King.

[DartmouthDave]

Hello,

I agree with a little light sedations as a means to preoxygenate the patient before intubation is a great idea.

The nasal cannulas for apneic ventilation is an other good idea.

I also like Kiwi idea of a LMA. As of late, I have been reading about the concept of sedation and ventilation with an LMA or King LT. I think the term is 'rapid sequence airway'. Personally, I have no experience with this.

Kiwi, do you use this as a bridge to intubation?

Cheers

[scubanurse]

I like the idea of a flight for this lady

It's an interesting idea to sedate then use an adjunct... what would you sedate with?

[Kaisu]

I would be extremely loathe to use any of the benzos in someone this compromised. I would RSI her without preoxygenation. If I couldn't get the tube on the first attempt then there is the Combi-tube and last but not least the crike.

[scubanurse]

I'm thinking like 2mg morphine with 25mg of benedryl or 6.25 of phenergan IV might be enough to settle her down long enough to pre-oxygenate before considering RSI.

If we get good compliance with BVM...maintain the morphine combo until advanced help arrives...

[Arctickat]

Kaisu, why no benzos? It may improve compliance. What we need to remember is the cause of her decompensation. She's septic and in respiratory compromise. We can fix the respiratory compromise definitively with a complete MFI. hmmmmm...is the reason you guys are trying to avoid intubation because you don't want to use a BVM for a couple of hours?