A simple fall goes wrong

[scubanurse]

Bagging anyways... I don't want to deal with the vomit from hours of using a BVM.

[mobey]

Excellent

I chose to use 100mcg of Fentanyl to get her sedated without hypoventilating. She then accepted an NRB.

I used the NRB to get her Sp02 to 85%.

Then I pushed 20mg Ketamine. At this point the 2 synergized to provide adequate sedation without affecting ventilation or blood pressure, and allowed BVM preoxygenation.

It took 3 people to provide adequate BVM with a OPA, and an NPA (which caused epistaxis btw).

Once her Sp02 reached 94% I pushed 100mg Ketamine, and 120mg Succ and intubated first pass.

OK ..... lets move on..... this aint over

Post intubation vitals

BP 72/40 Pulse 70 Spo2 90% EtC02 12 Temp 37.6

Air entry sounds= crackles throughout, wheezes in apex's.

To recap treatments

So far: 7.5 tube, easy ventilation at 36 breath/min. 3lt of fluid in. Dopamine at 10mcg/kg/min. Sedated with Ketamine.

[scubanurse]

Wheezes are making me want some albuterol or humidified O2 blowing in with the mech ventilation...

Still really not happy about BP...

I'm thinking the Beta Blocker is working against the dopamine and therefore not helping to get that BP up.

This may be completely off the wall but hey...I'm still learning

How about a beta agonist like dobutamine? Probably not a drug you have but it's worth a shot?

Start an albuterol neb through the tube maybe? We need something to get her pressure up.

[DartmouthDave]

RSI a decompensated patient is courting disaster.

A little light sedation for the combative hypoxic and hypercapnic in most situations works like a charm. Put on nasal cannulas and pop in an OPA and a NPA and use good two-person BVM technique with some PEEP.

Once you get the sats up and some more fluid in you can secure the airway. It also gives you some time to do an airway assessment (if you haven’t done one yet).

The beauty of this approach is if you can’t pass the tube then you just start bagging again and try plan B (change blade, bougie, et al.) Keep bagging until the sats are back up and you are ready with your plan B.

Plan B fails then insert an LMA or a King LT. Or, just keep using a two-person BVM approach.

The AIME text book by Kovacs and Law is an excellent progressive source:

http://aimeairway.ca/

The Levitian and Winegart article on apneic ventilation is also useful. The EMCRIT site has some podcast on it as well.

http://www.annemergmed.com/article/S0196-0644%2811%2901667-2/fulltext

I find this approaches makes airway management and ventilation less of a crisis. I have seen countless intubations in the ED, ICU, ward, and with EMS and this makes a difference in most cases.

Thank you for your time,

David

[HellsBells]

What is the deal with her pulse rate? Has her rate not increased soley from the beta blocker admin? I think we need to increase the dopimine to 15mcg, then up to 20mcg, if no success I think a epi drip is in order, starting at 2mcg per min up to 10mcg min. What does her End tital wave form look like? Any evidence of broncospam? Shark tooth waveform?

[paramatt_]

Word. 72/40 = a MAP of 50

With 3l of fluid in and a chest like that, sounds like she's fluid overloaded as well.

+1 for the adrenaline infusion.

To go alone with Kiwi's ceftiraxone, I'd be reaching for a steroid as well..8mg of dexamethasone should suffice

Also, have you done a BGL recently? Probably not the most pressing thing at this moment, but if you have a couple seconds

[Kiwiology]

OK so we have secured her airway, nice. Little morphine + midazolam to maintain sedation as required.

If she has crackles then I am going to stop infusing fluid and go with just an adrenaline drip. Wheezes to me signals extrinsic bronchoconstriction from acute pulmonary edema so no salbutamol.

Her BP is absolutely shit but we cannot simply keep dumping fluid into her it's not going to do any good

I dno hmm .....

[fakingpatience]

I know its a long shot, but could we consider giving glucagon, to possibly counter the beta-blockers she takes, on the chance she received an excessive dose of those, not allowing the dopamine drip to raise her BP and HR?

[scubanurse]

I know its a long shot, but could we consider giving glucagon, to possibly counter the beta-blockers she takes, on the chance she received an excessive dose of those, not allowing the dopamine drip to raise her BP and HR?

I like this idea

[DartmouthDave]

Hello,

It isn't uncommon in severe sepsis to have myocardial dysfunction due to immune/inflamatory response. Typically, once the patient is fluid loaded and pressor (Levophed) is started we watch for three outcomes; (1) a decreasing lactated level (2) a VBG sat >75%. (3) Slowly correcting pH

If this isn’t the case a second agent is added to improve cardiac output. Like Dopamine or Doubatamine for example.

As for fluids. How much? This is a hard case. But, with poor perfusion and poor urine output more fluid seems reasonable. Switching to RL or a solution with a higher pH (Normosol ect…) is also helpful if you have been giving lots of NS. Excessive NS will give you a hyperchloremic acidosis which you want to avoid.

SCANCRIT is an excellent critical care blog. Here is a study they posted about the benefits of beta blockers in selected septic patients with cardiac dysfunction.

http://www.scancrit.com/2012/09/28/%CE%B2-blockers-give-survival-advantage-sepsis/

“Early stage sepsis results in a cathecholaminergic overdrive that could result in myocardial injury or dysfunction. Septic patients who get cardiac dysfunction or injury have a two- to fourfold increase in mortality.”

Also, Dr, Rivers published an excellent sepsis article in 2001 I think. It is worth a look on PubMed. EMCRIT has three pods casts featuring Dr. Rivers that is worth the time.

I am not sure about the Dex and steroids. I would hold off until a good pressor is online.

Cheers

Edited January 16, 2013 by DartmouthDave