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About DartmouthDave

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  • Occupation RN/PCP

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  • Gender Male
  • Location NS
  • Interests Travel, EMS, Camping, Blogging

DartmouthDave's Activity

  1. DartmouthDave added a post in a topic Bad Lungs Bad Transfer   

    Hello Everybody,
    My apologies for the delay.
    Here is some much needed information.
    The chest tubes:
    The patient was difficult to ventilate.  The airway pressures (PIP and plateau) were very high and the patient blew a (L) and (R) pneumothorax.  The patient was unstable and this bad turn of events has worsened the situation.  A CXR shows complete whiteout of both lungs and two well placed chest tubes.
    The patient height and weight:
    As noted by all the volumes are a bit excessive.  Lets say according to IBW calculations  is 60kg (6cc/kg = 360 7cc/kg = 420 8cc/kg = 480)  Do we drop the Vt slowly or quickly? 
    The labs:
    ABG: 6.9 / 80 / 70 / -11 / 11.2 (ph/co2/o2/be/lac)
    WBC 25
    HgB 60
    K 7.0 Na 135 Mg .60
    Cr 1200
    Ur 50
    The vent:
    AC 20/650/.8/+5 PIP:44
    I am not an expert on scalars and loops (I suggest watching chbare YouTube videos) .  What I can say is the patient was too awake.  Things settle down with proper sedation (RASS-3) and a good suction (copious amounts of secretions) but work still needs to be done.
    After suctioning and sedation only Vt of 100-125 is being delivered.
    Thank you,
    • 0
  2. DartmouthDave added a post in a topic Bad Lungs Bad Transfer   

    The ET and CT x 2 are in good position.
    The patient decompensated from the pneumos and the insertion of the chest tubes.
    The Fentanly is at 100mcg/hr and Versed at 5mg/hr.  She moves her arms wealy from time to time.
    The patient is on AC-VC with a volume of 650cc with a rate of 20. However, the high pressure alarm is ringing madly (PIP 40).  ETCO2 is 55. They are considering stopping the ventilator and bagging the patient.
    You start some IV fluids.  You push IV pressor of choice and the BP improves some.
    The patient had an admission 18 months ago for an autoimmune vasulitis of her lungs.  Despite an extensive workup no soild dx was made.  However, she resonded to Methotrexate and was switched to oral steroids.  The patient secretly stopped taking the steroids due to excessive weight gains.
    Also, the patient had flu-like symptoms and has developed a red lesions on her feet.
    Thank you,
    • 0
  3. DartmouthDave added a topic in Scenarios   

    Bad Lungs Bad Transfer
    You are dispatched for an urgent transfer from a regional hospital ICU to a larger university hospital.
    You arrive to a very hectic and busy room in the ICU.
    An 18 year-old female was admitted  three days ago for worsening SOB that has progressed to respiratory failure that required intubation by day 2.  
    Things have worsened dramatically over the past 24 hours.
    She is sedated (Fentanly+Versed) and ventilated.  Alarms are endlessly ringing. 
    VS as follows:
    HR 150
    BP 70/40
    SpO2 72%
    Lastly, bilateral chest tubes have been inserted.
    Thank you,
    • 9 replies
  4. DartmouthDave added a post in a topic Unresponsive   


    Thank you for posting.

    Lets start with our initial assessment.


    Get her on the monitor and see what happens next.

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  5. DartmouthDave added a post in a topic Influenza & Bubbling Chest Tubes   


    In Critical Care Nurse there is an interesting article by Darcy Day 'Keeping Patients Safe During Intrahospital Transport'. In this article, MV was cited as one of the more frequent transport complications.


    I agree with iStater and Triemal04 that caution is the best option with these complex patients. Change things slowly.

    I have seen some teams (...and I have been guilty of this myself...) of mucking around too much.


    Hello iStater,

    "Transport ventilators do not compensate for compressible volume loss."

    How do you calculate this? Do you double you PIP?

    Thank you,

    • 0
  6. DartmouthDave added a post in a topic Whatcha Gonna Do?   


    This patient has chronic pain. In the initial post, if I recall, there was indication that he has been taking extra Oxy for pain. From my experience it is not uncommon for chronic pain suffers to take an extra dose. Especially when there is some acute on chronic pain. Also, it is difficult for these patients to OD with opiates alone (mixed OD is a different case). In fact, looking back, I have seen more opiate OD in the hospital setting with opiate naive patients. In the prehospital I only have seen one opiate only OD that was serious (of course some geographical areas are different....I had a friend who worked in Philadelphia in the 1990's....I degrees).

    Second, this fellow had a rapid decrease in LOC. Is it primary a cardiac event or is a neurological event? With a sky high blood pressure, abnormal muscle movements, and deviated gaze I am thinking neurological.

    As for the bradycardiac. First, take a quick listen to ensure that we have good air entry and make sure we do not have an pneumothorax on the go. I would give him Atropine 1mg IV (so much for pupils checks by neurosurgery.....lol). Give Propofol IV PRN and aim for deep sedation. With luck, this will reduce his assumed ICP. I would also work on bring down the CO2 to 40 or so.

    Get him loaded with the HOB at 30 degree and head inline to ensure good venous drainage.

    • 0
  7. DartmouthDave added a post in a topic Whatcha Gonna Do?   


    Thank you for post a scenario.

    I agree, this fellow needs an airway (protect and predicted course). I would do an airway assessment, set up the equipment and brief everybody on the plan.

    I am not sure about Vecuronium because I have no experience with it. If I recall it is fairly long acting.

    I would go with Rocuronium 50mg IV followed by Propofol 100mg IV. My rationale for Propofol is it is neuroprotective and we have plenty of pressure to work with.

    For post intubation management I would use a Propofol gtts (if you have a pump) or Propofol 50mg IV PRN. My goal ETCO2 would be 40.

    If possible, I would try and get the BP below 160.

    As for the ugly EKG this may be due to ICP and brain stem issues.

    • 0
  8. DartmouthDave added a post in a topic Anaphylaxis   


    Thank you for posting a scenario.

    If the ALS unit is only 15 minutes away perhaps staying might be a good idea. It will take time to get this unstable child into the ambulance. Second, this is an anxiety producing event so people will be on edge. I have seen a few BLS/ALS intercepts turn into a gong show because the units fails to RV at the correct location. Unless of course a hospital is very close. Then maybe transporting the patient to an ED could be an option.

    The BLS crew should give epinephrine IM, get him on a stretcher, monitor, o2, and a line. If they do not have epi they should see if the mother has another epi pen to give.

    • 0
  9. DartmouthDave added a post in a topic Influenza & Bubbling Chest Tubes   


    Thank you for the answer iStater. I have seen a few occasions in the past that people rush too fast to the minimal 6cc/kg VT or have made the VT so small that nothing much is left after deadspace. Thanks.

    I am unsure of all the details. As we all know follow up sometimes isn't the easiest. The patient had developed some sort of fistula from the spinal needle. Hence the massive air leak. Luckly, the leak went away with an occlusive pressure dressing.

    This lady was sick. The question is, "How much do you try and fix or change before you leave?" Sure, you know that things are a little off the rails but do you or can you fix it all?

    My point of view is effected by the fact that I have spent a long time in the critical care setting. You slowly make changes over a shift or a few days.

    • 1
  10. DartmouthDave added a post in a topic Dizziness with Fall   


    Thank you for an interesting scenario Chris.

    SAH and other catastrophic neurological events can cause a profound dilated cardiomyopathy. A neurosurgical unit I worked at many years ago saw a few 'stunned hearts' from SAH.

    Also, a year or so ago, a women came into the ED with a SAH (grade III) was hypotension despite and impressive ICP. However, I have never seen or heard of QRS prolongation from a SAH.

    In addition, it is fairly common to have ST elevations with SAH as well. Why this happens........who knows!!!!......I have never found an adequate answer nor received one the many keen people I have asked.

    Overall, I can not think of anything to add treatment wise. Fluid and a Levophed or Epi to support the BP.

    Chris, I am interested to hear what the outcome was.


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  11. DartmouthDave added a post in a topic Influenza & Bubbling Chest Tubes   


    I had a great reply and I lost it. =(

    Ok, iStater, she has been on these setting for around a day. I can not comment too much on the waveforms (not my strongest area). However, I can say they look like normal shark-fin like volume waveforms without any auto-peep. You work out her ideal body weight lung volume and lets say it is 450cc.

    The red spot is from the needle decompression after she developed a tension pnx from a central line attempt. Now, when you push down on it the air leak stops in the chest tubes. Also, when you push on it the turbulent noise stops. Very odd.

    Here is a question for you. I know that ARDSnet like small tidal volumes. Now, for the small peanut sized patients is there a point that you just can not cut the VT? Otherwise, the way I see it, the dead space will eat up most of your VT.

    Rock Shoes: Good idea, you push Tyl 1gm down her NG

    • 0
  12. DartmouthDave added a post in a topic Influenza & Bubbling Chest Tubes   


    I was going by memory, but in essence, the ABG shows ok oxygenation and co2 for such sick lungs. The bad BE and lactate is from poor perfusion and worsening renal function.

    Her earlier ABG look awful with low PaO2 (50) and hight PaCo2 (70) ON 100%.

    When you listen to her lungs you hear a loud turbulent sound and feel some subcutaneous air. Incidentally, there is a red spot were she was decompressed with a spinal needle. The chest tubes are bubbling vigorously.

    The consensus from the post seem to want to reduce sedation to improve hemodynamics. So, you back off on the sedation and for the sake of argument you go with Ketamine or Propfol. You can back off on the Levoped some as well (.3mcg/kg/min).

    This improves her pressure some. She is in the 100-120/50 range now. HR is still 100+ and her temperature is 39.5C.

    The nurse says she is doing ok now but if you move her too much she SpO2 bottom out.

    We are on the fence about the Nimbex it seems.



    She is 80kg and around 5 feet tall.

    You do an other gas (please don't look too closely at the numbers) and her PaO2 is 60 and her PaCO2 is 45 with a pH of 7.40 or so. The RT flow sheet and the notes are erratic and it is hard to figure out how she arrived at her current setting.

    • 0
  13. DartmouthDave added a post in a topic Influenza & Bubbling Chest Tubes   


    Sorry for the slow reply. I upgraded my computer at home and I can not figure out how to turn off the 'ad blockers' software and I can not login to EMT City. I will get my IT department (brother-in-law) to fix things for me.

    The chest tubes were put in because the patient developed a tension pneumothorax after a couple attempts at a central line. The patient coded and a spinal needle was used to decompress her (that all they could find in a rush) There is a small red spot where the needle was inserted.

    Her CXR is white out with a small effusion on the right side. The chest tubes are in good position on the left.

    She is positive 6000cc and her urine output has been falling.

    K 5.2
    Na 145
    Hgb 80

    Lact 9.0

    Cr 200
    Urea 12

    INR 1.5
    PTT 55

    She has a right femoral central line and IV x2. She was a right radial arterial line with a good waveform.

    She is on AC 25/550/1.0/+22 ABG (7.40/60/45/-11/9) with a PIP of 36

    She is on Levophed at .5mcg/kg/min (80kg so 40mcg/min)

    Propofol 150mg/hr + Fentanyl 150mcg/hr + Versed 5mg/hr. Her BIS is 35 so she is deeply sedated. The Nimbex is a 2mcg/kg/min (TOF 0/4).

    Otherwise, she is a healthy 52 year-old women who is a little overweight who walked in very ill.

    • 0
  14. DartmouthDave added a topic in Scenarios   

    Influenza & Bubbling Chest Tubes

    You are part of a ground critical care transport team and you have been dispatched to transfer an influenza patient from a community hospital ICU to the local university hospital. The transport time to the university hospital is 90 minutes.

    The patient is a 52 year-old women who present to the ED three days ago with SOB, confusion, hypotension, and respiratory failure.
    She was intubated, started on antibiotics, given IV fluids, and admitted to the ICU. Her condition has decompensate further and she has been started on Levophed to support her BP. In addition, she has been difficult to ventilate and has had two chest tubes inserted for a left-side pneumothorax.

    You arrive and you find the patient sedated (Propofol + Versed+ Fentanyl gtts) and paralyzed (Nimbex). Levophed is infusing as well. Two chest tubes are bubbling vigorously on the left side.

    VS are troubling (HR110 BP 90/40 SpO2 88% Temp 39). Lastly, your patient is looking gray with mottled feet.


    • 25 replies
  15. DartmouthDave added a post in a topic My back hurts   


    The pain out of proportion worries me. I have seen folks land in the ICU with soft-tissue badness this way (i.e. NF/Fournier).

    Also, I have seen pain out of proportion with compartment syndrome. However, I must admit, that I have never seen gluteal compartment syndrome. Besides, how did it develop? The patient did not pass out in one position for a long time from what I have read.

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