Threw up and can`t breathe

[DartmouthDave]

Fluids to get the CVP over 8 mm Hg and hopefully that will improve the SvO2 and urine output. This is not a good time to be in renal failure.

What is the BP now? There might be a pain issue that can be addressed without interfering with the respiratory drive. The BP MAP should be maintained over 65 mm Hg.

If the ABG was drawn on a NRBM, we would use 0.85 or 0.90 as the FiO2 for the PaO2/FiO2 calculation. That gives a PF ratio of 67 which is very, very serious. Some should take not that the SpO2 was mentioned at 88% which is possible but in this situation, the SpO2 does not reflect the seriousness of this patient.

If this patient is on a humidified high flow system delivering an FiO2 of 1.0, that may be difficult to transfer. BTW, if you see a standard humidifier running of a standard flow meter (not one capable of 70+ L/M) that device will not be delivering an FiO2 of 1.0 to an adult breathing at a RR of 34. It would take at least two ("Dual") humidifiers to get a little closer to an FiO2 of 1.0. The standard humidifier with an aerosol mask, even though it may say 100% on the adjustment, will probably be delivering an FiO2 of around 0.60 for an adult with a high respiratory rate and MV.

What do those of you from other countries have available on your CCTs for high flow O2? I know Canada and Europe will generally have the better meds and technology available to them long before the U.S. Even our ICU equipment and especially the ventilators are usually at least 5 years behind your latest and greatest.

Hello Vent,

Sorry, I left out some information in my last post. This fellow is on a high flow oxygen mount that wide open. So, odds are he is getting around 60% or so. It isn't a dual system. Just a standard hospital wall mount.

His Co2 has risen so he is getting tired as you know. His VS are worsening slightly as well. GCS 14 (Drowsy) BP=130/70 MAP=90 HR=130 SpO2=82%

Urine output is still low. There was 20 out on arrival. Since then, nothing. CVP = 6 Fluid is a good idea.

Sv02 is low. His Hgb is also marginal. But some fluid should help this.

The ambulance has an LTV1000 (no graphic displays with this model...flow loops ect..)and 2 Mini Med III pumps. A CPAP mask for the LTV (I am sure they can do this...correct me if I am wrong). Plus a good selection of medications. A Zoll CTT monitor that can transduce CVP and an arterial line.

So, yes, it would be very difficult to transport this patient in a back of an ambulance on high flow. Also, I wonder if the ambulances O2 tank has enough psi in it to last for a long drive.

Cheers...

PS....Don't read too much in to the gases. I am just making up the numbers to show resp alkalosis (resp failure) moving to a tried patient (working towards a resp acidosis). =)

I should clarify, this sort of job here would be undertaken by a physician or some specalist as even our Intensive Care Paramedics are not trained to take care of somebody this crook.

The hospital would send somebody because he is on a lot of meds and things Ambulance Officers have no experience in.

Hello Kiwi,

OK, the hospital is willing to send a nurse or an RT. Your pick. The RT in this ED has intubated patients before but not for a long time (over 18 months). The RN has lots of ICU and ED experience. She worked in a larger hospital and move to a small town for a more mellow life. Also, the EP has not intubated in quite awhile as well. He can't leave because there isn't anybody to cover the ED or the admitted patients if something goes wrong.

This is why there is trepidation about tubing this fellow.

Cheers.....

Summary of Discussion:

So, give it a go with high flow O2 and hope all is well by the time you arrive at the university hospital? Or, get a tube? If so, what would be the safest way to do this? What medications? RSI?

Is this BP elevated due to a stress response from the patient? He has had a 4-5 day history of poor intake. Or, is his volume fine? Low urine output as well. Give more fluid or not? (i.e. 1000cc plus or just maintenance rate of 125cc/hr)

What extra staff do you want in the ambulance?

Any lab concerns?

Cheers....

Edited April 3, 2010 by DartmouthDave

[VentMedic]

Sv02 is low. His Hgb is also marginal. But some fluid should help this.

The ambulance has an LTV1000 (no graphic displays with this model...flow loops ect..)and 2 Mini Med III pumps. A CPAP mask for the LTV (I am sure they can do this...correct me if I am wrong). Plus a good selection of medications. A Zoll CTT monitor that can transduce CVP and an arterial line.

So, yes, it would be very difficult to transport this patient in a back of an ambulance on high flow. Also, I wonder if the ambulances O2 tank has enough psi in it to last for a long drive.

For the H&H, blood products would be in order to improve O2 carrying capacity and help with the MAP.

As for the ABGs, you have given info on a CXR and a PaO2 that warrants an immediate plan of action. Just using the SpO2 would be inadequate for this patient even though that might be a accurate number given the low Hb and possible shift on the oxyhemoglobin dissociation curve.

The LTV 1000 is a good vent of choice and bilevel ventilation would be needed for a patient with increasing CO2. CPAP alone would tire the patient quicker. However, the esophagus, vomiting and gagging is still a great concern and NIV probably would not be the way to go. At well, with the PF ratio being less than 100, it would be very difficult to justify transporting out a definitive airway. Actually, it would be career suicide.

Even the tiniest of hospitals will have an Anesthesiologist and/or Pulmonologist on call. The airway should be secured at the hospital in a controlled environment. The anesthesiologist will more than likely have access to a fiberoptic scope or the RT can provide one which is commonly used for routine bronchoscopies (even in tiny hospitals) and intubations. Some tiny hospitals also have ENTs doctors who can be called to assist.

Without the extra resources and you make the decision to do RSI on this patient, the situation may be really bad. Due to the esophageal problems and other anatomical structure issues, you probably will not get the tube and the patient will die. Even placing the larygnoscope blade can be difficult. Bagging may end present some other issues with the esophagus and abdomen. Watch the belly. And,good luck with doing a cric without the consult of a really good ENT at bedside.

I see many of these patients in the ED, on Specialty transports and in the ICUs. Each day I get a list of which doctors are on call and their direct cellphone numbers. We don't screw around with beepers for these cases. If on transport, I find out the sending hospital's resources and have our physician (or I) make suggestions during the phone report as to who to call or what equipment to have available prior to our arrival. For some patients I may have the ability to speak with the surgeon who did the cutting and rearranging of the patient's anatomy. He/she may say something like the patient can be intubated by fiberoptic through the right nare only. Sometimes the larynx is relocated and modified. Not many ALS or even CCT teams have that luxury of speaking with the patient's physican or knowing the history. If I don't get much information, I prepare for the worst case and hope for the best. Luckily these patients usually know when they are getting into trouble and will contact their physician who will refer them quickly to the best facility or at least one that can be accessed quickly by a Specialty Team from another facility. Thus, EMS and ALS CCTs teams will not see these patients but they definitely do exist along with many bizarre airways.

A truck that is expected to do CCT calls should have a 50 psi regulator on their tank. All of our E tanks now have the 50 PSI port on them and the D tanks have a 50 psi port on the regulator which we use for transport ventilators.

Also, if the patient is seriously sick, a Specialty team may have access to an ICU vent that can be adapted to transport.

And, since a flu of some type might be suspected, respiratory precautions should be taken in the presence of any high flow O2 device. This also includes devices that EMS calls "high flow" such as the nonrebreather mask.

Edited April 3, 2010 by VentMedic

[DartmouthDave]

Hello,

So, the decision is made to tube this fellow (good call). The plan is to use a fiberoptic scope. The patient is given a small dose of Versed (2mg) and an awake laryscope is done. It is difficult to see the cords and there is tons of dried secreations coating the back of the throat and what can be seen of the cords. The EP feels confident that he can get the tube in. Back equipment is made ready.

He is given Propofol 50mg and then Succinycholine 100mg. A #8 ET is passed without comlications. The tube is suctioned for think brown nasty junk.

The patient develops profound post-intubation hypotension (77/40) and is given a bolous and Levophed is started at 10mcg/min. The patinet is placed on the ED's ventilator. No overtly high peak or plateau pressures. A good Vm is being given.

The VS are as follows:

GCS - sedated

BP = 97/40 Map 57

HR = 144 (alram sounds.....VT...the monitor shows a wide complex tachycardia)

SpO2 = 94% on the vent

Urine = 0

CVP = 4

Cheers.....