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Yet another respitory call


mobey

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Oh man, where's the rest of the thread? Come back and finish!!!

Wendy

CO EMT-B

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  • 3 weeks later...

Oh man, where's the rest of the thread? Come back and finish!!!

Wendy

CO EMT-B

Kinda forgot about this!

Thx for pointing out the obvious Dave.... ughh. Brainfart

Once the pt became hyperdynamic....

5.0mg Versed IVP w/100mcg Fentanyl.

Versed drip started at 5.0mg/hr and Fentanyl IVP prn (about every 20-30min.)

When the initial Versed.Fentanyl was pushed the pt's BP crashed to 60/40 MAP50ish.

I fluid bolused 1000ml NaCl and the BP recovered.

From that point it went fairly well. The Sp02 stayed up, EtC02 stayed acceptable and the pt was admitted to ICU.

The patient spent 3 days on the vent, then biPAP, then home 3 weeks later.

Reflecting on the call, I blamed myself for allowing him to break the CPAP, and my mngr for not having a spare available. I decided that was the reason he needed intubated.

On further research, it appears I may be wrong. I have not found literature supporting my theory that people suddenly removed from CPAP decompensate immediatly as this pt did. It appears it takes 4-6min for airway dynamics to change.

Squint: No PEEP for this fella!

Oh ya.... within the first 5min of being in the ICU, the tube was changed for an 8.0. How embarrasing :shutup:

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One quick question - do you think that any of his issues with ventillation and perfusion had anything to do with the smaller ET TUbe?

No, since I saw improvement the minute the tube went in. However, I did have to deal with a leaky cuff the whole time.

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No, since I saw improvement the minute the tube went in. However, I did have to deal with a leaky cuff the whole time.

I wonder what the ramifications of a leaky cuff are? I'd be interested to see if not having a good cuff seal has any types of detrimental long term effects on a patient. Just thinking out loud.

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I wonder what the ramifications of a leaky cuff are? I'd be interested to see if not having a good cuff seal has any types of detrimental long term effects on a patient. Just thinking out loud.

Well of course there are. A leaky cuff means the airway has not been isolated. This pt was paralyzed so active vomiting was not an option, but passive regurgitation causing a aspiration pneumonia is a real threat.

This is the reasoning behind EVAC et tubes.

In the case of a leaky cuff, I am diligent to ensure frequent suctioning of the hypooropharynx, although that offers minor protection. Raising the head of the stretcher a few degrees will use gravity to keep the stomach contents down, as well as maximizing lung physics.

What really needed to happen was the tube needed changed out, I am a little hesitant to do so on the road in the middle of but***k alberta though :|

Overinflation of the cuff is just not good practice due to the consequense of tissue necrosis from the increased pressures, unfortunatly, this often becomes first line defence.

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Kinda forgot about this!

Ditto.

Reflecting on the call, I blamed myself for allowing him to break the CPAP, and my mngr for not having a spare available. I decided that was the reason he needed intubated.

Ah don't be so hard on yourself .. you done good, for a stuble jumper :whistle:

On further research, it appears I may be wrong. I have not found literature supporting my theory that people suddenly removed from CPAP decompensate immediatly as this pt did. It appears it takes 4-6min for airway dynamics to change.

aka CRASHING ? Likely he was going to anyway, just a matter of time, "Pumped Out" a slang RT term, this is why serial ABG or and art line in ICU is so helpful in dx and knowing when to commit to a ventilator ..

Squint: No PEEP for this fella!

Good thing too .. with a pressure that labile BUT a question for you positive pressure ventilation, did you increase or decrease his mean airway pressure from the set CPAP numbers ? hmmmm .

Oh ya.... within the first 5min of being in the ICU, the tube was changed for an 8.0. How embarrasing :shutup:

Ah don't beat yourself up pfft no big whoop ... the main reasons for 8.0 are for doing a bronchoscopy, ie Bronchial Alveolar Lavage (BAL) and sounds if you were having to add air to the ETT cuff it sounds like you did have a leak cuffs do that :confused:

One quick question - do you think that any of his issues with ventillation and perfusion had anything to do with the smaller ET TUbe?

Good thought but very minimal, maybe more resistance for exhalation and slightly higher PIP on high inspiratory flow rates greater than 60 lpm. The HOB up had far more to do with VQ than 1.0 of an mm tube.

As a passing comment, receiving lots of Paramedic handoffs in ER and ICU ... the vast majority of cuff pressures are WAY TOO HIGH guys and girls .

cheers

Edited by tniuqs
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As a passing comment, receiving lots of Paramedic handoffs in ER and ICU ... the vast majority of cuff pressures are WAY TOO HIGH guys and girls .

cheers

Hence why you should inflate with a 10cc syringe to start.

Would it be a good idea if EMS systems would purchase a cuff pressure monitor for intubations?

Edited by Captain Kickass
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or you could just put the recommended amount of air on the cuff into it? ... or is it only the LMA that has that?

yes its a problem here too we put way too much air into the cuff of an endotracheal tube and y'know patients end up with tracheal stenosis n all that fun stuff

oops looks like ima needed for a Kiwiology consult best nick off

Edited by kiwimedic
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As a passing comment, receiving lots of Paramedic handoffs in ER and ICU ... the vast majority of cuff pressures are WAY TOO HIGH guys and girls .

Couple of quick questions:

* How long does it take for an overinflated cuff to cause tracheal injury?

* Is it acceptable to simply deflate the cuff until we can auscultate cuff leak or see the end of the capnograph drop off, then pump air in until it goes away, or is there a better method for doing this?

* I know none of us like to remove functioning ETTs, especially in patient as sick as this. Any thoughts about using a Bougie introducer as a tube exchanger, or is this too cumbersome / risky?

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