You look so good in mauve....

[fiznat]

I have never seen what you describe being done and I don't believe that it would be considered kosher by my BH however I am interested none the less. Improvisation is the name of the game.

I don't know why it wouldn't be considered kosher. Docs around here have been nothing but supportive of the practice.

I'm at work again on Friday, I'll set one of these bad boys up and take a few pics.

[Asysin2leads]

I'm going to jump in here for a sec.

Okay, because my eyes glazed over reading the back and forth, I'm not sure if I'm right here or not, but basically, this guy is turning purple and we don't know why.

First off: Purple people get tubed. I don't really care why they are purple, barring a grape soda accident, or a recent episode of old fashioned wine making, purple = cyanotic = tube. Yes, the mechanism causing the cyanosis is extremely important, and after I get them to stop turning purple I will use every single Dr. House trick of the trade I know to try and figure out why they were purple, so long as it doesn't interfere with timely transport. It doesn't matter if they are asthmatic, emphysemic, have a pulmonary embolism, foreign body, traumatic asphyxia, pneumothroax, APE, or diaphragmatic hernia, they are getting tubed. Even if they are blue because they are hypothermic, given their depressed LOC, they're getting tubed. The only way they are not getting tubed is if for some reason we have to go to the cric route. Then we can go for our survey, our neurologic exam, etc.

In the case of status asthmaticus, yes, you can attach a nebulizer to a BVM. Of course, you can also pour albuterol or even epinephrine directly down the tube if your protocols permit. At the purple stage, nebulized meds, in my mind are like a band aid on an arterial wound, right concept, but not effective enough.

[fiznat]

Pour Albuterol down the tube? Really? I've never heard of that or seen it done anywhere. Do your protocols allow that?

I still don't know if this patient needs a tube. Simple bagging and a NPA brought some color back to this guy, saturations to just under 90%, and mental status returning. Tubing people brings with it such a host of other complexities and dangers, honestly I would try to avoid tubing this guy if it is at all possible. If just bagging brought him back this far, I imagine a little nebulised treatment and perhaps some epinephrine might make a world of difference.

...And not all purple people get tubed. If the hypoxia is secondary to an issue that can be treated right away (OD, hypoglycemia, sometimes asthma/COPD/CHFers, etc), I believe in the philosophy that it is best to avoid the intubation if possible.

Let's also not forget that the guy wouldn't even take an OPA, so unless you've got some RSI or at least sedated intubation, you're not getting a tube regardless.

[Asysin2leads]

No, were not allowed to pour albuterol down the tube, but in some of the asthmatic horror stories I've heard from the Bronx, it has been known to be done on occasion at the ER. Now whether this is something you are actually supposed to do, I'm not sure, but in theory, any medication that can be nebulized and sent through the bronchioles should be able to be dumped in as well. I'm trying to find an article that says one or the other, if someone beats me to it, you win.

But, once you are purple and AMS, by in large, aggressive airway is the name of the game. Even in a purple guy who has "I'm a junkie and I'm ODing" tattooed across his chest, as per my protocols, is supposed to be tubed before the Narcan. Now, everyone knows that is a bad idea, but it is what is supposed to happen. I suppose you could, say, go CPAP, nitro, and Lasix for an APE, but at least my protocols say that CPAP is only for someone who is alert. So outside of clearing and airway with the heimlech, or bagging and narcaning, purple + AMS = tube.

[Richard B the EMT]

I have seen the Paramedics put stuff down the tube in cardiac arrest situations, but am unsure if it is either protocol or even effective with albuterol. Back later with an answer after talking to some Paramedics.

(See mantra below re protocols!)

[hammerpcp]

Okay dokay. If you were going to intubate him (which is what I was thinking) what drugs would you give him? Also, is your only rational to intubate because purple = intubate?

We don't carry albuterol and we wouldn't pour it down the tube if we did I am sure. Interesting point...the doc gave this pt mag sulf at the ER.

For me the question about giving Epi sc or not was two fold. According to our protocols only asthmatic pts who are 50 y/o or younger can receive it for SOB non anaphylactic in nature. The rational for this according to me, is that older pts have a higher tendency towards CAD and subsequently more cardiac complications with Epi. Plus this guy was already pretty tachycardic. So the problem here of course is that I don't have a very good history on this guy and I don't know exactly how old he is, but he is in the fifty y/o vicinity.

I think I would have at least attempted to tube this guy. The more I think about it the more sense it would have made. If he pinked up enough they could extubate him at the hospital.

This is another call where the most difficult decision is whether to be aggressive or conservative.

[fiznat]

As promised, photos of the nebulizing BVM setup.

Ingredients:

-BVM/Mask

-Nebulizing chamber with O2 tubing

-T adapter

-Male-to-male adapter

I'm sure there is more than one way to put it all together, but this setup works nicely:

Note that you will need TWO O2 sources. One for the BVM, and another to nebulize.

[JakeEMTP]

I've been reading this thread and I keep wondering if CPAP might be an option. The patient does have an airway albeit not a good one, he did improve with a NPA and BVM, but his O2 sats wouldn't improve to where we would like it to be. CPAP would help clear his lungs and is indicated for asthma. We have done this and it worked wonders.

If it is not in your protocols, talk to your Medical Director.

[Asysin2leads]

Negative, CPAP is used only on alert patients, at least in my protocols.

[hammerpcp]

CPAP would probably be a good idea actually. However the problem doesn't lie with our BH but rather with our tax base. Our service does not carry this nifty little device unfortunately.