An easy one for the weekend

[Smash]

Tell me what you would do with this patient. It's not a diagnostic conundrum, but I'm interested in decision making and treatment pathways.

It's 05:00 and you are called to a "Can't get off floor" job. The patient is reported to be a 68 year old male who is also reported to have "breathing problems" and a history of COPD.

You arrive at a small suburban home that appears to be well kept. You are met at the door by a woman in her 60s who identifies herself as the patient's wife. She seems distracted and vague and is not able to give you much information, except to say that her husband was well last night, but after getting up to go to the toilet became acutely SOB and then "fell down" and she would like help to get him back into bed.

You enter the bedroom and find a male patient, weighing an estimated 150kilograms slumped against the side of the bed. You can hear rales from the door. He is ashen grey and profusely diaphoretic. His GCS is 7 (E2V1M4), with a blood pressure of 80/50mmHg, a heart rate of 140 (sinus tachycardia) with occasional premature ventricular complexes. His SpO2 is 68% on room air with a good trace. EtCO2 is only available on intubated patients. Chest auscultation reveals full-field biphasic rales, no wheezes, no consolidation, no pleural rub. His respiratory rate is 30, with significant abdominal breathing, and is shallow. 12 lead ECG shows widespread ST depression except in aVR... He is afebrile. There is no significant peripheral edema and it is difficult to see his jugular veins due to his obesity.

His medications include albuterol inhalers, inhaled steroids, furosemide, an ace inhibitor, a beta-blocker, a thiazide, an angiotensin blocker and amiodarone.
He has no allergies.

You are at least 30 minutes by road from an appropriate hospital and working as part of a two medic crew. The transport time is actual in the rig and driving time; it does not include extrication.

Whilst you are assessing the patient, gathering history and all that sort of thing, the monitor alarms at you: the patient is now in a wide complex tachycardia with a rate of 160 beats per minute. His BP falls slightly to 70/40, his GCS drops to 5 (E1V1M3) and he has strong jaw tone.

What are your actions, and what is your rationale for this treatment pathway?

What is

 

[Melclin]

I realise you're looking for experienced opinion, but I thoughts I might as well put my thoughts out there for the purposes critique and discussion more than actual advice.

Well there is the bariatric ambulance which we can assume will be busy or at least 3 hours away.

His going into VT with obs like that kinda simplifies things doesn't it? Sync cardiovert, 100% with a nasal airway and maybe some "PEEP" (I've not had much success in using the closed circuit for PEEP though). The term crash airway comes to mind, but I know precisely d**k about intubating pts like this. Would have been nice to get some aspirin into him as well, but we're a bit past that.

If he reverts ...some amiodarone, assuming he stays reasonably hypoxic with some work of breathing with supplemental O2, given his perfusion status, I don't know that CPAP is appropriate. I think he needs a tube, a vent with PEEP and appropriate positioning. Improve APO, reduced workload. Easier said than done in a 150kg pt's bathroom though I suppose. An adrenaline infusion in this chap seems unwise but at the same time, totally necessary. Got any Milrinone on the truck ? Lets hope our other treatments improve his numbers a bit.

Extrication wise: Another crew/fire for lift assist. Role him onto the drag mat + straps. Position the spinal board as a ramp up onto an appropriately positioned stretcher. Never tried it on a pt that big, but its has worked well for me in the 95kg range. I can't see any other options anyway.

 

[systemet]

Well, this isn't good.

(1) Position patient in full / semi-Fowler's depending on how large his abdomen is.

(2) PPV via BVM w/ 100% O2.

I'm assuming from the narrative that we've done these things prior to the onset of WCT, and that we have IV access.

The problem here is that the WCT is likely caused by hypoxemia. We haven't corrected this, so cardioversion may result in VF / asystole. Then again, intubating without correcting the WCT might cause the same.

I think we have to cardiovert, but we can should be setting up to intubate concurrently. So.. 200mg of ketamine, 200 mg succinylcholine (he has produced urine recently, right?). Confirmation via multiple methods including ETCO2.

If he remains hypotensive post-intubation, we need to look at some dopamine 5ug/kg/min. Once the pressure tolerates, IV NTG and PEEP.

I've been taught not to give fluid here. But I'd be interesting in hearing other opinions.

Repeat ECG. Do we have an evolving STEMI? If so we need to look towards reperfusion therapy. Heart sounds? Any suspicion of papillary muscle rupture?

Edit: Forgot to mention, I'd like additional ALS if possible. I'd also want to contact rotary wing, if available early in the call.

 

[usalsfyre]

Ventilate him. Use both providers if need be to get a good mask seal, positioning and get his sats up and see if the rhythm resolves.

There's no way in flaming Hades I'm paralyzing a predicted difficult intubation laying on the floor with poor positioning at a sat of 68%. If it's that bad we're going BIAD till his sats come up or cutting.

150kilos is big but not unmanageable. We see 150 pretty regularly here.

 

[systemet]

Ventilate him. Use both providers if need be to get a good mask seal, positioning and get his sats up and see if the rhythm resolves.

There's no way in flaming Hades I'm paralyzing a predicted difficult intubation laying on the floor with poor positioning at a sat of 68%. If it's that bad we're going BIAD till his sats come up or cutting.

150kilos is big but not unmanageable. We see 150 pretty regularly here.

I agree that ventilation is of critical importance and that paralysing this guy would be scarey. If proper BVM ventilation and positioning relieves the critical hypoxia, then I think we can afford to finesse things a little more.

However, if we're not getting an improvement with a BVM, and there's "strong jaw tone", I'm not sure what better options we have.

 

[usalsfyre]

.However, if we're not getting an improvement with a BVM, and there's "strong jaw tone", I'm not sure what better options we have.

Personally I might stick a needle in his neck and try apenic oxygenation and see if we can at least get into the 80s. If that's not an option, then it's time to break out the scalpel (realizing this thing is already a bloody mess and the knife's liable to be ugly as well).

 

[systemet]

Personally I might stick a needle in his neck and try apenic oxygenation and see if we can at least get into the 80s. If that's not an option, then it's time to break out the scalpel (realizing this thing is already a bloody mess and the knife's liable to be ugly as well).

Is apneic oxygenation another name for a needle cric or a PTTV?

 

[usalsfyre]

Is apneic oxygenation another name for a needle cric or a PTTV?

That's one form of it. Others are things like O2 catheters for apnea test and pharyngeal insulation during laryngoscopy.

 

[KingCountyMedic]

Many of these patients are very easy intubations, you'd be surprised. Some of my most difficult airways have been on normal HWP looking folks. The key is to sit them up, use gravity to get all that extra weight going away from where you want to be looking with a #4 Mac or Miller. Many times I'll grab my Eschmann Bougie right off the bat and just go in with that. The beauty of the Eschmann is even if you can't see anything you can feel the trachea rings as you pass it. (I'd also push 200 of Anectine prior) There is also a neat trick known as "retro molar intubation" that can be a real lifesaver. Once I have the airway secure I'll go after everything else, probably some form of electricity.

 

[usalsfyre]

Many of these patients are very easy intubations, you'd be surprised

Many of them are, many aren't. What's your bailout plan if he's not? NMBAs are a bad, bad choice to throw around in a cavalier manner.

 

[KingCountyMedic]

Many of them are, many aren't. What's your bailout plan if he's not? NMBAs are a bad, bad choice to throw around in a cavalier manner.

My services bail out plan is that we always work with two Medics, have an MSO that can respond to bad airway calls that typically has 25 years of experience. I usually intubate several times a shift, we have a surgical airway lab that we do every other year and I can always do a surgical airway if nothing else works. I average about 30 tubes a year so I usually do okay. Not sure what NMBA is?

 

[fast65]

Well, as it is right now I'm going to call for an engine assist and we'll work on getting him out of the bathroom so we can work a little more efficiently. However, that's probably not an option, so we'll attempt to sit him up into a fowlers or sem-fowlers position like someone else mentioned, then we'll place an NPA and start bagging him as best we can. The WCT is more than likely being caused by hypoxemia, so hopefully with some PPVs we can resolve that.

I'm pretty weary about cardioverting this guy, I suspect it will likely send him into a pulseless rhythm, and I really hate to run a code on him right now. We'll get a line in. If the ventilating him hasn't resolved the WCT, then I'll end up synchronized cardioverting him and possibly dripping in 150 mg Amiodarone.

Right now I'll reassess vitals. If his SPO2 hasn't come up then I'll start thinking about intubation/cric. Hopefully the WCT has resolved and his BP has risen, however, if he's still hypotensive then I'm getting ready to hang dopamine, starting at 5 mcg/kg/min.

 

[usalsfyre]

My services bail out plan is that we always work with two Medics, have an MSO that can respond to bad airway calls that typically has 25 years of experience. I usually intubate several times a shift, we have a surgical airway lab that we do every other year and I can always do a surgical airway if nothing else works. I average about 30 tubes a year so I usually do okay. Not sure what NMBA is?

So while your MSO responds your patient dies because you started an RSI on a profoundly hypoxic patient that is ripe for a can't intubate/can't ventilate scenario. Not trying to pick on you personally but this is why loads of people advocate against paramedic RSI. You sound like someone who's yet to have an airway go truly bad on you. I promise it's career changing.

This is a patient that requires immediate action but careful consideration in that action. Immediately reaching for drugs and a laryngoscope is the wrong answer. The right answer is "anything that works to help the hypoxia". That may mean drugs to pass to pass a King or Combi to preoxygenate him prior to intubation, a needle cric, a surgical airway or even just good basic ventilations. But if you encounter ANY delay in DL your very likely to kill this guy. Trust me on this. Really, trust me.

NMBA is a neuromuscular blocking agent.

 

[Aidey]

My services bail out plan is that we always work with two Medics, have an MSO that can respond to bad airway calls that typically has 25 years of experience. I usually intubate several times a shift, we have a surgical airway lab that we do every other year and I can always do a surgical airway if nothing else works. I average about 30 tubes a year so I usually do okay. Not sure what NMBA is?

If you intubate several times a shift, and average 30 tubes a year, are you only working one shift a month?

 

[KingCountyMedic]

So while your MSO responds your patient dies because you started an RSI on a profoundly hypoxic patient that is ripe for a can't intubate/can't ventilate scenario. Not trying to pick on you personally but this is why loads of people advocate against paramedic RSI. You sound like someone who's yet to have an airway go truly bad on you. I promise it's career changing.

This is a patient that requires immediate action but careful consideration in that action. Immediately reaching for drugs and a laryngoscope is the wrong answer. The right answer is "anything that works to help the hypoxia". That may mean drugs to pass to pass a King or Combi to preoxygenate him prior to intubation, a needle cric, a surgical airway or even just good basic ventilations. But if you encounter ANY delay in DL your very likely to kill this guy. Trust me on this. Really, trust me.

NMBA is a neuromuscular blocking agent.

Well you run your calls and I'll run mine. If you have a system with a Medic on every street corner, every engine, every ambulance and doctors that don't take an active role in Paramedic education, require you to get a lot of tubes and remain proficient at your job then you go ahead and cast stones at me. Who are you to presume anything about me? I have had plenty of nightmare airway calls in my 23 years of practice. My system has one of the highest first pass intubations rates on the planet, one of the highest cardiac arrest save rates in the world. LOADS of people advocate against Paramedic RSI because most systems have too many Paramedics and not enough tubes to go around.

Look at it like cardiac or neuro surgery. Who do you want placing your stent in the cath lab, the guy that does 2-3 a year or the guy that does 2-3 a day?

 

[KingCountyMedic]

If you intubate several times a shift, and average 30 tubes a year, are you only working one shift a month?

LOL just depends on the month, the rig etc. work 8-10 days a month, some months might get only a few tubes other days 4-5 in a day.

 

[Smash]

Many of these patients are very easy intubations, you'd be surprised. Some of my most difficult airways have been on normal HWP looking folks. The key is to sit them up, use gravity to get all that extra weight going away from where you want to be looking with a #4 Mac or Miller. Many times I'll grab my Eschmann Bougie right off the bat and just go in with that. The beauty of the Eschmann is even if you can't see anything you can feel the trachea rings as you pass it. (I'd also push 200 of Anectine prior) There is also a neat trick known as "retro molar intubation" that can be a real lifesaver. Once I have the airway secure I'll go after everything else, probably some form of electricity.

So you carry a Bonfils stylet? Neat!

I'm not sure how comfortable I would be in paralysing a predicted difficult intubation who is already profoundly hypoxic, let alone paralysing one without any form of sedation or analgesia at the same time.

 

[systemet]

So you carry a Bonfils stylet? Neat!

I'm not sure how comfortable I would be in paralysing a predicted difficult intubation who is already profoundly hypoxic, let alone paralysing one without any form of sedation or analgesia at the same time.

Why not ketamine here?

Edit: I accept that it's a negative inotrope, and that this patient is already quite tachycardic, so it might not improve he MAP, but it seems like a better choice than anything else.

 

[firetender]

Simpleton Medic starts here...

#1. Nothing good is going to happen if the patient stays where he's at.


First consideration: stabilize ENOUGH to get the patient from there to where you can move fluidly for the next step.


First action: mobilize the support you need to get so the guy gets moved without killing him or any of you.


Just a thought: 330 lbs will get out the door easier standing than lying down, if you can pull that off QUICKLY without compromising the patient, start thinking in that direction and the sooner the better.


and that's why you first...


#2. Work with what you have on hand.


You all have established we've got respitatory deficit here, but did anyone think to ask (esp. given the obvious rales and rapidity of deterioration) if maybe the patient's Albuterol had been used? I bet not, and doubt anyone there would know anyway.

USE IT!


that might have avoided the rapid change you witnessed. On initial presentation, I'd say that's indicated and it could also act as something familiar to the patient enough to "snap" him back enough to work with toward the primary goal of getting him into a workable location.

All that would come first, long before consideration of using paralytics, intubation, cardioversion or crics in my book. On initial presentation, this is primarily a logistical challenge. Once he's out that door, then you can get medical.

I still don't get the idea of rebuilding the heads before you check the sparkplugs.