Morning Report: 12/13/13

Here’s a Friday the 13th edition of Morning Report presented by Dr. Waldman!

The Case:

42 yo F hx of asthma, heavy smoker p/w 3 days of wheezing and SOB.  Pt had been admitted for asthma in the past but never intubated. Albuterol and ipratropium were not helping at home.  Pt noted to be tachypnic, mild intercostal retractions, saturating 95% on RA.  Pt receives 3 combivents + prednisone + magnesium and her respiratory status begins to worsen.  Pt anxious, stating she can’t breath, tachypneic to the 40’s, abdominal breathing, saturating 90% on NRB, trying to rip off her mask.  Pt rushed to CCT… now what do we do?

AIRWAY, AIRWAY, AIRWAY!  But how?

RSI?

• First pass success: great you’re done
• Difficult airway: risks such as aspiration from BVM, without PEEP pts may not improve oxygenation, and now we are left with hypoxia and inevitable hemodynamic instability

Sometimes patients like this one, who desperately require preoxygenation will impede its provision. Hypoxia and hypercapnia can lead to delirium, causing these patients to rip off their NRB or non-invasive ventilation (NIV) masks. This delirium, combined with the low oxygen desaturation on the monitor, often leads to precipitous attempts at intubation without adequate preoxygenation.

DELAYED SEQUENCE INTUBATION

DSI = sedation allowing time for preoxygenation and then adding paralytic

How?

Delirious patient with hypoxia –>  ketamine 1-2mg/kg –> preoxygenate NRB/CPAP/biPAP –> administer paralytic –> intubate

Best case scenario: sedation allows the respiratory parameters to improve and pt avoids intubation!

Check out Dr. Weingart’s DSI post at EMCrit.org!

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• Bio
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Jay Khadpe MD

• Editor in Chief of "The Original Kings of County"
• Assistant Professor of Emergency Medicine
• Assistant Residency Director
• SUNY Downstate / Kings County Hospital

Latest posts by Jay Khadpe MD (see all)

• Save of the Month! December 2015 - December 23, 2015
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