Q&A: The Two Rams

Two listener questions answered in 5 minutes

 

From Dr. Ram Reddy of Canada:

Great thought to intubate a patient in hemodynamic extremis using the awake approach. I can’t tell you how many times I’ve given etomidate only to have to yell \start CPR\ immediately after( and i just started working). So this stuff about etomidate being HD stable is bullshit, when the pressure is super low.

With Regard to awake intubation for the HD unstable patient. My worry is two fold

1) when you are looking to secure the airway of somebody with a systolic of 50, the time required to administer glyco, nebulize lido, gargle( if they can) and atomize is too lengthy

2) I’m also willing to wager that the scenario where you don’t really get great topicalization is more common then maybe we think. now you have a patient gagging, bucking, fighting, making 1st pass success more difficult. if they get complete topicalization then i guess I would look heroic, but if it’s partial, and they fight you or the muscular tone remains too high to visualize cords well, i think it could look like a gong show? then you are stuck with going back to a conventional RSI with the disadvantage of having manipulated the airway already. what do you think?

how about a modified RSI, quick bolus of fluid, 500 of phenyl + half induction dose ketamine + succs + apologize later, if they live to remember that they were paralysed with some awareness. this is the typical induction for the anaesthetists when they need to do a trauma lap on a hypotensive patient at my institution.

this question refers to Podcast 23

——

from Dr. Ram Parekh of my shop:

the copd-er had a pH 7.05 and pCO2 119 at the time I decided to intubate, despite NIV and nebs. I put him on NIV SIMV with a minimum rate of 18 (using EtCO2 as a guide) , tv 550, FiO2 100% to make sure he ventilates some while pushing the meds before intubating.

Any thoughts? How are you optimizing your hypercarbic resp failure patients?

this question refers back to Podcast 3

Great thought to intubate a patient in hemodynamic extremis using the
awake approach. I can’t tell you how many times I’ve given etomidate
only to have to yell \start CPR\ immediately after( and i just started
working). So this stuff about etomidate being HD stable is bullshit,
when the pressure is super low. With Regard to awake intubation
for the HD unstable patient. My worry is two fold 1) when you
are looking to secure the airway of somebody with a systolic of 50,
the time required to administer glyco, nebulize lido, gargle( if they
can) and atomize is too lengthy 2) I’m also willing to wager that
the scenario where you don’t really get great topicalization is more
common then maybe we think. now you have a patient gagging,
bucking, fighting, making 1st pass success more difficult. if they
get complete topicalization then i guess I would look heroic, but if
it’s partial, and they fight you or the muscular tone remains too high
to visualize cords well, i think it could look like a gong show?
then you are stuck with going back to a conventional RSI with the
disadvantage of having manipulated the airway already. what do you
think?

 

how about a modified RSI, quick bolus of fluid, 500 of phenyl +
half induction dose ketamine + succs + apologize later, if they live
to remember that they were paralysed with some awareness. this is
the typical induction for the anaesthetists when they need to do a
trauma lap on a hypotensive patient at my institution.

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