Insane, Granular Intubating-Monkey Checklist
COVID Awake Repositioning and Proning Protocol (CARP)
Keep 'em from getting Intubated Flow (Adapted from Cam Kyle-Sidell's)
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Abbreviation list e.g. at the end of the checklist would help
Justyna Swol, No COI, PMU Nuremberg, Germany
it is our internal checklist–let me know any abbreviations that don’t translate and I will post them here.
CMAC, BVM, NIPPV
Thanks in advance
Hey Scott
I like Cam’s chart but I wonder how many hospitals are, like mine, unable to provide HFHO2 because the O2 needed across the site exceeds the supply available.
It’s tough but in many places, HGHO2 just isn’t possible because either the supply or the pipes just can’t cope with that demand.
Keep these posts coming, they’re invaluable. Thanks
home bipap machines could fill the niche in low O2 environments
I feel there will be a direct correlation between mortality and the patient’s V02max. There is a respiratory disease, but the main thing I see is a metabolic disease where our cells/mitochondria are stimulated to mass produce ATP and become very 02 hungry. That is why we see low blood oxygen/sat, but no signs or cellular hypoxia (normal lactates/pulse/mentation). If high WOB persist, there is probably another alveolar injury as a result of these high transpulmonary pressures. If you have good V02 max, you will provide you oxygen hungry cells with oxygen. If you have bad V02 max, you won’t… Read more »
Their normal to slightly low c02 in a patient who’s lung has no ventilation problem( L type/ happy hypoxic phase) kinda proves the point that they are in fact using tons of oxygen and so producing a lot of CO2. If not, our tachypneic patients (with minute ventilations of 10-15L) would have c02’s in the low 20s.
It’s an oxygen failure at first
they do have CO2s in the 20s
Great thoughts Scott. The potential detrimental effects of paralyzing critical patients and the advantage of having the ability to resume spontaneous breathing very quickly post intubation with Sux is something I have utilized on many occasions, but usually more so to maintain augmented venous return for hemodynamics in profoundly shocked patients (on high doses of multiple pressors). So we now have a few reasons why Sux is potentially preferable to Roc in the critically ill. Regarding a goal O2 Sat% post-tube: It’s so tough to say what that goal should be. Yes COVID definitely seems to make patients hypoxemic way… Read more »
i think it is that any pt tolerates pure hypoxemia wonderfully. COVID is just a rare disease that gives hypoxemia without all the rest of the baggage.
Any podcast on cardiac arrest/CPR on patients in the new Covid world?
Nice points regarding the PAPR brain concept. Cognitive performance declines have been well known in the military world with chemical warfare equipment (MOPP).
Wearing full MOPP 4 level protection certainly gives one a weird sense of isolation and cognitive distance that may affect performance. The solution seems to be just as mentioned: training/simulations and some form of procedural check-listing.
Thanks again for all of the great info!
Larry
thanks Larry!
Marie Star ,
Love your show till your comments about RT’s. RT here and we intubate at my hospital and not just push the vent in the room or allowed to break the circuit. Will continue to listen to your show because you have good info.
Thanks again. Do u still Rec clamp the et tube b4 connecting vent? If it is needed what do u use to clamp.
in what was described, there is no need to clamp ETT
Thanks for all u do. Do u still recommend clamping et tube b4 hooking to bag or vent. If so what do u clamp with
thankyou for this it was very informative. As an emergency nurse i can see what you are asking us to do makes great sense and is labour intensive and requires great vigilance. your thoughts and insights give me opportunities to question the rationales of interventions for the pathophysiology of my patients.
Hi Scott, thanks for this great resource.
It seems like Josh’s latest post has maybe swing back and now settled on a position opposite to yours and Cam KS’ with regard to O2 vs PEEP. He’s saying keep O2 down and use standard/high PEEP (or APRV) to try force recruitment in, and prevent atelectotrauma. So do you now disagree?
Would love to hear you two sit down and talk through it!
Cheers.
the disagreement is more subtle than that. it will be played out in a debate released tomorrow
Hey Scott,
Thanks again for another great insightful podcast – your work is really helping us all out there.
You mentioned that there was some literature demonstrating reduced recruitment in mechanically ventilated patients who do not have spontaneous respirations (e.g those paralysed).
Could you please provide some references to this literature. That would be super helpful.
Thanks again!
go to the theory articles on my original APRV podcast from last week
Hi Scott This is one of my favourite episodes in recent years. Exactly what we need in this EBM void is the thoughts of experts and masters who have worked on the front line One idea I wondered if you had a position upon: In anaesthesia for less urgent intubation we sometimes use a nerve stimulator to detect the loss of TOF twitches to “confirm” paralysis before laryngoscopy Is this worth doing in CoVid intubation as a way of getting objective data to make the tube a bit safer. Roc is notoriously variable in onset times. If the theory works… Read more »
variability is pretty much entirely gone at 1.6-2.0 mg of roc. Only way there is variability at those doses is if pt has low cardiac output. If you wait the 60 sec, they will be fully paralyzed. They are apneic but still exchanging oxygen if you are using the apneic cpap set-up.
Thanks so much for this post! We will be using the intubating checklist at our shop for sure.