Hi folks,
Sorry about the voice–got a cold off those damn ED keyboards
Thanks to my friend Reuben, this week we'll talk about the asthmatic patient that codes while on the vent
The DOPE mnemonic gives you a path to figure out why a patient is desaturating
(If anyone knows who created the DOPE mnemonic, please add a comment or send me an email. An EMCrit listener solved the mystery)
If the pt is asthmatic, add an “S” to make DOPES
The “S” stands for Stacked Breaths–and it's the first thing to address.
Address it by disconnecting the vent circuit. Don't think about it, don't dither, just disconnect the vent.
“E” is for equipment. Attach a BVM hooked up to O2 and you'll eliminate ventilator equipment failures.
“D” is for tube displacement. Verify the tube with ETCO2, either qualitative or quantitative.
“O” reminds you to check for obstruction of the tube. See if you can put a suction cath all the way down.
If all of these don't fix the problem, then consider “P” for pneumothorax.
Lung sounds are not always definitive. Throw on the UTS if you have the time.
Otherwise perform bilateral finger thoracostomies. What the hell is that, you say?
Listen to the podcast.
Then you can read more about it in this article
C.D. Deakin, G. Davies and A. Wilson, Simple thoracostomy avoids chest drain insertion in prehospital trauma, J Trauma 39 (2) (1995), pp. 373–374.Update:
Is the tube mainstem, is there a ball-valve obstruction?
Consider reintubation
Consider Bronchoscopy
Finger Thoracostomy BET
Emerg Med J 2017;34:417-418.
Additional New Information
More on EMCrit
- Origins of the Dope Mnemonic(Opens in a new browser tab)
- EMCrit 62 – Needle vs. Knife II: Needle Thoracostomy (Decompression)?(Opens in a new browser tab)
- EMCrit 15 – The Severe Asthmatic(Opens in a new browser tab)
Additional Resources
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Dear Scott
Love your work so many thanks from down under.
I spend a lot of my time flying in aircraft on the way to a remote clinic or evacuating a patient from remote area.
Yesterday whilst flying between base and a clinic I listened to your podcasts on trauma and asthma.
As a free service you provide I applaud you for extending this quality CME information to providers of emergency medicine and critical care.
Dr Minh Le Cong
RFDS Cairns base
Do you ever get flack from surgery/trauma surgeons about performing the finger thoracostomy? Don’t they want to get a chest tube in despite no needle was placed and no blood or air gushed out of the finger wound? How were you able to overcome the surgical dept’s bias to cut, and not persue chest tube placement?
–Jose Torres from NYHQ ED, Flushing, NYC
3rd year resident.
Lets say the finger thoracostomy was negative. Do you just suture it up?
Ammar Ali
yes
or just stick a chest tube in, either way is fine
excellent