The case.
An obese 86 year old female is bought to ED by private car with a 5-6 day history of progressive dyspnoea and fevers. She is promptly rushed into the resus bay in extremis with cyanosis & poor respiratory effort. She is hypoxic (SaO2 72%), febrile, tachycardic to 124/min & has a systolic BP of 98mmHg.
As you provide inspiratory assistance with a bag-valve mask & 100% O2, your team connects monitoring & gets IV access. This is her venous blood gas & CXR…
The IPPV improved things. Her SaO2 rose to the mid-90’s and her level of consciousness improved to the point that she maintained her airway & posture in bed… There are multiple issues here; Whilst we commence fluid resuscitation, IV antibiotics & early goal-directed therapy, we decide to trial non-invasive ventilation as a temporizing measure. This allows time to optimise her haemodynamics & discuss her management with the family…
Our decision to intubate this lady seemed straight forward due to the following reasons… For an excellent discussion on the decision-making process surrounding intubation, see Andy Neil’s post “Decision to intubate”… Essentially, we make a conscious decision to commit to a delayed sequence intubation ….
So….. This is what we did; The patient is induced sitting bolt upright with NIV still in place. We use 100mg Ketamine (~1mg/kg) & 100mg suxamethonium. As she fasiculates, we lower her onto the ready-made ramp & my airway assistant takes off the BiPAP mask, replacing it with nasal prongs which are cranked to 15L/min. The actual intubation runs smoothly. A grade 2 laryngoscopy with tube placed over a bougie (my ‘go-to’ first preference for all intubations). Her SaO2 remains above 96% throughout and her BP doesn’t budge. We start her on a lung protective 6mL/kg tidal volume and titrate up her RR to target a falling ETCO2 whilst keeping an eye on her volume-loops to avoid breath-stacking… This is her 10 minutes post-intubation…
I’ve been meaning to share this case for sometime now. It was actually a patient that I saw on one of my first night shifts in a new department. For my mate Alex & I, it served as a brilliant display of the powerful influence that online learning, podcasts and FOAM can have on our everyday practice. Neither of us had had formal teaching on such a scenario, but the application of various lessons (EGDT, DSI, apnoeic oxygenation) served us well on the night & truly made a difference to this patients outcome !! Thanks for reading,
Chris.
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