“There are some things you learn best in calm, and some in storm.”
– Willa Cather
Over the past several years, I’ve thought a lot about what to say during the immediate moments after a failed cardiac arrest or traumatic resuscitation. When the rush of adrenaline comes to a screeching halt and all that is left is a deafening silence, 1 roll Lace DIY hand roll table flag chair back fit for wedding
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Prehospital trauma team activation criteria allow for prompt mobilization of personnel and resources. Prehospital hypotension is one of those criteria. Read More
Children with knee monoarthritis from Lyme disease and septic arthritis can have similar presentations. The early disseminated stage of Lyme disease, Read More
Acid-Base Workshop: At the beginning of the conference year, multiple faculty members ran a workshop on acid-base abnormalities where we worked on identifying acid-base disturbances, determining primary respiratory or metabolic abnormalities, causes of such disturbances, and if compensation was appropriate. Perhaps one of the most challenging types of patients we encounter with an acid-base disturbance is an acidemic patient who we believe requires intubation. Below you will find a variety of resources on acid-base disturbances and more specifically, intubation and ventilation in this patient population. Read the case, consider reviewing the resources below, and think how you would approach this tenuous patient.
The Case:
A 23 yo F with a PMH of poorly controlled T1DM presents to your ED complaining of nausea, vomiting, and abdominal pain. She ran out of her insulin 3 days ago and didn’t have the funds to refill it. Her FS is 415 on POC testing.
Physical Exam
Vitals: 123/80, HR 120s, O2 98%, RR 32, Temp 98.2
General: sleepy but arousable to voice
HEENT: dry mucous membranes
Chest: CTAB, kussmaul breathing
Cardiac: regular rhythm, tachycardic
Abdomen: soft, NTND
Extremities: MAE
Labs
VBG: 7.03/14/65, Calculated Bicarb 5
BMP: 132/4.3/99/3/20/.09>423
What next?
You hang fluids and start an insulin drip, but the patient becomes progressively lethargic and has vomited twice despite anti-emetics. You decide you need to intubate. What next?
Questions
What are the risks of intubating this patient?
What would be your intubation strategy? Method, intubation medications, and things to pay attention to?
Would you consider giving any additional medications (apart from paralytics or sedation medications) prior to intubating? If so, why, and what would be the dosing?
What would be your ventilator settings?
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