Podcast 3 – Laryngoscope as a Murder Weapon (LAMW) Series – Ventilatory Kills – Intubating the patient with Severe Metabolic Acidosis - a podcast by Scott D. Weingart, MD FCCM

This lecture is part of the Laryngoscope as a Murder Weapon Series:



* Hemodynamic Kills

* Oxygenation Kills

* Ventilatory Kills



Sorry about the voice--blame the swine flu.

Case

Thanks to Joe Chiang



Severe DKA; Obtunded with pH 6.65, PaCO2 18, Bicarb 5

Pt’s mental status is worsening

The decision is made to intubate

Should you give NaBicarb?

Probably won’t help as patient is already breathing at their maximum. Unless they blow off the Bicarb-generated CO2, they won’t increase their pH significantly.

What you need

Properly fitted NIV mask

Ventilator, not a NIV machine

Someone who knows how to work the vent

Normal intubation stuff

If available, Quantitative ETCO2

Procedure



* Place pt on pseudo-NIV



Settings are

Mode Volume SIMV

Vt 550 ml

FiO2 100%

Flow Rate 30 lpm

PSV 5-15

PEEP 5

RR 0



* Attach ETCO2 and observe value

* Push the RSI Meds





* Turn the Resp Rate to 12

* Perform jaw thrust

* Wait 45 seconds



This violates the tenets of RSI, but keeping the pt alive is probably more crucial right now.

Most experienced operator should intubate the patient



* Attach the ventilator

* Confirm tube placement by observing ETCO2

* Immediately increase Respiratory Rate to 30

* Change Vt to 8 cc/kg predicted IBW

* Change Flow Rate to 60 lpm, this si the normal setting for intubated patients (forgot to mention this in the audio)



Why 30 BPM? Listen to the podcast.



* Make sure ETCO2 is at least as low as it was when you started

* Check ABG

* Pat yourself on the back



PreVent to prevent Death (coined by Sara Crager)

Now on to the Podcast...

Further episodes of EMCrit Podcast

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