Q&A: The Two Rams - a podcast by Scott D. Weingart, MD FCCM

Two listener questions answered in 5 minutes   From Dr. Ram Reddy of Canada: Great thought to intubate a patient in hemodynamic extremis using the awake approach. I can't tell you how many times I've given etomidate only to have to yell \start CPR\ immediately after( and i just started working). So this stuff about etomidate being HD stable is bullshit, when the pressure is super low. With Regard to awake intubation for the HD unstable patient. My worry is two fold 1) when you are looking to secure the airway of somebody with a systolic of 50, the time required to administer glyco, nebulize lido, gargle( if they can) and atomize is too lengthy 2) I'm also willing to wager that the scenario where you don't really get great topicalization is more common then maybe we think. now you have a patient gagging, bucking, fighting, making 1st pass success more difficult. if they get complete topicalization then i guess I would look heroic, but if it's partial, and they fight you or the muscular tone remains too high to visualize cords well, i think it could look like a gong show? then you are stuck with going back to a conventional RSI with the disadvantage of having manipulated the airway already. what do you think? how about a modified RSI, quick bolus of fluid, 500 of phenyl + half induction dose ketamine + succs + apologize later, if they live to remember that they were paralysed with some awareness. this is the typical induction for the anaesthetists when they need to do a trauma lap on a hypotensive patient at my institution. this question refers to Podcast 23 ------ from Dr. Ram Parekh of my shop: the copd-er had a pH 7.05 and pCO2 119 at the time I decided to intubate, despite NIV and nebs. I put him on NIV SIMV with a minimum rate of 18 (using EtCO2 as a guide) , tv 550, FiO2 100% to make sure he ventilates some while pushing the meds before intubating. Any thoughts? How are you optimizing your hypercarbic resp failure patients? this question refers back to Podcast 3 Great thought to intubate a patient in hemodynamic extremis using theawake approach. I can't tell you how many times I've given etomidateonly to have to yell \start CPR\ immediately after( and i just startedworking). So this stuff about etomidate being HD stable is bullshit,when the pressure is super low. With Regard to awake intubationfor the HD unstable patient. My worry is two fold 1) when youare looking to secure the airway of somebody with a systolic of 50,the time required to administer glyco, nebulize lido, gargle( if theycan) and atomize is too lengthy 2) I'm also willing to wager thatthe scenario where you don't really get great topicalization is morecommon then maybe we think. now you have a patient gagging,bucking, fighting, making 1st pass success more difficult. if theyget complete topicalization then i guess I would look heroic, but ifit's partial, and they fight you or the muscular tone remains too highto visualize cords well, i think it could look like a gong show?then you are stuck with going back to a conventional RSI with thedisadvantage of having manipulated the airway already. what do youthink?   how about a modified RSI, quick bolus of fluid, 500 of phenyl +half induction dose ketamine + succs + apologize later, if they liveto remember that they were paralysed with some awareness. this isthe typical induction for the anaesthetists when they need to do atrauma lap on a hypotensive patient at my institution.

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