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From Ordinary to Extraordinary - Dr. Pearson

4/27/2017

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Picture
  • Post-Intubation Hypotension: 15% higher in-hospital mortality
    • Predictors:
      • Pre-intubation shock index (SI ≥ 0.8)*
      • Chronic renal disease
      • Intubation for acute respiratory failure
  • Push-dose (Bolus-Dose) Pressors:
    • Supportive bridge in selected patients:
      • Peri-intubation hypotension
      • Procedural sedation
      • Transporting long-distances from the ED
    • Push-dose Pressor Options
      • Phenylephrine in pre-mixed “STICK” (most common – be careful in brain injured or heart failure patients)
      • Epinephrine – will need to mix yourself
  • Pre-oxygenation: Rule of 15’s: Preoxygenation
    • Position: Head of bed                     @ > 15º
    • Non-rebreather mask                     @ 15 L / min
    • Nasal cannula                                    @ 15 L / min
    • CPAP / BVM + PEEP valve              @ 15 cm H2O
  • Delayed sequence intubation (DSI) Overview
    • “A procedural sedation, where the procedure is pre-oxygenation”
    • Basics: Delirious patient with hypoxia -> ketamine 1-2 mg/kg IV -> Preoxygenate (Preferably with CPAP/BiPAP)  ->  Wait 2 to 3 minutes ->  Administer paralytic -> Wait 45 to 60 seconds -> Intubate
  • DSI: Safe Apnea 
    • Safe Apnea = Duration of apnea until a patient reaches a saturation of 88-90%
    • Patients with increased metabolic demands and shunting desaturate faster.
  • DSI: Who might benefit from it? Patients with vital signs that are unobtainable, or unacceptable:
    • “Good Lungs, Bad Brains”: Agitated head injury / ETOH / Psych
    • Bad Lungs: Hypoxic  COPD, Pneumonia, ARDS
  • Apneic Oxygenation:
    • Alveoli continue to take up oxygen even without ventilation
    • Keep Nasal Cannula in place at 15 L/min during intubation attempt(s) to further prolong duration of safe apnea


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    • RESIDENCY
      • About CMC
      • Curriculum
      • Benefits
      • Explore Charlotte
      • Official Site
    • FELLOWSHIP
      • Global EM
      • Toxicology
      • (All Others)
    • PEOPLE
      • Program Leadership
      • PGY-3
      • PGY-2
      • PGY-1
      • MATCH 2022
      • Alumni
    • STUDENTS/APPLICANTS
      • Prospective Visiting Students
      • Healthcare Disparities Externship
      • UNC/Wake Forest Students
    • #FOAMed
      • EM GuideWire
      • CMC Imaging Mastery
      • Pediatric EM Morsels
      • Blogs, etc. >
        • CMC ECG Masters
        • Core Concepts
        • Cardiology Blog
        • Dr. Patel's Coding Blog
        • Global Health Blog
        • Ortho Blog
        • Pediatric Emergency Medicine
        • Tox Blog
    • Chiefs Corner
      • Top 20
      • Current Chiefs
      • Schedules >
        • Conference/Flashpoint
        • Block Schedule
        • ED Shift Schedule
        • AEC Moonlighting
        • Journal Club/OBP/Audits Schedule
        • Simulation
      • Resources >
        • Fox Reference Library
        • FlashPoint
        • Airway Lecture
        • Student Resources
        • PGY - 1
        • PGY - 2
        • PGY - 3
        • Simulation Reading
        • Resident Wellness
        • Resident Research
        • Resume Builder
      • Individualized Interactive Instruction
      • Evaluations/Interview Season