What Should You Do?

42 y/o M is bibems for AMS.  The patient has signs of head trauma and will likely need a Head CT.  The patient becomes lethargic, shows signs of respiratory distress and is safely intubated via RSI with pre-treatment.  Tube placement is confirmed via ETCO2.  Although sick, the patients vs are normal.  The patient is transported to radiology where the Head CT is negative for acute pathology.  Upon return to the ED, the patient begins to desaturate and becomes hemodynamically unstable.

What should you do?  If the patient was an asthmatic, what should be your first action?

---

Answer: Check for Reversible Causes

In an intubated patient the acronym D.O.P.E.S can be used to guide the initial search for reversible causes.

D: Displacement - Verify the tubes presence w/in the trachea with ETCO2

O: Obstruction: A patient with copious secretions may be occluding the tube, see if you can slide a suction catheter all the way down the tube

P: Pneumothorax - Use the ultrasound machine to check for lung sliding; presence of breath sounds are not a reliable indicator to r/o pneumothorax

E: Equipment Failure - Disconnect the ventilator and attached a BVM with oxygen, check for restoration of vital signs and correction of hypoxia

If the patient is an asthmatic …

S: breath STACKING - Asthmatic patients may become increasingly more difficult to ventilate if the patient has been stacking breaths → increased intrathoracic pressure → hemodynamic instability

If the patient is an asthmatic, the FIRST thing you should do is disconnect the ventilator and allow the patient to exhale!

Reference: http://emcrit.org/podcasts/finger-thoracostomy/

Happy Studying,

Doc Roddy