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MAY
06

Adult Burn - Case Review - Part 4

fire spark flame koster burn campfire bonfire burns 477867

Let’s jump right back in…

Our patient is pre-oxygenated to an SpO2 value in mid-to-upper 90’s, the drugs go in, no problems identified so far…

The HEAVEN criteria we identified in the last post give us a hint of what we have to look forward to.  She has long history of COPD and has some potential airway anatomical issues due to smoke inhalation.  Knowing that, we proceed with caution.  We properly elevated her head about 30 degrees, lead with suction and encounter a relatively dry airway (thank goodness).  We move suction left, insert the video laryngoscope and have a nice, Grade 2 view…it’s the best we can get. We insert the bougie, then follow with the tube. We delight in the fact we watch the tube pass the cords, see some good fogging in the tube, inflate the cuff and pull the laryngoscope out.  Beautiful.  ETCo2 is placed and we notice a reading of 47 and a relatively normal shaped wave form.  Spo2 remains in the mid 90s the whole time and we are good to go.  A commercial device is used to secure the tube, the back doors shut, and we are off to the burn center.

Let’s talk about post intubation care.  There are a number of things we must consider after we get the tube.  Jocko Willink talks training in his book “Discipline equals Freedom: A Field Manual”.  He says that during training missions, Navy SEALs (and everyone else for that matter) tends to relax a little after the main objective is complete…so he hit them even harder AFTER the main mission was done.  He wanted to wipe away the feeling of being comfortable and getting cozy just because the mission was “complete”.  Same thing here.  Just because we have successfully intubated our burn patient, doesn’t mean we can sit back and chill.  There is work to do!  Post intubation management is crucial and unfortunately, often suboptimal.  Do we have enough sedation?  How about pain management?  Paralysis?  Are we looking and talking about the clinical data we are getting and applying it?  How’s the blood pressure?  Do we need fluid or vasopressors?  What’s the HR?  What are the Sp02 and EtCO2 doing?  Has the wave form changed?  This type of call we need to HOLD THE LINE (another Jocko-ism), stay on top of, and ANTICPATE the needs of our patients.  Speaking of pain…this is a burn patient.  Think your measly 50 mcg of fentanyl is gonna do the trick?  How about the 15mg of Ketamine?  Eh…think again!  Of course, you must follow your protocols/PCG’s, but remember that this patient is “someone’s someone”.  Put yourself in that position and think what you would want to have done… And DO THAT!

That’s what I have for now…we’ll talk soon!

Peer Review #1:

Well, he let us off the hook with that straightforward intubation!  I was hoping for a bit more drama and certainly a little blood, sweat, and tears…

The point about a mental “let down” after intubation is very real!  In fact, we kill an order of magnitude more patients with poor ventilation than missed intubations.  In our ventilation training modules, we emphasize that ventilation is NOT about providing as many breaths as humanly possible for the remainder of the transport.  And don’t take the ED approach of standard settings for everyone (FiO2 100%, VT 500 mL, rate 14/min).  It’s not even a simple as keeping the SpO2 high and the EtCO2 in a therapeutic range (35-40 mmHg).  Instead, correct ventilation involves providing optimal (NOT maximal) oxygenation and ventilation while balancing the often-competing factors of protecting the lungs but avoiding hemodynamic compromise due to intra-thoracic pressure.

It’s also good to see the emphasis on patient comfort.  In this patient, we must consider both the burn injury as well as the intubation itself as sources of discomfort.  While in the past we were often forced to withhold morphine and/or midazolam in the setting of extreme hypotension, we now have more hemodynamically friendly alternatives in fentanyl and ketamine.

Finally, we must remain vigilant to immediate post-intubation deterioration due to either hypoxemia and/or hypotension.  Every advanced provider should be able to identify and correct the short list of etiologies for immediate collapse following placement of an ET tube.  Perhaps a topic for another day…

Dr. Dan Davis, MD

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MAR
01

Adult Burn - Case Review - Part 3

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Welcome to part 3 of our series on the Adult Burn patient.  As both Tyler Christifulli and Dr. Dan Davis pointed out in the last article, we are in a bit of a pickle.  We have an elderly patient that was rescued from a house fire. She is alert and talking but showing sign of decompensation.  Her oxygen saturations are terrible, she has a history of cigarette smoking and we have come to the conclusion that we need to manage her airway. Her vital signs are listed below:

  • BP: 160/70 mmHg
  • HR: 100 BPM
  • RR: 20 BPM
  • SpO2: 89% on a NRB
  • EtCO2: 50 mmHg
  • SpCO: 16 PPM

Due to her age, past medical history and the fact she potentially has both upper and lower airway issues, we know we will absolutely have a battle on our hands to get her (and keep her) oxygenated.  Do me a favor, right now, go listen to this FlightBridgeED Podcast with Eric Bauer and David Olvera, then come back…I’ll wait!

https://www.flightbridgeed.com/index.php/the-flightbridgeed-podcast/2-flightbridgeed-podcast/268-heaven-lemons

The HEAVEN criteria is crucial to consider in this patient.  The fact that she is 89% currently is a significant red flag – remember the first letter - the H…. Hypoxia.  I’m reminded that in the oxygen desaturation curve, a normal, sized healthy adult can get to 100% and really stay that way for around 8 and a half minutes…that’s pretty good.  Not much help to us now however! Remember, we have an elderly, hypoxic patient who is critically ill.  Even if we get her up to the mid 90’s, her time of safe apnea will be so minimal, we really need to consider (as Dr. Davis pointed out) if RSI/DSI will cause the patient more harm than good.  Would it be better to defer this procedure with a short transport, ventilate her as needed with additional PEEP to maximize oxygenation? Perhaps BiPAP or CPAP would buy us enough time?

These are all great questions and ones only YOU can answer.  For our purposes, we are going to perform a medication facilitated intubation and the medications we are going to use are as follows:

  • Ketamine: 2.0 mg/kg
  • Rocuronium: 1.2 mg/kg

Then depending on how she does, we will administer Ketamine and / or Versed and Fentanyl for continued sedation.

The patient has the procedure explained to her, she is on both a NC at 15LPM as well as a NRB, and medications are cross checked and prepared.  Equipment is gathered and prepared including VL (video laryngoscope), Bougie, iGel, Suction (On and running), surgical airway kit is out and ready.  The ETCO2 filter line is on the tube and ready (7.0mm, by the way).  She is on the cardiac monitor, oxygen saturations have made it to 92% on the Masimo Ear Sensor and we are ready to rock and roll.

The team leader has double checked with the team and we push the Ketamine through the patent IV line.  Approximately 90 seconds later, the patient becomes disassociated.  The patient is reclined to a 30° head up position and the Rocuronium is pushed.  Another 30 seconds go by and her saturations start to plummet.  Her ear sensor is showing a rapid decline from 92% to 87%.... a decision has to be made…what is the next step?

As Paul Harvey used to say…. ”come back for the rest of the story!”

Peer Review #1:

This case should raise the hackles on our collective necks!  Whenever you have the opportunity to explain an emergency intubation procedure to a patient, the stakes are high as any resultant neurological injury will likely be a consequence of our airway decision making rather than some pre-existing injury or condition.  So let's do this right... 

 A key concept raised in Part 2 and emphasized here in Part 3 concerns the "deoxygenation curve".  The brilliant design of the hemoglobin molecule allows blood to "load up" on oxygen in the lungs but efficiently "dump" oxygen in tissue that has only slightly lower oxygen concentrations.  This transition in function from "loading up" to "dumping" occurs at SpO2 values of 93%.  Unfortunately, when the patient's systemic circulation crosses through this same SpO2 threshold, the speed of desaturation accelerates tremendously.  Navigating these treacherous waters is made even more problematic given the inherent latency with peripherally placed (e.g., finger) pulse oximetry probes reflecting central SpO2 values.  In this case, we have an ear probe, which provides SpO2 information in "real time".  Unfortunately, it is telling us that we're already below the SpO2 threshold of 93% and falling down the steep part of the desaturation curve.

So where do we go from here?  Not wanting to be a spoiler, I will only provide a few salient thoughts to guide your decisions.  First, recognize that we've fallen off the desaturation cliff edge and are plummeting toward arrest, a situation that this paralyzed patient cannot improve on her own.  Also recognize that even the fastest intubator may not be quick enough to prevent bradyasystolic arrest, or at least hypoxic brain injury.  Second, appreciate that we were able to improve SpO2 values to 92% with passive oxygenation via non-rebreather.  That makes her a "responder" and informs us that we have some control over her oxygenation status.  In other words, we should be able to repeatedly "re-oxygenate" her back to that same SpO2 value.  Third, realize that we have more pre-oxygenation tricks up our sleeve, all of which help optimize alveolar surface area for oxygen absorption.  Good luck!
Dr. Dan Davis, MD
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