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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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