This case was referred from a small rural hospital with limited facilities to ARV on the weekend.
45 year old male who re-presented with epigastric pain having been discharged 48hrs earlier with a diagnosis of GORD and treated with a proton pump inhibitor and antacids.
His pain got worse and his ECG now showed this:
He was thrombolysed and had a brief run of VF which he was successfully defibrillated from and his ECG pre-transfer was almost back to normal.
Ventilation in severe asthma can be problematic
1. Adequate oxygen to keep sats >90-92%
2. Allow the patient to exhale – short inspiratory time, long expiratory time
- tidal volume based on lean body weight 6-8mls/kg
- low respiratory rate 6-10/min
- high inspiratory flow rates – up to 90L/min
- zero PEEP initially
- tolerate high CO2 to pH >7.15
3. IF AFTER CONFIRMED INTUBATION THEY DROP SATS AND BP – DISCONNECT THE VENTILATOR – THEY MAY HAVE DYNAMIC HYPERINFLATION
Follow the links to the presentation and ten minute tute.
You arrive for handover, a 52 yr old lady awaiting ablation for WPW has presented with palpitations sits in resus. Stable.
What’s the rhythm?
She slows with flecainide.
Before reverting to SR
Her last ECG, just before leaving for inpatient ablation reveals the ‘delta’ wave in V3 and V4 – also develops T wave inversion in V1-3.
Slide show from session on ventilating in asthma.
1. Low respiratory rate 6-10/min.
2. Tolerate hypercapnia and consequent respiratory acidosis to > 7.1
3. Maximise I:E ratio – 1:4 – 1:5
4. Reduce your inspiratory time by increasing your flow – 80-90 L/min if you can
5. Watch you plateau pressure NOT your peak inspiratory pressure – aim <30
6. Reduce FiO2 to achieve sats >90%
7. ZEEP – zero PEEP – see the accompanying article for more information
Summary of categorisations and rewarming strategies.
Essentially, you only move to active core rewarming if you have haemodynamic instability not responding to conservative techniques.
Bear in mind that in the hypothermic state you don’t need a pulse, blood pressure or conscious state of a normothermic patient. Depending on how cold you are this is to be expected. Re-warming is the aim and you should expect an improvement in these parameters.
Clearly, as signs of life fade away, more and more aggressive intervention is required.
The coldest accidental hypothermic patient resuscitated started at 16.5 degrees!
Check out the new ten minute tutes page. Topics will grow.
Albury sessions will be added