Podcast 3 – Laryngoscope as a Murder Weapon (LAMW) Series – Ventilatory Kills – Intubating the patient with Severe Metabolic Acidosis

This lecture is part of the Laryngoscope as a Murder Weapon Series: Hemodynamic Kills Oxygenation Kills Ventilatory Kills Sorry about the voice--blame the swine flu. Case Thanks to Joe Chiang Severe DKA; Obtunded with pH 6.65, PaCO2 18, Bicarb 5 Pt’s mental status is worsening The decision is made to intubate Should you give NaBicarb? Probably won’t help as patient is already breathing at their maximum. Unless they blow off the Bicarb-generated CO2, they won’t increase their pH significantly. What you need Properly fitted NIV mask Ventilator, not a NIV machine Someone who knows how to work the vent Normal intubation stuff If available, Quantitative ETCO2 Procedure Place pt on pseudo-NIV Settings are Mode Volume SIMV Vt 550 ml FiO2 100% Flow Rate 30 lpm PSV 5-15 PEEP 5 RR 0 Attach ETCO2 and observe value Push the RSI Meds Turn the Resp Rate to 12 Perform jaw thrust Wait 45 seconds This violates the tenets of RSI, but keeping the pt alive is probably more crucial right now. Most experienced operator should intubate the patient Attach the ventilator Confirm tube placement by observing ETCO2 Immediately increase Respiratory Rate to 30 Change Vt to 8 cc/kg predicted IBW Change Flow Rate to 60 lpm, this si the normal setting for intubated patients (forgot to mention this in the audio) Why 30 BPM? Listen to the podcast. Make sure ETCO2 is at least as low as it was when you started Check ABG Pat yourself on the back PreVent to prevent Death (coined by Sara Crager) Now on to the Podcast...