Dr Rob Bryant of Utah shares some cracker casesRob emailed this :
Great post on intubating the crazy sick pneumonia patient.
I have been involved in three intubations in the last month that have been as scary as the case you and Brian discussed, with the added degree of difficulty being unobtainable (N of 2) or transiently obtainable pulse oximetry, even with the use of an ear probe.
68yo hypoxia, hypotensive pneumonia with UTI and abdo wall abscess.
2l crystalloid, multiple rounds of push dose epi with pre intubation BP of 80 systolic.
Pulse ox giving poor wave form O2 sat in mid 80’s for about 20sec before the pressure from the ear probe clip exceeded the ear perfusion pressure (my theory) and we would lose the reading.
Pt ramped, NC on, ketamine and NIV with PEEP at 15cm from vent for DSI, 20mcg of epi with roc.
Sats in the intermittently obtainable low 80’s, seemed to hold steady, residents first tube in the esophagus, re-bagged using vent (2 great RT’s in the room), second attempt with glide scope successful, matched post intubation end tidal to pre-intubation end tidal due to pt having low venous ph on 1st gas.
70 yo female, likely severe sepsis, vasculopath with no radial pulses, automatic cuff reading in the 50’s despite full tank, good fem pulses and mentating well. Left the ED with a BP of 67syst on high dose levophed sitting up eating ice chips.
Called to ICU 30 min later, pt with agonal resps, no readable pulse ox waveform despite multiple probes and locations, and mid forearm art line with poor waveform reading in the 50’s. Still had good fem pulses.
Head of bed elevated, IV Ketamine, NC, bagged with PEEP valve at 10cm (taken from DSI bag sitting on crash cart in ICU) 20mcg epi, Rocc. , intubated with DL .
I assisted one of my partners with a pt that had been drinking isopropyl alcohol, decompensated in ED with pressure in the low 80’s, venous pH 7.00 peripherally clamped down with mottled everything.
2l crystalloid, multiple rounds of push dose epi, and no readable pulse ox despite use of ear probe.
Head of bed elevated, 20 mcg epi, Ketamine, oral airway, bagged, pre intubation end tidal CO2 15, bagged until her lips were pink, intubated with glidescope, matched post intubation end tidal to pre intubation end tidal. Given calcium post intubation, post intubation venous gas had improved pH and BP improved. Initially grossly normal cardiac fn on US, then really crappy cardiac fn pre intubation, then sig improved cardiac fn.
What tricks do you have to magically obtain an unobtainable pulse ox?
What else would you do in these ‘no pulse ox situations’?
With no pulse ox, how would you gauge how long to look on your first intubation attempt?
This is a situation where it would be nice to have an art line in, all three patients were extremely hard access, and did not have useable art line data.
I am looking forward to some simple answers to these questions on the ‘die in front of you patients’
Thanks for your opinion
ANY SUGGESTIONS OUT THERE?