Thread by @ercowboy

How to Kill an Asthmatic by
@CriticalCareNow

35M asthmatic hx mult intubations

Nebs and Mg and steroids but no better.
#SMACC

Waiting for Heliox...and waiting.

Pt. says "I'm going to die. Intubate me."

Difficult intubation, 4 attempts.
Get the tube, then arrests.
Extended code, then called.
#SMACC

Epinephrine.

No one with asthma should have been intubated without getting epi.
#SMACC

This is a great great drug and everybody needs to stop being afraid to give it.

Heliox.

Improves laminar flow, gets down to little airways.

Marginal benefit and often delays in getting.
Not a priority.
#SMACC

Ketamine.

Ketflix and chill. Air hunger and anxiety leads to tachypnea and breath stacking leads to suffering leads to the Dark Side.

Ketamine also has direct bronchodilator effects.
#SMACC

NIPPV.

Fatigue and tiring lead to slower but less effective respirations.

Help them ventilate.
#SMACC

Fluid.

These pts. are volume depleted. They have transpiration deficits and are really sick so potentially hemodynamically unstable.

Give them fluid early to help them with pos. pressure ventilation.
#SMACC

Analgesia.

Remember the chill? Just as important to optimize the pain response when intubating. Fentanyl, Remi, whatever.

#SMACC

The airway.

Fast. These pts. are relying on their resp. drive and you just took it away. Not the time for trainees taking a look.

#SMACC

The vent.

Rate slow.
Flow high.
Ignore high pressure alarms (mostly).

emcrit.org/emcrit/vent-pa…

#SMACC

The complications and the code.

Breath stacking. You set the rate low? Flow high? Did the sedation package? Still. Unplug from the vent. Push on the chest to get that exhale.

Barotrauma. Fix the PTX.

No to the above? Ok. ACLS.
#SMACC

Fast blood test.

Check the K. Hypokalemia from all the nebs needs to be fixed or the code will fail.
#SMACC