Case Summary:

An ALS crew was dispatched to the home of a middle-aged man for a welfare check.  Upon gaining entry to the home, a 450+ pound man was found sitting in a chair.  He is alert but lethargic and drowsy, tachypneic with shallow respirations and rales, weak radials and delayed cap refill.  The crew quickly assesses vitals.

Initial vitals: BP 124/76,  HR 118,  RR 32,  Sat 68% RA,  ETCO2 72,  Glucose 188

While obtaining vitals, crew requests a second ALS and obtains history from family that are now on scene and reporting this patient has never seen a doctor.  Patient placed on CPAP with 100% O2 to help with work of breathing and severe hypoxia.  Given need for immediate vascular access and him being a difficult stick, crew placed humeral IO.  EKG obtained and did not reveal STEMI or arrythmia.  On CPAP, sat improved to 78% but the patients BP dropped to 86/48.  Crew gave doses of push dose epi as needed to support the BP and placed two more IOs in bilateral tibias to ensure multiple points of access.  Push dose epi was able to get the BP up to 124/76 however, the patient became progressively unresponsive and remained hypoxic in the 70s.  Crew decided patient needed emergent advanced airway and prepared for intubation.

Crew kept patient in his chair for improved respiratory physiology given body habitus.  They also got everything ready (including back up devices) prior to pushing any meds.  This crew was not RSI capable so they planned to sedate using ketamine.  The crew bagged the patient up to a sat of 92% and titrated their doses of push dose epi to get the BP up to 132/72 given they anticipated a drop in the BP after sedation was given.  Crew gave a dose of 2mg/kg of ketamine, suctioned the airway and then successfully placed the ETT which they confirmed with waveform ETCO2.

After intubation, patient dropped his BP to 78/40 post intubation which the crew treated with push dose epi and was able to keep the SBP >100 for the rest of the patient encounter with frequent repeat doses.  The crew also placed soft restraints so that the patient could not self -extubate if his sedation waned too much.  The crew then carefully extricated the patient from the home and transported the patient to the ED.  Throughout this process, they frequently re-assessed the ETCO2 waveform to ensure the ETT remained in proper position.  The patient arrived in the ED with far better hemodynamics than at the time the crew first found the patient.

Highlights of the case:

Resuscitation before extrication

Most of our critical patients are “stay and play” patients.  This means that the best thing we can do for them is to start our EMS care immediately prior to extrication.  The reason for this is that often these patients are at risk of (or are already accruing) irreversible organ damage and/or hemodynamic collapse.  If we start our care right away, we might be able to intervene before this occurs.  The exception to this rule is our trauma patients where we instead prioritize transport.  This crew provided almost all of the resuscitation in the house and once the patient was as stable as possible, the began the difficult process of extricating this very large patient.

Requested back up early

This crew noticed that this patient required additional resources both for his care as well as for the extrication, so they requested back up early.  It takes time for back up to arrive, so we want to mobilize the help as early as possible.  If it turns out they are not needed given an unexpected improvement in the patient, you can always disregard them.

Resuscitation before intubation

Most patients who get an advanced airway placed will drop their blood pressure.  This occurs for multiple reasons.  The first being that all sedatives blunt a patient’s natural stress response which involves the release of norepinephrine and epinephrine.  This drop in these hormone levels lead to a drop in a patients BP.  The second reason is that we are switching a patient from negative pressure ventilation to positive pressure ventilation.  Non-intubated or bagged patients’ breath by expanding the thoracic cavity which sucks air into the chest.  This also sucks blood into the chest and fills the heart more leading to a higher BP.  If you breath for the patient using positive pressure ventilation, you are forcing air into the chest.  This increased pressure decreases the amount of blood getting to the heart and will cause a drop in the BP.  For this reason, we need to assume a patient will drop their BP when we intubate them and we need to support their BP as much as possible BEFORE we intubate.  This crew planned for this and used push dose epi to get the patients BP to a safer range before pushing ketamine and intubating.

Preparation for intubation

Intubation is a dangerous time for the patient since tons of things can go wrong and we have very little time to address them if they do go wrong.  For this reason, we want to prepare as much as possible in advance.  This includes anticipating everything that can go wrong and preparing for these things.  Our RSI drug boxes have a laminated copy of our RSI check-list that lists all the things we need to have ready before we perform RSI.  This is also listed in our protocol and we want to utilize this every time we intubate so that our intubation attempts go as smoothly as possible.  Part of preparation is resuscitating the patient as much as possible before we intubate which was described above.  This crew had everything planned out and prepared in advance which made a very difficult intubation go as smoothly as possible.

Maintained proper patient positioning for good respiratory mechanics

Proper patient positioning is very important for any of our patients in respiratory distress.  All patients breath better sitting upright than lying down.  For this reason, we want to keep them in that position whenever possible.  This is especially true for our obese patients since the weight of their chest wall is so great that it prevents proper inspiration when they are lying on their back.  The crew found this patient sitting up and they correctly left him in that position for as long as possible.  They even intubated him sitting up and I suspect that if they attempted to flatten him out prior to intubation that he likely would have rapidly decompensated and went into cardiac arrest.  We often need to place our patient’s supine to extricate.  If you notice that a patient is in severe respiratory distress while sitting up, they will likely not survive being placed supine even for a few minutes so this should trigger you to treat them enough in the home that they have improved enough to potentially survive the extrication process.

Re-dosed push-dose epi (PDE)

Push dose epi is a fantastic treatment modality for our patients in shock.  There are two critical things to remember is with this medication.  The first is that the more hypotensive the patient is, the more PDE they need; and the larger the patient is, the more PDE they need.  The exact dose you give is based on the degree of shock and the size of the patient.  The second key thing is that PDE only lasts one or two minutes.  This means that if you think you need PDE, you likely will need to give it every couple of minutes unless you somehow fix the underlying cause of the patient’s hypotension.  This crew understood this and was constantly re-assessing te BP and giving doses of PDE every couple of minutes for the entire patient encounter which included during the extrication.

Soft restraints were used for a patient with an advanced airway

Any patient with an advanced airway is at risk for loss of this airway.  One of the potential causes for this is the patient starting to wake up and self-extubating.  The best way to prevent this is by keeping our patient chemically sedated during transport; however, sometimes the sedation wanes more than we realize due to the complexity of all the things we do in the prehospital environment.  Use of soft restraints can restrict a patient with too little sedation from accidently extubating themselves and give us the time to treat the patient with additional sedatives to ensure the patient is both comfortable and safe.  Despite doing a ton of things for this patient, they did not forget to place soft restraints.

Re-assessed ETCO2 during all patient movements and transfer of care in the ED

Waveform ETCO2 is the gold standard for correct positioning of an advanced airway and is mandated for all prehospital advanced airways.  Not only does to prove our tube is in the airway, but it also helps us monitor for ETT dislodgement.  Due to the nature of what we do which includes difficult extrications and potentially bumpy rides in the back of an ambulance, ETT we place in the field are at higher risk for dislodgement than tubes in the hospital.  For this reason, we need to monitor and document that the ETCO2 waveform remains intact during ETT placement, all patient movements and upon transfer of care in the hospital.