January 5, 2026

A 48-year-old male fell from scaffolding at work, is currently seizing and otherwise unresponsive. He has suffered trauma to the head, but no other bruising or trauma, with snoring respirations and significant saliva from the mouth. He is also vomiting. 

You appropriately manage the airway with full C-Spine precautions.  

You evaluate the Glasgow Coma Scale (GCS): 

• Eyes: Not opening even with noxious stimuli=1 

• Verbal: Making only incomprehensible sounds=2 

• Motor: He withdraws from noxious stimuli=4 

• Total=7 

How will you manage his airway? It is clear that he needs an airway. He is seizing, and this must be controlled immediately. 

185/105, p=45, Pulse Ox=93%, Glucose 133 

You chose Versed 2.5 mg IV with control of seizures. He is now exhibiting decerebrate posturing. GCS is now 6. 

You are 30 minutes from the trauma center; air support is grounded due to weather, and the patient’s trajectory is getting worse. There is a gag reflex. 

You are trained in rapid sequence intubation (RSI) and so is your partner; you also have an EMT to assist. The three of you go through the 7 Ps: 

1. Prepare (all equipment, suction, tubes, recue airways, meds, tubes, tube holder, capnography, and video equipment) 

2. Preoxygenate 

3. Premedicate (Ketamine 1-2 mg/kg) 

4. Paralytic medications (Rocuronium 1-2 mg/kg) 

5. Positioning (C-Spine precautions with this patient) 

6. Place tube (and confirm with visual partner confirmation capnography waveform, breath sounds and Pulse Ox as well as colorimetric CO2) 

7. Post-intubation care (watch the waveform, pox, and patient condition until arrival) 

Excellent job by the crew. The patient is found to have an expanding SDH and is taken rapidly to surgery. Decompression is complete, and after a long recovery, the patient is left with memory issues but is physically at baseline. 

Summary 

• RSI is for trained medics, and they must be with another trained RSI medic as well as a third assistant.  

• Video equipment, as well as backup airway care, is required. 

• Complete the 7 Ps for intubation under RSI. 

• Constant patient monitoring is required. When you sedate and paralyze a patient, their total care is in your hands. 

We are all in this together. Always call medical control for support. 

Sincerely, 

Don Spaner, MD

January 12, 2026

This week, we review a 70-year-old female:  

• 180/110, p=90, r=32, pox=88% co2=26 

• Can’t lie flat. 

• JVD to jaw line, +HJR, 4+ pitting edema. 

• PMH: IDDM, CHF, CRF on dialysis 3x/week. 

• Patient SOB speaking in two-word sentences. 

Treatment?  

You have correctly identified an acute exacerbation of heart failure. 

The patient is identified as having a moderate to severe CHF exacerbation. 

Treatment? 

• Be aggressive with CPAP. 

• Confirm that she is alert and the airway is intact. 

• Confirm that she is not vomiting. 

• Confirm that she is not hypotensive. 

• Confirm that there is no trauma to the chest. 

• Confirm that she tolerates the mask. 

• Confirm that there are no contraindications for CPAP. 

Pressures between 5-10 are in the green zone and barotrauma is low risk. Here, we will open the alveoli, recruit more surface area for gas exchange, allowing for better O2.

Be aggressive with nitro, continue S/L nitro until systolic is less than 120. This will dilate the vasculature and rest the heart whose pump is failing. 

If you find severely worsening heart failure and the B/P is now low, they have moved from CHF to cardiogenic shock. As much as the ED would love to vasodilate them and provide CPAP, they won’t tolerate this, and we sadly ask you to use push dose epi to provide a systolic of 90 and or a MAP of 65. Pressors are taxing on a failing pump and simply make the heart work harder. We have moved to early intervention with Impella, aortic balloon pumps, and evaluation for LVADs. In the field, we can’t let the patient suffer cellular death from lack of perfusion. We ask you to maintain these numbers and use the push dose as needed. 

Thank you for your time this Monday morning, 

Don Spaner, MD