EM Educator Series: The High-Risk Intubation (Peri- and Post-intubation)

Authors: Alex Koyfman, MD (@EMHighAK) // Edited by: Brit Long, MD (@long_brit) and Manpreet Singh, MD (@MprizzleER)

Welcome to this week’s EM Educator Series. These posts provide brief mini-cases followed by key questions to consider while working. The featured questions provide important learning points for those working with you, as well as vital items to consider in the evaluation and management of the specific condition discussed.

This week has another downloadable PDF document with questions, links and answers you can share with learners as educators in #MedEd. 

Case #1:

A 77-year-old male with history of COPD presents with severe shortness of breath, difficulty with ambulation, productive cough, and fevers. He has felt weak and feels his normal activity is severely limited. He has also needed to increase his baseline oxygen from 2L to 5L, though it isn’t helping. His VS include RR 28, HR 110, BP 89/48, T 38C, and Sats 82%.  What should you consider regarding this patient’s airway and respiratory status?

Case #2:

A 23-year-old male is brought in by EMS with head trauma after a motorcycle crash. He was not helmeted, and his GCS is 4. He is hypertensive, bradycardic, and has a dilated pupil on the right. What airway and intubation considerations are required?

Case #3:

A 55-year-old female with severe respiratory distress and diffuse interstitial infiltrates on chest x-ray has been intubated. She is receiving empiric treatment for pneumonia with antibiotics, as she was febrile, tachycardic, and tachypneic with productive cough. Her ETT was confirmed with ETCO2 and X-ray. You are concerned about ARDS, but what ventilator settings should you utilize?

Considerations:

What do you need to know regarding the airway and physiology in intubation and ventilation for these patients?

  1. COPD / asthma
  2. Metabolic acidosis (e.g. DKA, salicylate tox)
  3. Shock e.g. septic, cardiogenic
  4. Pulmonary hypertension
  5. Elevated ICP
  6. Upper GI bleed
  7. PE
  8. Cardiac tamponade
  9. Anaphylaxis / angioedema
  10. Aortic stenosis
  11. Morbid obesity
  12. Pregnancy
  13. ARDS
  14. Post-intubation crash

From Dr. Katelyn Hanson and Hanson’s Anatomy:

Suggested Resources:

 

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