Sorry about the voice–blame the swine flu.
Case
Thanks to Joe Chiang
Severe DKA; Obtunded with pH 6.65, PaCO2 18, Bicarb 5
Pt’s mental status is worsening
The decision is made to intubate
Should you give NaBicarb?
Probably won’t help as patient is already breathing at their maximum. Unless they blow off the Bicarb-generated CO2, they won’t increase their pH significantly.
What you need
Properly fitted NIV mask
Ventilator, not a NIV machine
Someone who knows how to work the vent
Normal intubation stuff
If available, Quantitative ETCO2
Procedure
- Place pt on pseudo-NIV
Settings are
Mode Volume SIMV
Vt 550 ml
FiO2 100%
Flow Rate 30 lpm
PSV 5-10
PEEP 5
RR 0
- Attach ETCO2 and observe value
- Push the RSI Meds
- Turn the Resp Rate to 12
- Perform jaw thrust
- Wait 45 seconds
This violates the tenets of RSI, but keeping the pt alive is probably more crucial right now.
Most experienced operator should intubate the patient
- Attach the ventilator
- Confirm tube placement by observing ETCO2
- Immediately increase Respiratory Rate to 30
- Change Vt to 8 cc/kg predicted IBW
- Change Flow Rate to 60 lpm, this si the normal setting for intubated patients (forgot to mention this in the audio)
Why 30 BPM? Listen to the podcast.
- Make sure ETCO2 is at least as low as it was when you started
- Check ABG
- Pat yourself on the back
Podcast: Play in new window | Download
{ 3 comments… read them below or add one }
Thanks for the useful info. It’s so interesting
It would be interesting to have this great approach modified if ED has no quantitative ETCO2. Thanks.
You can definitely manage without quantitative, in which case you just have to go by the 240 ml/kg/min, which translates to 30 breaths per minute if you set the tidal volume to 8 ml/kg. Just make sure to get the post-tube abg with alacrity.