Tuesday, October 15, 2013

Spidey-sense

I was having an interesting conversation with a resident earlier (and actually, gasp, enjoyed it) about how to know when to intubate a patient that looks like poop, but has a relatively normal blood gas. It was interesting in the sense that he really was looking for my opinion/experience on the matter. We bounced ideas back and forth and came to a few major points to look over. 


1. What does the patient look like? Labored, sweaty, pale, jaundiced, only awake when aroused, old/young? 
2. Are they oriented to time/place (sans hypercapnia)? (ie could they anticipate vomiting and warn someone about it?) 
3. What disease process(es)/history is causing this? Someone with ESRD can usually be fixed with bridge bipap/dialysis, whereas a stage 4 met lung CA patient is terminally ill and will succumb to the disease eventually.
4. What are the other vital signs/labs? Basically, are they about to code b/c their BP is labile and HR is jumping from 120's to 180's with a few pvcs thrown in there? 
5. Does the patient/family want aggressive care? Code status and the patient's wishes should always be respected if they are of sound mind (medical power of attorney plays a role, too)
6. Spidey-sense? This one is just something I've acquired over time. Call it intuition, my experiences in the ED, ICU or pre-coding patients on the floor... I just can tell when a patient is coming up close to needing life support. 

Those are just some good starting points (no particular order) in making a call on those borderline patients. I feel like one of the most obvious green lights for intubation on airway protection is status epilepticus that won't respond to benzos/barbituates (also taking into account respiratory drive depression from those drugs as well). Flash pulmonary edema in extreme cases, epiglottis (this is an absolute), hemoptisis, unstable NSTEMI going to cath lab, drug overdose, and history of very difficult airway in resp distress are the other big ones that I would push for intubation. 

Personally, I tend to go with that if the patient is exhibiting at least 3 of the 6 points I brought up, I will voice my opinion. Now, most of the time I don't make that call, but at least I can put forth my two cents (whether it's taken seriously depends on the boss man in charge). I do find it hard to swallow some days when I can see an intubation coming from a mile away, but no one will listen to my plea because abcdefg reasons.

I know I have more to elaborate on this subject, but it's late and I have another long long shift coming forth tomorrow. 

I hope you are all enjoying the lovely fall weather :) 

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