Emerge in EM
Emerge in EM is a dynamic podcast dedicated to exploring the cutting edge of Emergency Medicine Education, Resuscitation, and Global health Empowerment. Each episode brings together leading experts, frontline healthcare professionals, and change-makers from around the world to discuss the latest advancements, case studies, and innovations shaping the field of EM. Whether you're a seasoned emergency physician, an aspiring medical student, or a global health enthusiast, Emerge in EM delivers insightful conversations and practical knowledge to elevate your skills and broaden your understanding of life-saving care. Tune in for in-depth discussions that not only address clinical excellence but also emphasize the global movement towards equity and empowerment in emergency medicine.
Emerge in EM
E1: Pearls and Pitfalls When Intubating the Crashing Patient
Dr. Obiajulu Anozie joins me to discuss the challenges, pearls, and pitfalls when managing the airway of a crashing patient.
Dr. Anozie (known for his Instagram page @icuexplained) is a dedicated critical care physician with a passion for providing physiologically driven, life-saving medical care.
Born in Canada to Nigerian parents, Dr. Obiajulu Anozie brings a unique perspective to the healthcare field, blending diverse cultural insights with advanced medical expertise. Outside of the hospital, Dr. Obiajulu Anozie enjoys staying active through regular exercise and unwinding with video games, balancing the demands of a rigorous medical career with personal interests. Committed to both professional excellence and personal well-being, Dr. Obiajulu Anozie exemplifies the dedication and resilience required in today’s fast-paced medical environment.
All right. I am so happy to start this new podcast and share some of the intelligent and smart, and of course. Always great voices in emergency medicine, critical care, and resuscitation. My name is Mohamed Hagahmed and welcome to the Emerge podcast, where we'll be delving deep into emergency medicine, education, resuscitation, and also global empowerment in emergency medicine. My first guest, and it's my honor to introduce today, my brother from another mother, always From all the way back from the continent, Obi. I'm glad you're here, man. Tell us more about you. Tell us who you are.
obiajulu-anozie_3_09-08-2024_193030:Yes, my brother, born and raised in Canada. But as I'm from the motherland. I'm from Nigeria. My family is from Nigeria, but brought up in Canada. I consider myself to be a French speaking Canadian. And when I'm not deep diving into the world of critical care and all the physiology and just the fun derangements that we typically see, you can find me gaming. You can find me in the gym. Absolutely. And and as of recently, you can find me out enjoying nature, taking nice long walks.
mohamed_2_09-08-2024_193030:I feel you, man. I feel like you and I have shared the same hobbies, I agree with you, like being outdoor. It's such a rejuvenating time. Recharge you for the next shift. Do you listen to anything or what's, by the way what's your favorite music style? What do you like to listen to sometimes?
obiajulu-anozie_3_09-08-2024_193030:Soul,
mohamed_2_09-08-2024_193030:Ooh,
obiajulu-anozie_3_09-08-2024_193030:Soul, artists like, DiAngelo, Erica Badoo. There's actually a group that used to be out and their name was the internet, but they don't, they're not making music anymore together. But, groups like those they're very good. They're, I do listen to the Afrobeats like a lot of people are into now. But I was actually brought up on. Really old school, classic West African music, which is the original Afrobeat, if you ask me.
mohamed_2_09-08-2024_193030:Obi, you and I can talk about music for days, but I don't think that's what our, guests are here to listen to. Maybe how about this? Maybe I'll leave a little bit of your music taste at the end of this podcast.
obiajulu-anozie_3_09-08-2024_193030:Sure. Sure.
mohamed_2_09-08-2024_193030:I think what I was thinking about the first topic, it's it's based on a recent case and a discussion that I had with a colleague about how soon should we jump on intubating someone who comes in sick. And it's, we had we went back and forth with our discussion, but I wanted to bring you in and I want you to. to hear your expertise and your experiences with intubating patients who are critically ill. And I'm going to start with the case if that's okay with you.
obiajulu-anozie_3_09-08-2024_193030:Absolutely.
mohamed_2_09-08-2024_193030:So the case it's of a patient that I recently took care of with a colleague. And it's a case of a 63 year old gentleman who was found unresponsive by bystanders who called 911 when EMS arrived. The patient was moaning to painful stimuli, no signs of trauma. They tried some Narcan that did not work and they also gave some oxygen via high flow nanobreather mask. He wasn't, salivating or there's no secretions. So with that 15 liters, his SATs was up to about 90%. And by the time he got to the ED, he had a blood pressure of 90 over 60, a heart rate of 135, and it showed sinus tachycardia on EKG without evidence of ischemia or infarct. Now he was breathing at 12 breaths per minute. And like I said, he was just moaning to painful stimuli and had an initial blood glucose of 118. So my first question to you, would you get up from your seat, get ready for intubation and do it right away? Or would you do, would you wait a little bit more to see what's happening?
obiajulu-anozie_3_09-08-2024_193030:I think that's a great question, and it's a great question because, when you think about it fundamentally, intubation itself is probably the most, one of the most quintessential things we do. As resuscitationists is people that work in the ER, working in the ICU, but at the same time, intubation is probably the most dangerous thing you can do. This is what I always try to impart on my trainees, there's nothing more dangerous than intubating someone, even if you think it's just going to be smooth, it's as simple as just putting the breathing tube through the vocal cords. There's so much more that goes into it. When you intubate someone, you essentially, what I like to say is you open Pandora's box because you don't know what's on the other side of that breathing tube. You're taking normal physiology and you're reversing it. And when we're encountering critical patients who we don't have the most clear picture of what's going on with, you can only imagine that if you now introduce, you Positive pressure ventilation and the ramifications of positive pressure ventilation, it could be, it may not be well tolerated and that may come with some dire consequences. Now, one thing that comes to mind when I think about this particular case is time or the illusion of time, one thing I like to talk about is, Sometimes we just, we feel pressured to act immediately, because of this illusion of time or lack thereof. But in our wheelhouse, in our in, in our area where we're comfortable, whether it's the ER or the ICU, where you have all your resources available, I argue that in most patients, even if they're, even if they're deteriorating, you probably have a little bit more time than you actually think you do. And when you stop and take a breath and realize that, I'm in control of this situation, that's when it empowers you to think of do I need to immediately put this breathing tube in or are there other things we can do to Further stabilize the patient maybe delay the need for intubation or at least set us up to intubate at a later time
mohamed_2_09-08-2024_193030:No, man, it's all great points. I guess from my perspective, working in ED, sometimes I feel like there is a pressure to go ahead and just do that intubation and provide a definitive airway. Not only from a clinician standpoint, but also from an operational standpoint, because now you have like nurses that going to be at bedside closely monitoring their patient. So these nurses will be pulled aside. just on one patient. And then we have other people waiting in the waiting room or in other beds that also need care too. In addition to of course, having pharmacy and other resources like labs, x rays and all that stuff. So I, I definitely see that point now when it comes to clinical parameters, do you base your decision on some number like you get from a gas or is it a pulse ox that actually worries you and tells you maybe you should proceed sooner than later. Do you have is this something that you rely on like numerically data wise that you use for intubation decision or what do you normally, how do you normally act on that?
obiajulu-anozie_3_09-08-2024_193030:you know that's a good question because you know There are, especially when you're in the education phases, when you're learning and you're being instructed on, when do we normally intubate patients in a critical setting, the indications are typically, you can't ventilate them. So if you get a blood gas, maybe your PCO2 is high, pH is low, maybe less than like 7. 25 or lower Or severe hypoxemia, such as in the case of your patient on 15 liters, face mask, but only setting 90%. So that's pretty severe hypoxemia. That's potential indication into base or just the need to establish a definitive airway because the patient's not protecting their airway appropriately, such as the abundant patient. In the case. But for me, I'll just be honest with you. I'm not so much of a numbers driven person. I think it's just that instinct, that instinct that tells you that, the best way that I could support this patient is by intubation. That's when I intubate a patient. I intubate them when after looking at them, um, looking at the data that I have available, whether it's pulse ox and, blood gas and combine that with what I'm seeing in the patient, their level of extremists and what's going on. I put that together and if my decision and what my instincts tell me is that, the best way I could support this patient and give them the best way to survive and get them through whatever they're going through right now is through intubation. Then I proceed.
mohamed_2_09-08-2024_193030:I agree with you. I feel like experience does play a big role. And I would tell you when I was an intern, I probably Was a blade trigger happy. So to say, I always want to intonate people the sooner they come to the ED, whatever, like their stats drops below 90%. That was my threshold. But I think now with time and experience, I feel like I agree with you completely. I am now thinking about the sequelae. Post intubation, meaning that they're going to, how long they're going to be on the ventilator how their disease process will end up, panning out and what their code status or their other comorbidities. Like I'm thinking about all these things now more before deciding to place in a definitive airway.
obiajulu-anozie_3_09-08-2024_193030:yeah, and a lot of that comes with experience too. I don't think it's necessarily the worst thing, just a caveat. Like it's not necessarily the worst thing, especially when you're in the training stations or the training stages or when you're just stepping out into the world on your own. It's good to have that to fall back on, especially while you're learning and just gaining experience. Okay. I probably need to intubate if the. If the pH is this low and the PCO2 is this high, or if they're so hypoxemic, it's not necessarily the worst thing to fall back on those while you're developing, like your, while your clinical instincts are growing and while your experience is growing. Because I think, it's potential that some people, might watch this and say that I need to, exercise that level of experience. But my thing is, no, you need to grow at your own rate and acquire that experience so that you know scenarios in which it is appropriate to intubate, or maybe whether you can step back and watch a little bit and try to stabilize the patient.
mohamed_2_09-08-2024_193030:okay. So you also touch. Briefly on intubating someone solely for airway protection. Can you just tell us what does that actually mean?
obiajulu-anozie_3_09-08-2024_193030:It, yeah. I think when you have an abundant patient or, the classic literature saying, GCS less than eight intubate, what are the things that you're actually, Watching for it's those airway reflexes when you're conscious, there are certain airway reflexes that you have that'll prevent secretions that are produced in the oral cavity from going down where they're just not supposed to be going from going down into the vocal cords and just speaking anecdotally from my own experience, I have been burned by that in the past where, I've had a patient that was, Fairly uptunded, I kept them in the upright position and they still maintain spontaneous respirations. So my thought process is let me observe and see what happened. But then O2 stats started to drop a little bit. And when we went into intubate, it was just a flurry of secretions. A lot of thick secretions. So sometimes it's even those patients where, you know we may tend to underestimate just the severity of the secretions that patients that are uptended may tend to accumulate. But when it comes to establish, intubating someone and establishing a definitive airway for airway protection, that's essentially what we're talking about. The encephalopathic uptended patient whose airway reflexes may be impaired and can hurt themselves. From secretions going into the lungs.
mohamed_2_09-08-2024_193030:now? I agree. And I also want to add to this, that there is this sense of there's a false assurance that once you intubate. Somebody by placing a plastic tube in there, you completely prevent aspiration. Is that true?
obiajulu-anozie_3_09-08-2024_193030:Absolutely not. There's so much that, that goes into it. You establish obviously some measure of defense, we've all had scenarios where that patient's vomited, even they're intubated, but they've had an alias and they vomited. And some of that actually has gone into the lungs. We actually had a case. There was a case I could recount on a patient had an ileus, actually a small bowel obstruction. while on the ventilator was actually recovering from a COPD exacerbation on minimal oxygen, but unfortunately had an emesis event. And ended up aspirating despite having a definitive airway. And you know what happened? That patient ended up on ECMO.
mohamed_2_09-08-2024_193030:Wow.
obiajulu-anozie_3_09-08-2024_193030:That patient ended up on ECMO. Whether you have a trach whether you have an ET tube, the possibility of aspiration is there. With an ET tube, the possibility of aspiration is diminished versus, not having a protected airway in someone who's obtunded. But that possibility still exists.
mohamed_2_09-08-2024_193030:Yeah, man. This is definitely an eye opener, especially for me and a lot of our trainees that. Just by placing a plastic tube, you have to be really mindful of secretions and clearing them and also providing adequate suctioning. So when you go over your steps of optimizing oxygenation, just walk us through some of the things that you would do in this case.
obiajulu-anozie_3_09-08-2024_193030:Okay. So the patient is already the patient in the aforementioned scenario is already on
mohamed_2_09-08-2024_193030:High flow, not
obiajulu-anozie_3_09-08-2024_193030:mask liters, but not on high flow heated, high flow nasal cannula.
mohamed_2_09-08-2024_193030:nasal cannula. No! you know,
obiajulu-anozie_3_09-08-2024_193030:I'm a huge fan of heated high flow. And one of the reasons why I'm a huge fan of heated high flow is because, unlike a face mask, you can keep it on throughout the entire intubation. So I think a good way to pre oxygenate the patient would be to put heated high flow and then on top of that you can put your face mask on top of that and use that for pre oxygenation. I always like to keep patients in the upright position, especially for oxygenation and during intubation. I prefer these patients to be in the upright position for multiple reasons diminishes the risk of aspiration using gravity. The transit from the G. I. content coming up, the or pharynx will probably be a little bit slower if they're upright. And if the patient is flat on their back I also prefer that you're thinking about lung physiology, the patient that is satting 90 percent on a face mask. One can only imagine that there's some measure of de recruitment, that there's some infiltrative lung disease. Maybe there's been some aspiration and you have collapsed alveoli potentially diffusely. So in that case, you have to think that using gravity to your advantage to try to use gravity to pull open those air spaces might help you out. One thing, and this is, this varies from, this can vary from the case to case scenario, especially if you have a patient that has an aspiration risk using non invasive ventilation. To pre oxygenate, especially if you know that you have recruitable lung tissue now in a patient like this who's sat in 90 percent on so much oxygen. And you're worried about aspiration. You may want to put an NG tube so you can get an NG tube down there to, clear the stomach keep the patient upright and then maybe put some noninvasive on something like CPAP where you can have, just apply a constant mean airway pressure to gradually open and recruit airspaces. That's something that I would look at, and I've actually had some pretty good experiences using noninvasive ventilation to recruit. And, when you venture into that territory, you're starting to venture into the world of, transitioning from like a rapid sequence type intubation to more of a delayed sequence, where we're really just focusing efforts on pre oxygenation. So the question is via apneic oxygenation, using heated high flow nasal cannula and face mask, is that gonna be enough to preoxygenate your patient? Or do you need to put an NG tube down on an obtunded patient and then put to non-invasive on to see if you can recruit them? Those are two things I would definitely consider in a patient like this.
mohamed_2_09-08-2024_193030:that's why I love you, man. Cause you exactly read my mind and you always provide the most perfect segues to that next discussion. Cause I'm like, I feel like throughout the years, there's some people that would just say long time ago, even, you When I was in training, I'm sure this is also when you were in training too. Oh my God, this person cannot control their airway or their secretions or their mental state is like drowsy. You can never place a CPAP or a BiPAP mask on them. How did that change over the years? What is now your practice? Cause I feel like I am, I tend sometimes to place a BiPAP on someone who is So mentally depressed, but I can still give it a try. Do you still do the same or you what's your style with that?
obiajulu-anozie_3_09-08-2024_193030:Absolutely. I believe that you can do that. I don't. Everything is patient selection, that's the most important thing. And I think this is one of those things where, they're everybody's comfort level is going to be different. And that's why the onus is on you as the provider to provide that reassurance. Whether it's explaining to the resident or, to the APP nurse practitioner or the bedside nurse that, this is why I think that, we can at least, we can try this method, provide that reassurance. Especially when it comes to, someone with an ileus, we've put the NG tube down, so we're going to be continuously suctioning the stomach and that should give us a barrier against someone with an Ilius and also causing a gastric distention. Also, yeah, the patient may be obtunded, the obtundation is probably from CO2 narcosis, and when it's purely from CO2 narcosis, putting them on, on, on noninvasive ventilation, is the thing to do essentially for those patients and actually might buy us a chance to prevent this patient from getting intubated. What if we put them on and we wake them up, versus. We intubate them and we cannot get them off the ventilator. So is it not worth a try? I think, as providers, we have to make this, the people around us comfortable, what this is, what the decisions we make, you need to bring all the stakeholders. to the table and I like to explain, what I'm doing, and why I'm doing it, medicine does not always have to be conventional, that is a huge misconception, because if your thinking strategy is restricted to what is considered conventional, then you're going to miss out on patients that you can help. Sometimes we've got to dive into things that are a little bit unconventional, such as, putting non invasive on uptended patients to try and get them better.
mohamed_2_09-08-2024_193030:Oh man, I couldn't agree more. I like how you also involve the team like an in team approach way of deciding what's best for the patient. Also just as not only it's helpful for them to know your thought process, but also it's a nice opportunity for education as well.
obiajulu-anozie_3_09-08-2024_193030:Exactly.
mohamed_2_09-08-2024_193030:Now, like when you. See this patient, for example, who is now hypotensive, 90 over 60. Do you start something before or do you have any type of a mental paradigm or a mental checklist or something that you use to predict post intubation hypotension and walk us through some of the steps and how do you manage post intubation hypotension?
obiajulu-anozie_3_09-08-2024_193030:Absolutely. So there's multiple layers to this. Okay. So I was schooled on the philosophy that every hypotensive patient gets an ultrasound, and I firmly believe that, especially if you have some times in this particular patient, I think there is some degree of time to, to plan this this out if we're going to intubate this patient. So the patient's tachycardic with a heart rate, in in the 100s or was heart rate again, like one,
mohamed_2_09-08-2024_193030:Yeah, no one thirties
obiajulu-anozie_3_09-08-2024_193030:one 30s. Okay. So one 30s in the blood pressure, you said it was like 90 over 60. Okay. So there's a thing called a shock index, which is a predictor of post intubation. Hypotension. And, it's interesting because I've read literature that shows that, and it's startling that as many as like over 30 percent of intubations that we do in a critical setting are complicated by hemodynamic collapse. And, some of these factors. Maybe within or not be within our control, but I think the onus is on us to try to modify those factors to diminish, that percentage. I think that percentage can go down. How many times have you seen, we intubated this patient and then they coded, so a patient like this, I think I would have already put the probe on them and done some point of care echo to try to ascertain what the volume status looks like. One thing that comes to mind is when you have a hypotensive patient and the heart rates fast, oh, they need fluids. But what if resuscitation demands something else? What if you put the probe on them? And the right ventricle is just absolutely ginormous. And it's completely crushing the left ventricle. Then giving a fluid challenge really isn't going to help you. What, what stands, what comes to mind and what is obvious about this patient, is this patient It's some sort of resuscitation before intubation, resuscitate before you intubate resuscitate before you intubate. I think Levitan said it's a resuscitative intubation. I think you said something like that at some point. Assuming that, I put the probe on this patient and it's just, you hyperdynamic circulation, the walls of the LV are just, smacking each other, patient is bone dry. Then patient needs fluids, fluids can be helpful. When you're preparing to intubate someone I'm a firm believer in having You know, two good IVs, if I had my way, if I had my way, any patient that came into the intensive care unit would have two ultrasound placed, 18 gauge IVs, so you have that you're ready to rock, like you're ready to get the show started, I can take a 500 ml bag of IVs. Of LR and put it in a pressure bag and I preface this by saying pressure fluids under pressure, not maintenance fluids, not a bolus, get it in, right? You want to make a hemodynamic change in a patient, then get the fluid in, get it in fast. And I think, a good approach might be to get a good bolus of fluids in under pressure, see what it does to the hemodynamics. And then when it comes to intubation, have another one ready, have another one, have another bag primed and ready to go. And also have a bag of levophed probably primed and ready to go. So that once the patient is on the ventilator, you're ready to get fluids in quickly. And if you have to, you can turn on pressors right away.
mohamed_2_09-08-2024_193030:now is, um, norepinephrine is your first choice of vasopressor in undifferentiated shock. Do you use phenylephrine? Do you have any other specific choices?
obiajulu-anozie_3_09-08-2024_193030:I've seen phenylephrine given I've used phenylephrine. But I think I prefer, push dose epi is something that, you have to have in your toolbox. There's so much you can do with Push Dose Epi. I've had, especially when it comes to, okay, the hemodynamics aren't stable, but the patient is in so much extremis that we just, we got to go now, that's when you have a crash cart, you make a push dose of Epi and what I'll do in those patients, try and get some fluid in as fast as I can, but I'll give my induction meds and I'll flush it with Push Dose Epi and I'll flush it with Push Dose Epi. So I might say, okay, let's go with the and, I'm bringing up the induction meds here, but let's go with the ketamine flushed it with the Roc flush it with two cc's of push dose epi. And then flush it with saline. So push those epi needs to be in your repertoire as far as like continuous, continuously infusing basal pressors. What I use in general, my approach to basal pressors in general depends on what I see on point of care ultrasound. Okay. And also the kind of access that I have to. If I have for instance if I had a patient with RV failure that needed to be intubated, I, if I had a central line available, I put them on vasopressin, because there is some evidence that it's, that it has some pulmonary vasodilatory capacities and you're going to get the blood pressure up, maybe something like I'll have them on vasopressin and some epi if I have someone who's bone dry particularly do not like norepinephrine because norepinephrine has chronotropic properties. So you can speed the heart rate up. If you have someone who's already dry and you're speeding up the heart rate, then you have no diastolic filling. So you're essentially compromising preload, right? And the whole process of putting someone on positive pressure ventilation can convert someone who is otherwise, euvolemic to a preload dependent state. So it doesn't necessarily make sense. to just jump to norepinephrine as your first presser, especially in someone who's hypovolemic. You might want to use something like phenylephrine in that case as well as and maybe vasopressin. If you have a central line,
mohamed_2_09-08-2024_193030:That's a really interesting point to be about the vasopressin because I feel like vasopressin is underutilized in the ED with having norepinephrine usually as our first choice. And then normally we don't jump to vasopressin unless we almost max on our norepi drip to like a one micro per kilo per minute. But I am seeing more and more people like advocate for starting vasopressin sooner given the depletion of vasopressin. in the shock state or the septic shock state specifically.
obiajulu-anozie_3_09-08-2024_193030:yeah, absolutely. Yep. There's evidence that vasopressin levels fall in septic patients, especially when they're a little bit older
mohamed_2_09-08-2024_193030:patients? Do you have a certain MAP goal? Do you I guess when it comes to MAP, do you rely on a blood pressure cuff or do you go ahead with placing an A-line sooner than later? I know that's I know you're an intensivist, so for you probably A-line is always the right answer for us. It's how do we place an A-line? And this one is your thoughts.
obiajulu-anozie_3_09-08-2024_193030:know, I will put an a line in if I've evaluated the patient and I feel that the risk of hemodynamic collapse. Is so high that, you just, you need to know that information right away. I don't want to wait for a cuff cycling to occur. I just need to know, one of the, one of the experiences I could recall was actually in fellowship. We had a patient with RV failure and from a PE and also had a GI bleed at the same time. So that was like a quagmire situation. You're just, you're, Whichever way you turned, we were in trouble, but this patient just needed a definitive airway, but we had a little bit of time, so we decided we're going to do this the right way, put a subclavian in, and we got them started on, on, on some vasopressin and some epi. And then, yeah, we put an arterial line into, so that we can just have a good grip on the hemodynamics on a real time basis. And then we proceeded with our intubation. So it really depends. I don't think in every scenario, you need to have an arterial line. Of course, if you can get one in or if you already have one it's always welcome, but I feel like, how severe is the presentation, how severe is what you're seeing on point of care echo, what are your instincts telling you, does, is this a patient that looks, you'll meet patients, It's that the blood pressure is fine. When you when you approach intubation, their hemodynamics look fine, but you can tell that the only reason why their hemodynamics are fine is because they're in just catecholamine surge. They're an absolute surge, like they are in fight or flight mode. And the minute you push meds and you take that drive away from them, even if you give ketamine, even if you give ketamine, because if you give ketamine and patients That are already just in fight or flight mode, they may have no more catecholamines left and they'll become hypotensive. So in those patients, if you can somehow, manage to get an a line in, I think that's helpful too. But, I think it goes back to that thing I mentioned earlier, patient selection, I think probably the majority of patients that we intubate probably don't need an a line, but I think there's definitely some patients depending on the severity and what you're seeing. They would do well with an a line.
mohamed_2_09-08-2024_193030:I love this man. Nice. So for the sake of time, I'm going to put you on a spot. Is that okay?
obiajulu-anozie_3_09-08-2024_193030:Sure. Go for it.
mohamed_2_09-08-2024_193030:I'm going to throw some situation at you and what I want you to tell me your perspective and experience. On dosing for induction paralytics, your vent settings in each of these scenarios. All right. You ready?
obiajulu-anozie_3_09-08-2024_193030:Yeah. Let's go.
mohamed_2_09-08-2024_193030:So your first patient is hypotensive and needing intubation secondary to septic shock.
obiajulu-anozie_3_09-08-2024_193030:so they're hypotensive. I'm going to go with as an induction agent, I'll go with ketamine. Say I, I probably, I typically will usually induce with Two mgs per kg. But in, in a vasodilated septic shock patient, I may drop that, to somewhere between, one to 1.5 makes per kg. And then with rocuronium behind it, somewhere between 0.7 to 0.9 makes per kg.
mohamed_2_09-08-2024_193030:Okay. So I agree with you. I feel like my induction dose in that case will be lower. I would go actually higher on a paralytic for me, probably like to 1. 2. What about ventilatory setting for them will be your initial go to for septic shock patients?
obiajulu-anozie_3_09-08-2024_193030:So when we talk about ventilatory settings the first thing to mention is. They're hypotensive. Typically before we even get them on a ventilator we're, we attach them to the ambu. And one thing I'm always vocal about is, do not squeeze the entirety of the bag. And do not squeeze it fast too. Because last thing you want to do is auto peep and hyperventilate and breath stack these patients that are already hemodynamically compromised. So that's one thing. I, when I transitioned them to the ventilator I usually will start with about six mgs per kg. About roughly somewhere between five to eight a peep. I am a, I'm a huge fan of pressure control but some institutions will use PRVC, pressure regulated volume control as the as the standard mode. So 6 mgs per kg or whatever that amounts to on pressure control, I'll usually have a standard rate between, typically around like 14, I think is a good starter rate. But then again, it depends on the labs, some of these patients, they have metabolic acidosis or they have high CO2 and you might need to, clear some of it. They might have a need for a higher degree of ventilation, but what they don't need is a perfect pH. Nobody needs a perfect pH. Okay. So I don't ventilate people to get those perfect numbers on the blood gas. I just give you what you need. To get by and you've got to do the rest, right? With my help, like I need to treat the underlying condition and you've got to recover. But my job is not to make you thrive on the ventilator. It's to give you what you need to keep going and keep you safe at the same time. So I think a respiratory rate of 14 kind of meets those standards. Cause I've seen a lot, Someone will get intubated. The starting rate is always 20. And I asked myself why is the default starting rate 20 in so many places? That's, walking around the way as you are right now, none of us are breathing 20 times a minute, so why do we need to do that on the ventilator? Exactly,
mohamed_2_09-08-2024_193030:these magical numbers magically, I don't know, came up with them. I don't know who breathes 20 breaths a minute all the time. I don't.
obiajulu-anozie_3_09-08-2024_193030:Exactly.
mohamed_2_09-08-2024_193030:valid point. How about the patient in status asthmaticus, because I know we can talk about that in a whole different podcast. But just briefly, induction, your intubation techniques, style, method, And your ventilatory settings for them.
obiajulu-anozie_3_09-08-2024_193030:and patients with status asthmaticus. I'll just preface that by saying, if you don't respect status then there's a problem, that's just, it's a nightmare, but in those patients, ketamine is definitely your friend. As a delayed sequence agent rapid sequence, sedation on the ventilator, just ketamine is your friend. So induction would definitely be with ketamine. Perhaps I would have had it infusing over a certain amount of time because, I think the big problem in status asthmaticus is these patients are, they're auto peeping themselves. And, when you have that anxiety of not being able to breathe, because they really literally cannot breathe. They're hyperventilating and they're bronchoconstricted. So they're gas trapping, so maybe Inducing that cataleptic state Is a little helpful with ketamine and then I'll typically have them on a little bit of an epidrip, you know I like putting these patients on epidrips and I'd probably induced With once again, ketamine Roc, but I might push a little epi behind it and flush that. Now, once they're on the ventilator I would, once again, I'd probably start with an even lower rate than 14, because you can only imagine if you're putting a patient on the ventilator for status asthmaticus, you can only imagine that those bronchi, those are not only just constricted, they're pretty much just absolutely closed shut. So if you think you're going to get a respiratory rate of 20, it's just not going to happen. It's just not going to happen to those patients. You're thinking maybe 10 or less. And, really trying to get tidal volumes through them is. Honestly, it's a little bit of a plug and play thing. You're configuring the ventilator to see, like, how can I just get a manageable, title volume, those patients, if I can get away with four to six cc's per kg, I'm happy. And sometimes what I've had to do, I've had to turn the respiratory rate very low, but increase my i-time because it's like you're in the gym and you're strong enough to bench press 300 pounds. But if you push the bar for two seconds rather than push it for half a second. So you need to push on that bar. So that's the same thing when it comes to a ventilator, you might need to apply an inspiratory pressure of 20. But if you apply it over a period of, 0. 8 seconds, nothing's going to happen. But if you apply that pressure over a period of time, you might sneak in 300 cc of tidal volume. And in those patients, once again, like I mentioned before, you're not looking for perfect numbers because it's just not going to happen. You're looking to just give them survivable numbers to buy you time to reduce the inflammation. So that their respiratory mechanics get better and then they can gradually start to thrive.
mohamed_2_09-08-2024_193030:That's just a, so many, I feel like we can bring you back with a different podcast when just managing status asthmaticus, but that I time tip is, I would say is like spot on. Additionally, I also keep an eye on plateau pressure to try to make, try to keep it below 30 and then also. The I:E ratio as well, like you, you mentioned by sometimes I go like on the expiratory phase, like four to one, for
obiajulu-anozie_3_09-08-2024_193030:Exactly. As long as the longer the time, the better, because even what people don't realize is even if the expiratory curve reaches baseline, that does not necessarily mean that there's no auto peep, and we could do a deep dive on ventilators on that, but, just the take home point. In general, yeah, you should be aiming for the expiratory flow waveform to return to baseline before the next breath. And you might need an IE ratio of like 1 to 4 or 5 or longer. And that's part of the reason why you put them on such a low respiratory rate. I put them on such a low respiratory rate because that assures me a long I:E ratio so that they can, to minimize auto peak. Because I think in most of these patients, There is, it'll be, it's very difficult to avoid some measure of intrinsic peep because they're just so Bronco constricted, but your goal is to just keep it as minimum as possible. And by extending the amount of time they have to expire. You give yourself that higher chance of making sure they clear the alveoli, all empty their air.
mohamed_2_09-08-2024_193030:nice. Now, last but not least a patient with TBI. So induction, paralytic and ventilatory settings.
obiajulu-anozie_3_09-08-2024_193030:Yeah, so this is where my experience is a little bit limited, but there's a lot of back and forth as to the role of ketamine in these patients, this ketamine. Increase intracranial pressure and does it not increase intracranial pressure? I think in a lot of studies, ketamine is actually considered to be neuroprotective. Do we need to blunt the sympathetics when I was a trainee? And we had patients with evidence of increased ICP and we intubated them. We pre treated them with three to five mikes per kg of fentanyl, And obviously, if you give that as a rapid push, then you better be at the head of the bed ready to go. But I would pre treat these patients with three to five three to five mics per kg of of fentanyl. And then I would still use ketamine because I'm on the side that believes that ketamine does not raise the intracranial pressure. And then I would push the paralytic. Behind that now on intubation you still, it's it there's two things to think about once you've got the breathing tube in, there's a temporary benefit with respiratory alkalosis, but at the same time, if you hyperventilate these patients and if you hyperventilate these patients and cause auto peep. What else are you causing? You're increasing central venous pressure. If you increase central venous pressure, then secondarily, what do you increase? ICP. You gotta strike, you gotta strike that balance, and if you're causing respiratory alkalosis. What is the degree of respiratory alkalosis? It's like, how far do you want to take it? I think you need to be mindful of, don't set the ventilator and walk away. You need to be mindful of what's happening on the ventilator. I'm hyperventilating the patient, the flow waveforms are still returning to baseline. So I'm not really causing much auto peep. So my CVP isn't, necessarily going through the roof and maybe you can even use the ultrasound. You can estimate CVP by looking at, by looking at your IVC and looking at how much, there's the variation is. Between breaths. If you're, if you have a baseline of that and then you put them on the ventilator and then you're hyperventilating them and then you estimate the CVP is going higher than you need to change things on the ventilator. But if we're past the window where, inducing respiratory alkalosis can create a benefit, then, yeah, then it's standard, ventilator settings, 14 breaths per minute, six cc's per kg, mitigate peep. You don't want to have too much high peep on these patients. Because once again, if the peep is too high, then, that can secondarily raise the CVP and that will cause issues that you don't want.
mohamed_2_09-08-2024_193030:Man, that last point is so crucial. I will tell you like how many times we just have this false sense of safety that once you intubate a patient, you put them on a ventilator, you're done. You put your hands, your pocket, you leave that room. I agree with you completely. I feel like reassessing the patient, especially for our crew, like the flight crew or the ground EMS crew that take care of these patients for maybe sometimes hours, in a snowstorm. We need to make sure they know what's happening with them minute by minute reassessing their condition as they evolve during the transport, in flight, making sure that their needs are met, by using that ventilator. I agree with you completely. I feel like it's just not a you just intubate them, put them away. You leave. It's you have to continually to reassess them.
obiajulu-anozie_3_09-08-2024_193030:You got to continue to reassess. Absolutely.
mohamed_2_09-08-2024_193030:Absolutely. Now I tell you. I feel like the last piece, it's the most important piece out of all this discussion, which is post intubation sedation. I didn't intentionally put it there last. I feel like this is something we should be thinking about even before we intubate. So just for a few minutes, tell us about what's your strategy with post intubation sedation and what do you normally use and how do you manage that?
obiajulu-anozie_3_09-08-2024_193030:For sure. Typically I like to have, so my two go to's Are going to be propofol and fentanyl, I think probably across the board most commonly those are going to be your two most common agents propofol for the amnestic properties and fentanyl. for the analgesic properties. But, you can just use one, and there are scenarios where you can just use one and really get away with just using one agent alone, and that's got to be fentanyl. Because if I were to place a priority for one, sedation or analgesia, I will prioritize analgesia. I've seen very often, I'll go into a patient's room and they're just on propofol. They're on propofol and yeah, they're, they look like they're asleep and everything, but they're also, they also look uncomfortable and they're desynchronous with the ventilator. Because there's no analgesia, there's this term called an analgosedation, so you have to prioritize the analgesia over the sedation. And when it comes to using propofol and fentanyl, I prefer to start at low doses of propofol and prioritize more the analgesia and really see how the patient's doing from there. If it's a patient that I'm intubating purely for, just. Pretty severe encephalopathy lack of airway reflexes. Then I'll usually just use like a low dose fentanyl by itself. We're talking about, maybe like 50 mics an hour to start with, um, another fan favorite agent of mine, I love to use ketamine.
mohamed_2_09-08-2024_193030:I was waiting for it.
obiajulu-anozie_3_09-08-2024_193030:I I love to use ketamine. It's just it's just a great agent. It is an N, NMDA receptor antagonist. So you'll, you will have those patients. That are just, for some context, the NMDA receptors, the receptor that's involved in withdrawal, so if you have an agent that can antagonize that receptor, then it could be useful when it comes to, to sedation and analgesia combined with the fact that ketamine is a beautiful analgesic, it has very strong analgesic properties. And it's a good sedative agent. And on top of that it doesn't blunt the respiratory drive, which means that you can extubate patients on, you can put them on ketamine and you can extubate them on ketamine. So it's just very handy. It's something that needs to be, in your toolbox. Especially when you have that patient who's resistant to something like fentanyl. Fentanyl is short acting, short acting, which means. Patients will develop a tolerance and can go as far as developing withdrawal while you're giving them fentanyl. So you're on a fentanyl drip and you're withdrawing from fentanyl. We talk about fever in the ICU, right? And I always preface this by saying there's more causes, there's more non infectious causes of fever in the ICU than there are infectious. And withdrawal is one of them. Withdrawing from like fentanyl while on a fentanyl drip is part of it. I love to add some ketamine in those patients. I have never had an opportunity to use Remifentanil, hopefully one day in the future. And then, yeah precedex is definitely a great agent, especially when you're, when you're trying to mitigate how much propofol you need, when you're trying to start getting patients, a little bit more awake because you think that there'll be more appropriate for extubation using precedex. in combination with fentanyl, because you do know that, standalone agent for most patients isn't necessarily going to cut it. Even though the textbooks will say, Oh, precedex has some analgesic properties, honestly when you have a big breathing tube in the vocal cords, I don't necessarily know that unless you're very encephalopathic to begin with that you're going to get very far with precedex. One thing I would say I don't use and that I don't encourage use of, but then once again, there's what the textbook tells us, and then, there's patient selection and every patient is different. But in general, I try to avoid benzos.
mohamed_2_09-08-2024_193030:I was going to make you uncomfortable. I was going to tell you like OB is number one fan of benzodiazepine for,
obiajulu-anozie_3_09-08-2024_193030:I'm the
mohamed_2_09-08-2024_193030:that would be for sure.
obiajulu-anozie_3_09-08-2024_193030:Yep, yep. I try to avoid benzos. In, in the ICU,
mohamed_2_09-08-2024_193030:Why do intensivists hate it so much?
obiajulu-anozie_3_09-08-2024_193030:Just because you know it, the association with delirium and just the problems that delirium brings. You're talking about prolonged stay on the ventilator, increased tracheostomy. And ultimately increased mortality, and like I said, there's always some scenario where it could be useful, and so if I were to use it on a patient, they'd probably be intubated for status epilepticus, they'd be in like some kind of refractory status, I'd put them on a benzo infusion because, you have to. I don't, I've seen them used on withdrawing patients that are on ventilators, alcohol withdrawal, that's where pushes the phenobarbital come into play. And you have all these other adjuncts you can use. You've got pushes of phenobarbital and you even have ketamine that you can use because alcohol has everything to do with, GABA and NMDA. And as ketamine is a NMDA receptor antagonist, which means. It could have some uses in in alcohol withdrawal. So that's just to say, in my personal opinion, there really isn't much reason to be using benzos on mechanically ventilated patients.
mohamed_2_09-08-2024_193030:to make a friendly ICU doctor so happy, do not use a benzodiazepine for post intubation sedation. I completely agree with you. Never been a fan. Man, I am so happy we had this discussion. I feel like I can keep you here for a long time, or I'll keep you, man I'll get you back on sooner than later. Yeah. I'm happy that I would get the chance to do this. Thank you so much for everything, man. Go save some lives and I'll put some music represent the power of our continent, man. Nice to talk with you.
obiajulu-anozie_3_09-08-2024_193030:bro.
mohamed_2_09-08-2024_193030:Thank you. I appreciate
obiajulu-anozie_3_09-08-2024_193030:Thank you. Bless. God bless
mohamed_2_09-08-2024_193030:you.