Trick of the Trade: Nasal cannula oxygenation during endotracheal intubation

You are managing a 300-pound patient with a long history of severe COPD, who now requires intubation because of a pneumonia and COPD exacerbation. You anticipate that the patient may be a difficult airway intubation and may desaturate quickly during laryngoscopy. While you are setting up to orotracheally intubate this patient, you preoxygenate this patient as best as you can with a non-rebreather mask.

What can you do to prolong the patient’s time-to-desaturation so that you aren’t as rushed to place the endotracheal tube?

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By Michelle Lin, MD|2019-01-28T22:35:50-08:00Oct 25, 2011|Tricks of the Trade|

Paucis Verbis: Ventilator settings for obstructive lung disease

Following up with last week’s Paucis Verbis card on Ventilator Settings for Acute Lung Injury and ARDS, here is the card on Ventilator Settings for Obstructive Lung Disease. This is for patients who present with acute asthma or COPD exacerbation who require endotracheal intubation.

What initial ventilator settings should you set for these patients?

Go to ALiEM (PV) Cards for more resources.

Thanks to Dr. Jenny Wilson for the card and Dr. Scott Weingart for the original stellar podcast from which this card was derived.

By Michelle Lin, MD|2021-10-12T15:47:16-07:00Oct 21, 2011|ALiEM Cards, Pulmonary|

Paucis Verbis: Ventilator settings for acute lung injury and ARDS

A patient presents with severe multilobar pneumonia and refractory hypoxia requiring endotracheal intubation. The respiratory therapist connects your patient to the ventilator.

“What settings would you like your patient on?”

Back in 2010, Dr. Scott Weingart posted a great podcast on “Dominating the Vent“. It’s such a fantastic distillation of the practical aspect of ventilator setting management of all intubated patients except those with an acute asthma or COPD exacerbation, Dr. Jenny Wilson and I thought this would be a great Paucis Verbis card to have in your peripheral brain.

Note: The tidal volume should be calculated based on Predicted Body Weight (PBW), which is based on patient gender and height. The calculation is at the bottom of the card. Using a patient’s actual weight might yield a tidal volume that is way too high. The initial vent settings in the example box are for a patient with a PBW of 70 kg. That’s basically a 5’9″ man or 5’11” woman.

PV Card: Ventilator Settings for Lung Protection

Adapted from [1]
See ALiEM (PV) cards.

Thanks to Dr. Jenny Wilson for the idea and writing this card, and Dr. Scott Weingart for a great podcast as always.

Reference

Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301-1308. [PubMed]

By Michelle Lin, MD|2021-10-12T15:50:38-07:00Oct 14, 2011|ALiEM Cards, Pulmonary|

Trick of the trade: Quieting the shaky EKG tracing

A patient with Parkinson’s disease presents with chest pain to your ED. Her tremors prevent you from getting a good quality EKG because of the movement artifact.

How can you eliminate this artifact? (No cheating with rocuronium.)

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By Michelle Lin, MD|2019-01-28T22:36:03-08:00Oct 11, 2011|ECG, Tricks of the Trade|

Paucis Verbis: Neutropenic fever in cancer patients

A 65 y/o man with a history of prostate cancer presents to your ED from home appearing fairly well and a mild cough for 3 days. His vital signs are:

Temperature 39 C
BP 160/80
HR 60
RR 14
Oxygen saturation 99% on room air

His absolute neutrophil count (ANC) comes back at 300 cells/mm3. His chest xray shows a right middle lobe pneumonia and a central line catheter tip ending in the SVC.

Is this patient “high” or “low” risk per the Multinational Association for Supportive Care in Cancer (MASCC)?
Does this person require inpatient admission?
What antibiotics would you start on this patient?

Answers

The patient’s MASCC score is 5 (mild symptoms) + 5 (no hypotension) + 4 (no COPD) + 4 (solid tumor) + 3 (no dehydration) + 3 (outpatient) = 24 = LOW RISK
NOTE: “Burden of febrile neutropenia” is a subjective scoring of the patient’s symptoms
The patient is, however, ultimately HIGH RISK clinically because of the finding of pneumonia on CXR. Admit.
Abx = Cefipime + Vancomycin

FYI: Vancomycin is not always indicated in cancer patients with a neutropenic fever.

PV Card: Neutropenic Fever in Cancer Patients (IDSA 2010)

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Thanks to Alissa and Hemal for suggesting the topic!

Reference

Freifeld A, Bow E, Sepkowitz K, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clin Infect Dis. 2011;52(4):e56-93. [PubMed]

By Michelle Lin, MD|2021-10-12T15:54:10-07:00Oct 7, 2011|ALiEM Cards, Heme-Oncology, Infectious Disease|

Trick of the Trade: Opioids for air hunger

A patient presents with significant shortness of breath from a COPD exacerbation. His room air saturation is 80%, respiratory rate of 30, and is uncomfortably seated in a tripod position. You administer the usual regimen:

Oxygen by face mask
Nebulized albuterol and atrovent
Solumedrol
Bipap
Set up for possible intubation

With the Bipap mask on, the patient’s subjective sense of dyspnea and “air hunger” seems to make it harder for him to tolerate the tight-fitting mask.

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By Michelle Lin, MD|2016-11-11T18:51:57-08:00Oct 4, 2011|Tricks of the Trade|

Trick of the Trade: Needlestick hotline 888-448-4911

You are a fourth-year medical student and super-excited to be doing your first supervised central line procedure on an actual patient. You have done so many central lines on mannequins and simulations. You feel ready. In your excitement, however, you stick yourself with the 22 gauge finder needle after you successfully get a flash-back of the patient’s venous blood.

After handing off the procedure to your senior resident, you go into a mild panic. Your patient is a known HIV patient with an unknown CD4 count and viral load. After taking off your gloves and washing your hands, you report this to the attending.

Should you start post-exposure prophylaxis medications for HIV? You remember that if post-exposure HIV medications are recommended, you should start it immediately and definitely within 2 hours of exposure.

It’s difficult to concentrate when faced with so many questions whirling in your mind.