DSI Extension and Poor's man BiPAP
Hi Guys !
I had an interesting case 1 week ago, and a lot of questions ;-) !
I got a call from the paramedics for a 34 years old male who jumped from a 4th floor on concrete because he saw a "ghost" while on amphetamine.
When the guy arrive, the scene is quite surreal. He is in a wild adrenergic toxidrome, with complex facial fracture screaming : #pain
There is 4 paramedics trying to restraint him, but he is sitting down spitting blood on everyone..
He was given a dose of 5mg IM of midazolam on arrival with no effect
It was impossible to get any vitals
I wanted to take control of the situation quickly, it was obvious that this guy needed intubation but i didn't want to rush things
So i gave him 1mg/kg of ketamine and 2 subsequent boluses of 0.5mg/kg
He became fully dissociated so i was able to do my bedside ultrasound assessment and make sure there was no pneumo/hemothorax/free fluid/tamponnade.
I put him on NRB and Nasal Canula 15L and got a sat of around 95%
I wasn't fully satisfied of the sat at that point so i put the peep valve on the BVM and it climbed to 99%
I then gave him a full dose of roc and intubated him without any problems
So here's my thoughts and questions
1) Do you think the concept of DSI would apply not only to optimise the preoxygenation but also to potentially optimise preload or detect a pneumothorax before intubation ?. Have you ever use it in trauma ? It was my first experience of DSI in trauma and everyone were amazed of how fast we gained control of the chaotic resus.
2) The respiratory therapist were once again completely against the "Poor's man CPAP thing" . They feared the patient would "suffocate"
Tell me if i'm wrong, but i think it's true that there is no flow of air on a BVM if you don't squeeze. So it implied that the patient have to initiate a breath to trigger the valve to open. Is it possible for a very weak patient to be unable to trigger the valve ? Is the nasal canula helping to trigger the valve ?
3) Finally, i am not sure why we don't put a PEEP valve on every single intubation ?. From Scott article, you first look if the sat is below 95% with 100% FiO2 to see if there is a shunt physiology,. But considering the patient is sick and not taking full vital capacity breath, wouldn't PEEP be helpful to fully recruit the patient even if his sat is 95% ?
Could we prolong the time to desaturation by driving the PaO2 further up with peep even on patient sating at 100% ?
Sorry for the lenght, thanks for your thoughs ;-)