Increased work of breathing occurs when the patient is hungry for air and using all those accessory muscles to try to get more air in. Watch the muscles of the neck, chest and belly…if these are in high gear, note that the patient will wear out, so you need to hop on this quick. Dropping O2 sats. Not that they need to be intubated, but something in their status clearly changed, and you should go figure it out.
Chances are, it will continue to trend downward…a good nurse will catch it before it gets serious. Try some coughing and deep breathing to start could just be atelectasis , listen to lung sounds could be fluid overload or check for problems swallowing could be aspiration. Do a little detective work and solve this mystery before it becomes an issue. If your patient becomes somnolent, checking an ABG is always a good idea. For more on this, check out my post on this very topic!
ARDS is serious business and your patient will definitely need to be intubated if this condition is confirmed. Adventitious lung sounds could indicate a need for intubation. A few crackles can usually be dealt with by giving Lasix or encouraging coughing and deep breathing.
Inability to protect airway. This occurs when your patient has some kind of neurological deficit either from stroke, drugs or they are really really really sick. Your need to intubate…now what? Your patient is intubated…now what? To improve patient outcomes who are on a ventilator, you will ensure… HOB degrees.
Ketamine is the agent of choice in most circumstances, as it sedates without depressing respiration or airway reflexes. In somewhat cooperative patients, 20 mg boluses, titrated to effect, work very well. For those patients where raising heart rate or blood pressure is undesirable, benzodiazepine sedation will have a less effective but still salutary effect.
Dexmedetomidine is probably a better agent in these scenarios, but is a little tricky to use and not available in most EDs. Even if using full dissociative dose ketamine, do your best to anesthetize the airway, using the steps listed in the box above, excerpted from the ED intubation checklist. Local is much facilitated by a dry mucosa, so the first step, if possible, is to dry the mucosa with glycopyrolate or atropine, followed by suction and dabbing with gauze.
I do believe everyone in class went out with her at least once with the exception of me being that I was not 18 yet and had a girlfriend and my classmate was For anyone that wants to see a conscious intubation and the use of a whistler device: O. They are using a fastrach airway then intubationg through it.
Just to weigh in, unless the gag reflex is severely depressed you will have a fight on your hands. Georgia only allows RSI on air services with the exception of a few test studies. In my service we intubate when needed and then and only then we can give versed. For years we used the term "trismus" to get the point across that conscious intubation is rough and barbaric as hell. We as a profession need sweeping reforms to ensure we are giving competent, compassionate care.
Fighting with a patient with an intact gag reflex is not compassionate. The John Wayne days should be over. Something has got to give. Just a few thoughts. Here are some links for you to reference involving most things with entubation which also discuss things relevant to your thread!.
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