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How to place ultrasound guided peripheral IVs with our very own amazing senior residents, Dr. Charlotte Croteau and Dr. Jay Lin.

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Case: C3 – Critical Care Case (September)

CC

Nausea, vomiting, and abdominal pain

HPI

Acid-Base Workshop: At the beginning of the conference year, multiple faculty members ran a workshop on acid-base abnormalities where we worked on identifying acid-base disturbances, determining primary respiratory or metabolic abnormalities, causes of such disturbances, and if compensation was appropriate. Perhaps one of the most challenging types of patients we encounter with an acid-base disturbance is an acidemic patient who we believe requires intubation. Below you will find a variety of resources on acid-base disturbances and more specifically, intubation and ventilation in this patient population. Read the case, consider reviewing the resources below, and think how you would approach this tenuous patient.

The Case:

A 23 yo F with a PMH of poorly controlled T1DM presents to your ED complaining of nausea, vomiting, and abdominal pain. She ran out of her insulin 3 days ago and didn’t have the funds to refill it. Her FS is 415 on POC testing.

Physical Exam

Vitals: 123/80, HR 120s, O2 98%, RR 32, Temp 98.2

General: sleepy but arousable to voice

HEENT: dry mucous membranes

Chest: CTAB, kussmaul breathing

Cardiac: regular rhythm, tachycardic

Abdomen: soft, NTND

Extremities: MAE

Labs

VBG: 7.03/14/65, Calculated Bicarb 5

BMP: 132/4.3/99/3/20/.09>423

What next?

You hang fluids and start an insulin drip, but the patient becomes progressively lethargic and has vomited twice despite anti-emetics. You decide you need to intubate. What next?

Questions

What are the risks of intubating this patient?
What would be your intubation strategy? Method, intubation medications, and things to pay attention to?
Would you consider giving any additional medications (apart from paralytics or sedation medications) prior to intubating? If so, why, and what would be the dosing?
What would be your ventilator settings?

Motion Pro 08-0119 Pilot Screw Adjusting Tool

Motion Pro 08-0119 Pilot Screw Adjusting Tool

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Motion Pro 08-0119 Pilot Screw Adjusting Tool

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VINTRONS Battery Replacement Compatible for Samsung SEC-YP5Z, YP: Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial

Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial Lancet, 2018

Aftermarket Replacement for Honda Accord 03-04 Right Rear Brake: Performance of Novel High-Sensitivity Cardiac Troponin I Assays for 0/1-Hour and 0/2- to 3-Hour Evaluations for Acute Myocardial Infarction: Results From the HIGH-US Study

Performance of Novel High-Sensitivity Cardiac Troponin I Assays for 0/1-Hour and 0/2- to 3-Hour Evaluations for Acute Myocardial Infarction: Results From the HIGH-US Study Annals of Emergency Medicine, 2020

Case: C3 – Critical Care Case (September)

CC

HPI

Physical Exam

Labs

Questions

What are the risks of intubating this patient?

What would be your intubation strategy? Method, intubation medications, and things to pay attention to?

Would you consider giving any additional medications (apart from paralytics or sedation medications) prior to intubating? If so, why, and what would be the dosing?

What would be your ventilator settings?

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