Tamingthesru
Oxygen is Good, Methods for Delivery Often are Not
An elderly patient with steroid and oxygen dependent COPD, and NYHA Class IV CHF, presents with dyspnea. The patient is alert but looks somewhat desperate, confused, and exhausted. Exam reveals accessory muscle use, grunting expirations, poor air movement, and cool clammy skin. The patient speaks in two-word phrases. Attempts to improve the situation are made with Lasix, nebulizers, and non-invasive ventilatory support. The patient cannot tolerate BiPAP due to anxiety.
Pericardiocentesis
First, pericardiocentesis should be considered a temporizing procedure. In the setting of trauma, you are hoping that the pericardiocentesis will clear a small amount of blood from the pericardial space and remove any tamponade the might be present. It is likely, however, because of the mechanism of injury, that blood will again rapidly accumulate leading to recurrent tamponade physiology. Ultimately (but not on Air Care — DON’T do a clamshell), these patients will need a pericardial window, exploration, and repair of whatever injury is causing the accumulation of blood.
Look Before You Leap - Awake Fiberoptic Intubation
Look Before You Leap, Drive Your Ferrari Like it is a Wheelchair, Harken Ye to the Wicked Witch of the West!
A 37 year-old woman presents with stridor, drooling, tachypnea and accessory respiratory muscle use. She has an adequate blood pressure, but is tachycardic to 120. Her oxygen saturation on room air is a reassuring 97%. She cannot answer questions, appears to have an altered mental status though she follows commands, and suddenly has a brief period of either myoclonus or seizure with unresponsiveness. No post-ictal period is noted after this episode.