Not all airways that need eventual intubation, can be managed that recklessly. Yes recklessly.

I will tell you about a case that happened last week in our resuscitation room. 

What happened to this patient who will be reenacted by me.


Patient in his 50s, with CAD with stents, and prior femoral bypass, former tobacco smoker. with on/off chest pain with dyspnea since spending time with his wife at a mall. Went to his pmd who is a cardiologist and sent him to the ED for eval. Pt with respiratory rate of 40 per minute. unclear if his o2 sat was ever measured, but pt with sinus tachycardia and significantly elevated bp. 

Bipap was quickly placed. Done before even triaged.

Pt kept using both of his legs to inch towards the edge of the bed, as if to escape his dyspnea. The patient kept panting for air and pulling the Bi-pap mask off his face to gasp for more air. He was told he would be intubated if he failed to get better on NIV and said, "Do it. Intubate me. I am going to Die." Slapped the NIV facemask back on, and the started to cough up frothy blood tinged sputum. Hacking cough, keeping his NIV mask off. Then when the NIV mask replaced, he syncopized for few seconds, abruptly awoke and started to pant again. NIV GAME OVER. 


Decision for intubation, but how to preoxygenate him optimally. O2 sats stayed at 36% even with bag mask ventilation. I decided better than bagging this patient who was in cardiac or respiratory arrest, yet very close to it. I needed to be invasive. 

RSA. Rapid Sequence Airway was needed. I didnt want to risk the patient gagging or moving with placing a supraglottic device. I gave etomidate and vecuronium. Couldn't find the rocuronium. 

His bp was 220/100. I didnt think ketamine was the appropriate choice for a patient in flash pulmonary edema. likely from a still left ventricle. 


I did it. Not how the video shown below how RSA was used for a difficult airway to preoxygenate the patient. In the video there was time to speak to the patient and assess the patient for being a difficult airway.  and then once adequate preoxygenation has occurred, then the patient was intubated with a glidescope video laryngoscope.




Idea learned from Dr. Darren Braude of New Mexico/the Cave simulation/EMS medical director/Emergency Medicine Physician. Here is his link describing RSA. 




link to a case almost like mine. But my patient didn't have cardiogenic shock.



Different in my case. I didn't care if the patient had a predicted difficult intubation. 

Why not paralyze the patient and induce him for a better airway device for Rescue Oxygenation than the Bag Ventilation Mask? I did it. Had to. My overzealous wanted to intubate the patient with sats of 36%. I wanted to control the situation. I wanted to resuscitate his hypoxia. If not I would have to deal with hypoxia induced PEA, bradycardia and asystole. I try not to be the master of this scenario. I try to prevent the hypoxia induced ACLS scenarios. That is my job to prevent. 



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