Week 9: The Physiologic Nightmare with Salim Rezaie

The patient: a 27-year old who’s altered, moaning, tachynpeic and hypotensive with a glucose of 711mg/dL.  We all know this patient well.. but now throw in a pH of 6.89 and you have a serious peri-intubation problem, that’s if you even choose to intubate.  In this week’s vodcast, Salim Rezaie (@srrezaie) of RebelEM.com and I take on the patient with severe metabolic acidosis and go through a case which requires some specific honing and preparation to intubate without getting anyone killed.  A must know scenario for anyone taking care of sick patients.

Key Points from this case:

  1. Adopt “Resuscitate before you intubate”: identify what physiologic conditions might make an intubation difficult.
  2. In the case of severe metabolic acidosis, intubation is a risky procedure and should only be performed if absolutely necessary.
  3. In acidosis, you require a higher partial pressure of oxygen to maintain sats, cardiac function is decreased and O2 consumption is increased, all leading to a complicated intubation scenario.
  4. RSI drugs in this case were low dose ketamine (0.3-0.5mg/kg) and high dose rocuronium (1.6mg/kg) to make for ideal intubating conditions.  Succinylcholine was avoided secondary to hyperkalemia.
  5. Use end-tidal CO2 to monitor worsening acidosis during the apneic period.  Apnea will lead to a respiratory acidosis compounding the metabolic acidosis.
  6. Consider bagging during the apneic period to blow off CO2 and prevent respiratory acidosis.
  7. If an intubation is prolonged, there is considerable risk of worsening acidosis and even arrest.  Prep for the worst-case-scenario ie backboards, code drugs and fingers on the pulse.



Screen Shot 2018-03-14 at 5.15.51 PMRezaie, S. Resuscitation Sequence Intubations. RebelEM.com 2017

read_icon_512Heffner AC et al. Incidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation 2013.

read_icon_512Moiser et al. The physiologically difficult airway.  West JEM 2015.

read_icon_512West, J et al.  The effect of the apneic period on the respiratory physiology of patients undergoing intubation in the ED.  AJEM 2017