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:
- Adopt “Resuscitate before you intubate”: identify what physiologic conditions might make an intubation difficult.
- In the case of severe metabolic acidosis, intubation is a risky procedure and should only be performed if absolutely necessary.
- 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.
- 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.
- Use end-tidal CO2 to monitor worsening acidosis during the apneic period. Apnea will lead to a respiratory acidosis compounding the metabolic acidosis.
- Consider bagging during the apneic period to blow off CO2 and prevent respiratory acidosis.
- 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.