Podcast Episode 53: Ventilating in the Prone?!
What happens when your patient has been given a cric or intubated but continues to decline… SpO2 continues to slowly drop despite taking control of the airway. You have placed your patient on a ventilator and slowly adjusted the PEEP up to 20cmH20… which quickly leads to hypotension. Do you go lower? Higher? Change volume or rate? You are out of bottled O2 and your oxygen concentrator does not seem to have much effect. The SpO2 continues dropping. Telemedicine is not available. You try positioning the patient by sitting them up. You try a couple other recruitment maneuvers you heard about.
Nothing is working.
What would Doug do?
Prone the patient???
Your patient may be suffering from ARDS, Acute Respiratory Distress Syndrome caused by a number of etiologies such as pneumonia or other lung injury. Carefully turning your patinet on their stomach may improve oxygenation by recruiting alveoli formerly compressed and “drowned” as demonstrated in the picture below. Positioning your patient on their stomach in the prone position must be practiced with anyone who will be helping you. Put someone else in a similar position and have the team with which you plan to help move the real patient do a couple rehearsals. You don’t want to flip them over only to lose your IVs, IOs and yank the airway out. Check out this Brazilian article which includes a proning checklist and some informative pictures and tips.
You also don’t get an automatic win by flipping them on their belly and calling it a day. You will have to be even more vigilant about any potential complications with a dedicated airway person as is is a little harder to recognize a patient in distress if you are not used to it.
You will also have to do more nursing care on the delicate skin of the face and other surfaces not normally on the down side: Shoulders, hips, knees tops of the feet. Put yourself in this position for a few minutes on a litter and you can quickly tell where the major pressure points will be. All of these complications increased along with the benefits of the study. While no prolonged field care patient should be on a bare litter, there is even more reason to move them to a mattress or other more comfortable padded surface.
Listen to what Doug has to say and his discussion on a recent telemed consult he recieved through the US DoD ADVISOR Telemedical Consult line:
Patient Proning Technique Video
Link to original New England Journal of Medicine Proning article
Check out these airway and vent resources below:
Current Role 2/3 JTS Clinical Practice Guideline on Airway Management
Original PFC WG Airway recommendations (April, 14)
Original PFC Airway Video:
PFC Airway Presentation Slides
SPO2
Next Generation Combat Medic Embrace the Full Power of your SPO2
PulmCrit-Top 10 Reasons Pulse Oximetry Beats ABG for Assessing Oxygenation
Airway Prep
MSMAID Acronym with Minimum, Better, Best Packing List
EMCRit Airway Positioning and Bougie
Manual Bag Valve Mask
ProlongedFieldCare.org Optimizing Manual Ventilation
PEEP Valves
ProlongedFieldCar.org PEEP Valves
Cric
Intubation
RSI technique and checklist 2016
EMCrit-Dissociated Awake Intubation
EMCrit Ketamine Facilitated Intubation
ETCO2
Post Intubation
Tube Depth
Cuff Pressure
ProlongedFieldCare.org Cuff manometer
PulmCrit-Liberating the Patient with no Cuff Leak Extubation
Ventilators
Mayo Clinic Vent Cards Mar 2017
SAVent
No. It is detrimental for long periods of time.
It has no PEEP or adjustability. If you do end up using it, do it for no more than 20 minutes at a time and then take them off in order to use a BVM with a PEEP valve. The only time I would use this is for the extreme emergency where you need to bag a patient but must also do something else like drive and really need more hands.
SAVe II Vent
The savent has a very low maximum minute volume and may not be appropriate for acidotic patients. These patients may require a higher minute volume than is possible with the pump in the SAVeII. These patients may require manual ventilation in order to keep up.
SAVe II Ventilator Easy Set Up Guide
Zoll/Impact Eagle 731 Vent
Zoll Impact Eagle 731 Vent Easy Set Up Guide
Zoll/Impact 731 ventilator Cheat Sheet
Old Impact Eagle 745 Vent
Old Eagle Impact 754 Ventilator Cheat Sheet (Rule of 5s
Next Generation Combat Medic 5 part Ventilator Series
Next Generation Combat Medic Intro to Vents
Next Generation Combat Medic Applied Ventilator Theory
Next Generation Combat Medic Ventilatory and Respiratory Control
Next Generation Combat Medic Ventilator Theory
Next Generation Combat Medic Vent Practicalities
Even More Vent Stuff!
Scott Weingart,s EMCrit Dominating the Ventilator Handout
EMCrit-RACC Vent And PREVENT Episodes
Blood Gas
PulmCrit-Converting a VBG into an ABG
Misc
EMCrit How do you know you are actually good at airway management
PulmCrit-Mastering the Dark Arts of BiPAP & HFNC
PulmCrit-Fighting Refractory ARDS with Physiologic Jiu Jitsu
Documentation
can I download the podcast??