January 28, 2011

What Would You Do?

Quick little scenario:

Call for respiratory distress. On arrival, you can hear coarse sounds across the room. Patient has accessory muscle use of the SCM. Coarse crackles in ALL lung fields.
Respiratory rate of 50-60/min
BP- 80/30s
HR- 110-120s, sinus rhythm w/o ectopy
Spo2 going from 99% to 93% despite being put on a non-rebreather.
EtCO2 of 5 with good square waveforms
GCS of 3-4 (pt opens eyes, but you'd be hard pressed to say it's "spontaneous").

No history of respiratory problems, had a CVA a few weeks prior, and has Hypertension

Per nurse, patient had vomited just prior to your arrival but no secretions spotted. In the ambulance, both you and your parter cannot get an IV despite multiple attempts.

Let's just say it screams "sepsis", with the stupidly-increased ventilatory rate most likely a compensatory mechanism for the metabolic acidosis.

You're 15 minutes from the hospital. What do you do?
Now you're 45 minutes from the hospital. Change your plan?

IO and RSI?
IO and Etomidate (forgo the paralytics)
OG/NG tube?
Or haul butt to the hospital?

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