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airway trouble with neurologicaly depressed patients


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#1 mighty medic

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Posted 20 March 2009 - 03:06 AM

Hi all,
I had an intresting case the other day .we were sent out to a possible cva the other evening in a nursing home.On arrival we found an approximatly 70 year old female with a history of parkinsons ,hyperthyroidism ,who had left sided hemiparysis a blown pupil left and some right sided myoclonic jerks gcs was about 5 at this stage.a gp and a nurse had suctioned approximatly 50 mls out of patient .she was cyanotic and her head due to the amount of pillows was on her chest .sats at this stage was 76% on 6 ltrs of o2 .we postioned her on to our trolley and tryed to open the airway ,but due to a the patient having no teeth ,a large tounge and a very short neck ,this proved difficult.her ecg was sinus tachycardia at arate of 136 with frequent pvcs multifocal bp on left arm was 156/90 andlthough she initally appeared to have a respiratory rate of 32 she wasnt moving much air.I initally tryed to insert an npa but due to a deviated septum the attempt failed ,i then attempted a opa while using a jaw lift and she tolerated this .sats were still low at this stage at 79 and came up to 84% after airway was inserted ,i ventilated patient with bvm and sats came up to 98%.I continued ventilating to hospital but found it was difficult to maintain an ec grip due to the patients jaw and short neck .in hospital the patient was intubated by anesathist and pt transported up to icu .

my question is this

would it have been apropriate to attempt an lma insertion on this patient.I have only had one insertion of an lma since being upskilled ,and I no that the cpg says apnoea ,but with sats in the low 70s ,an ineffective respiratory effort and a history of vomiting leading to patient requiring suctioing prior to our arrival does it not amount to the same thing .I am just curious for other peoples input as although patient benefited from the basic airway management would the lma have been easier for maintainance and safer for the patient .

#2 dfbfirefighter

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Posted 28 June 2009 - 03:50 PM

I hear what your saying mighty medic... unfortunatly we can only operate as per our c.p.gs if the pt. is making respiratory effort we cant use L.M.A however if she tolerates opa i dont see why we cant use L.M.A. As i mentioned above we can only operate as per CPGs.. :(

#3 firefly123

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Posted 02 July 2009 - 08:16 PM

Insert an airway in to an apnoic unresponsive patient only. For your own benefit. I know the temptation is there but you have be bound by your CPG's. Now if the person is unresponsive and so tachypnoic that there is insufficent air exchange then I would use common sense and bung an airway in. If they ask questions tell the staff she improved enroute and is still accepting the airway. What you want to be careful of is laryngospasm (not as likely with an LMA as an ET tube but can still happen).
you dont have to be mad to work here but it helps.

#4 GudByeLunars

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Posted 04 July 2009 - 08:09 PM

apnoea is not the only indication. on that cpg (advanced airway) it says apnoea OR special indications.
the special indications are listed in red on the same page

#5 edr

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Posted 16 July 2009 - 11:23 AM

Hi all,
I had an intresting case the other day .we were sent out to a possible cva the other evening in a nursing home.On arrival we found an approximatly 70 year old female with a history of parkinsons ,hyperthyroidism ,who had left sided hemiparysis a blown pupil left and some right sided myoclonic jerks gcs was about 5 at this stage.a gp and a nurse had suctioned approximatly 50 mls out of patient .she was cyanotic and her head due to the amount of pillows was on her chest .sats at this stage was 76% on 6 ltrs of o2 .we postioned her on to our trolley and tryed to open the airway ,but due to a the patient having no teeth ,a large tounge and a very short neck ,this proved difficult.her ecg was sinus tachycardia at arate of 136 with frequent pvcs multifocal bp on left arm was 156/90 andlthough she initally appeared to have a respiratory rate of 32 she wasnt moving much air.I initally tryed to insert an npa but due to a deviated septum the attempt failed ,i then attempted a opa while using a jaw lift and she tolerated this .sats were still low at this stage at 79 and came up to 84% after airway was inserted ,i ventilated patient with bvm and sats came up to 98%.I continued ventilating to hospital but found it was difficult to maintain an ec grip due to the patients jaw and short neck .in hospital the patient was intubated by anesathist and pt transported up to icu .

my question is this

would it have been apropriate to attempt an lma insertion on this patient.I have only had one insertion of an lma since being upskilled ,and I no that the cpg says apnoea ,but with sats in the low 70s ,an ineffective respiratory effort and a history of vomiting leading to patient requiring suctioing prior to our arrival does it not amount to the same thing .I am just curious for other peoples input as although patient benefited from the basic airway management would the lma have been easier for maintainance and safer for the patient .


The CPGs say no, but you are right - the patient may well have benefited. Her GCS of 5 would suggest that she would tolerate it, although you can have a GCS of 3 and maintain a gag reflex. However as you managed to insert an OPA without problems, there's every reason to think that she would also tolerate an LMA. The LMA would certainly have been easier although not necessarily safer. The LMA does not protect the patient from aspiration of vomit (although it certainly offers greater protection than an OPA!).

You should suggest this to PHECC as they seem to be open to new CPGs if you read their Spring 2009 newsletter:

http://www.phecit.ie...letterFINAL.pdf

#6 BAT1

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Posted 27 July 2009 - 06:34 PM

Hi all,
I had an intresting case the other day .we were sent out to a possible cva the other evening in a nursing home.On arrival we found an approximatly 70 year old female with a history of parkinsons ,hyperthyroidism ,who had left sided hemiparysis a blown pupil left and some right sided myoclonic jerks gcs was about 5 at this stage.a gp and a nurse had suctioned approximatly 50 mls out of patient .she was cyanotic and her head due to the amount of pillows was on her chest .sats at this stage was 76% on 6 ltrs of o2 .we postioned her on to our trolley and tryed to open the airway ,but due to a the patient having no teeth ,a large tounge and a very short neck ,this proved difficult.her ecg was sinus tachycardia at arate of 136 with frequent pvcs multifocal bp on left arm was 156/90 andlthough she initally appeared to have a respiratory rate of 32 she wasnt moving much air.I initally tryed to insert an npa but due to a deviated septum the attempt failed ,i then attempted a opa while using a jaw lift and she tolerated this .sats were still low at this stage at 79 and came up to 84% after airway was inserted ,i ventilated patient with bvm and sats came up to 98%.I continued ventilating to hospital but found it was difficult to maintain an ec grip due to the patients jaw and short neck .in hospital the patient was intubated by anesathist and pt transported up to icu .

my question is this

would it have been apropriate to attempt an lma insertion on this patient.I have only had one insertion of an lma since being upskilled ,and I no that the cpg says apnoea ,but with sats in the low 70s ,an ineffective respiratory effort and a history of vomiting leading to patient requiring suctioing prior to our arrival does it not amount to the same thing .I am just curious for other peoples input as although patient benefited from the basic airway management would the lma have been easier for maintainance and safer for the patient .



Check out CPG 3rd on LMA useage, new guidelines allowing LMA on patients who are not Apneic

#7 doc176

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Posted 02 August 2009 - 09:17 PM

Mighty I don't think the LMA would have been any better than what you ended up doing with the BVM.
The LMA does not protect the airway from aspiration so really the BEST thing to do would have been to intubate
and second best was probably what you did (98% SaO2 sounds like a winner to me).

#8 The Gap

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Posted 18 October 2009 - 11:44 PM

If the patient was able to tolerate an OPA you should have tried the LMA. Although its not gold standard for airway maintenace its much better and easier to manage than an OPA. Although the patients outcome wasnt affected by the lack of LMA it most likely would have made your job easier. If it walks like a duck and talks like a duck its usually a duck, in other words dont doubt yourself the next time.
We the willing
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Are doing the impossible for the ungrateful
We have been doing so much for so long with so little
We are now qualified to do anything with nothing




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