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Old 11-20-2013, 16:03   #31
Patriot007
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Quote:
Originally Posted by Sdiver View Post

-- This patient is lacking preload due to the inferior MI and his exam is consistent with RIGHT sided heart failure (JVD and swollen ankles) that is often seen in inferior MIs. He has trace crackles in his lungs, but this should not be a distractor. He needs fluids and lots of them, place on NS or Lactated ringers on a pressure infuser. This is due to Starling's Law of the heart which states that the strength of the heart's systolic contraction is directly proportional to its diastolic expansion. More fluids = more preload = more contractility = less failure.

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With all due respect as this is your thread I disagree with the above. You are correct about Starling's Law/Curve, but it is just that, a curve. When you get to a certain preload (tank is full) contractility (pump function) actually starts to decrease. The physiology is that the cardiac muscle is stretched beyond its ideal length for function. As this patent has JVD this means that preload or central venous pressure is extremely high. This is the nitty gritty and the bottom line is nitro is contraindicated, you need an inotrope/pressor, and fluids probably aren't going to help further and may harm if the patient has JVD.

Did someone say airway?!

Bonus question before we close out this great case. Let's say the patient's mental status declines and is not protecting his airway. You are ventilating well with a BVM (good chest rise) and you are getting sats no higher than the low 80s. Breath sounds are equal but with diffuse rales (lots of fluid). Knowing that he may desat, brady and code when you attempt to intubate what small piece of equipment may be helpful to increase O2 sats before intubation, or even just keep him alive while hauling ass if you don't have RSI capabilities. (it's not an oral or nasopharyngeal airway, you are ventilating well)
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Old 11-20-2013, 17:07   #32
adal
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capnography?

We have also used a nasal cannula on 6lpm While performing intubation to maintain/increase sats with the procedure in conjunction with BVM.

I was gonna mention the airway. This is a perfect pt that as soon as you traditionally RSI, they code. Ketamine might be the way to go here.

Still a great discussion.

PEEP- didn't think of that because it's on all our BVM's already. Good call.
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Last edited by adal; 11-20-2013 at 17:11.
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Old 11-20-2013, 21:28   #33
Patriot007
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PEEP Valve correct!

I like the nasal cannula on while pre-oxygenating and leave it on while intubating. (If you can spare the O2). It's only a short time, crank that sucker up to 15 LPM and get some flow going, you won't dry out their nasal mucosa and cause harm in that time period.


It's called passive oxygenation and it increases the time your patient can be apneic before desating. It works because you are entraining the nasopharynx and airway with high flow oxygen even though you are not ventilating.

I agree Ketamine is the way to go if sedation is needed.
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