TSRA Content:
Author: Rebekah Boyd, MD
This is a revision and update from the previous edition of the TSRA Primer in Cardiothoracic Surgery written by Xiaoying Lou, MD, Elizabeth H. Stephens, MD, Kevin Beers, MD, Brendan Dewan, MD, Vakhtang Tchantchaleishvili, MD, and Panos Vardas, MD
One of the most urgent calls you will get as an intern. Go and see the patient immediately.
Before you even get there, plan what you will do first: place on oxygen and monitor, CXR, EKG, ABG, other labs, call for respiratory for nebs, high-flow nasal cannula, non-invasive positive ventilation, or potential intubation help. As soon as you get there, assess respiratory effort, saturation, and listen to the lungs. Try to get a baseline exam from the bedside nurse and think about the last time you saw the patient – is this an acute change, or have they been deteriorating over the last several days? Did anything acute happen today (think aspiration event, choking, fall causing rib trauma that could lead to pneumothorax, procedure)?
Your job as the first responding intern is to decide what level of care they need AND to know how to identify appropriate oxygen equipment and get the patient placed on a non-rebreather as a temporizing measure while determining next steps. Familiarize yourself with where supplies are stored and how nasal cannulas and non-rebreathers are connected to the facility oxygen supply at your hospital. Familiarize yourself with the wall suction canisters. Do you have suction tubing and a Yankauer in the room? Know what the limitations of different units are – the medical-surgical or basic floor ward will have a much lower threshold to be able to work a patient with respiratory distress up. Know what kinds of monitors are available – can you get continuous pulse oximetry? Does your hospital have capability of measuring end-tidal CO2 on the floor? Above all, temporize and think about escalating care. A patient who requires a non-rebreather mask to keep their O2 sat up should not stay on the floor; a non-rebreather should be viewed as a shorter bridge to recovery, or a bridge to intubation/ICU. A patient who is altered and in respiratory distress should not stay on the floor (aspiration risk, may develop hypercapnia 2/2 respiratory failure, or may need emergent intubation). It is important to think about the long-term sustainability of the patient’s respiratory effort; do not be falsely reassured by a normal ABG if your patient is using accessory muscles of respiration, is tachypneic, or altered.
YOU CAN ALWAYS TRANSFER A PATIENT TO THE ICU if you think they need it.
If you cannot manage the patient on the floor, even if you cannot get a hold of an upper level, be safe now and get the patient to the help they need.
Most concerning DDx:
• Pneumothorax/hemothorax/pneumohemothorax
• Aspiration
• Pulmonary Embolism
• MI
• Hypervolemia/CHF
• Bronchial plugging
• Bronchospasm/status asthmaticus
• Pneumonia
• COPD exacerbation
• Anaphylaxis
Work-Up:
• Quick history – What was the patient doing when it started?
• Acute or subacute?
• Pleuritic component? Chest pain? Cardiac history? History of pulmonary disease? Smoker?
• Current Meds?
• On O2? How quickly has O2 requirement changed?
Physical exam:
• General: comfortable, diaphoresis, able to talk
• Neck: +/- JVD
• Chest: stridor, rales, rhonchi, wheezing, equal breath sounds, diminished or absent breath sounds
• CV: rhythm, murmur, gallops, pulsus paradoxus
• Ext: edema (unilateral or bilateral), cyanosis
Treatment:
• Pulse ox, ABG, EKG, portable CXR, chest CT (discuss with senior prior to ordering a CT scan), US doppler lower extremities (if concerned for PE)
• 100% O2 via non-rebreather (except COPDers)
• Respiratory therapy
-Needle decompression for tension pneumothorax (16- or 14-gauge needle, second intercostal space, midclavicular line)
-Pigtail or chest tube for definitive management of pneumo-, hemo-, or pneumohemothorax (call a senior to help walk you through chest tube placement – you should not attempt this on your own as an intern)
• Wall suction, intubation tray, RSI medications
If you are having trouble getting help, call a rapid response. Call anesthesia early if you fear intubation will be necessary and if you are not skilled in intubation. If the patient is unresponsive and you are not able to intubate, you can always place an oral airway and bag the patient until more help and/or intubation equipment arrives. Learning and mastering effective bag-valve-mask ventilation is one of the most important skills to develop and is harder than it looks – ask your anesthesia colleagues to help you with tricks/tips to get a good seal, especially in difficult patient populations (e.g. edentulous, beard, vomitus, or other foreign objects in the oropharynx)
Rapid Sequence Induction and Intubation:
(unlikely you will be the one doing the intubation, but good to know the general steps)
• Preoxygenate with 100% for 3-5 minutes
- If patient has spontaneous respirations, allow him/her to breathe
- If not breathing, use bag-valve-mask ventilation
- Always perform head tilt chin lift or jaw thrust to keep airway open
- Use oral airway to prevent collapse of tongue
• Sedate
- Etomidate 0.3mg/kg (NO TIME TO CALCULATE? 30 mg) Some institutions are moving towards using ketamine for rapid sequence intubation – take the time to familiarize yourself with your hospital’s policy and how to order the proper medications
-Be careful with induction! In patients with severe CHF exacerbations, cardiogenic shock, right ventricular failure, loss of afterload with sedating agents can lead to cardiovascular collapse and arrest. It is never a bad idea to have vasopressors (think norepinephrine) ready and in the room prior to administering rapid sequence intubation medications
• Paralyze
- Succinylcholine 1mg/kg IV (NO TIME TO CALCULATE? 100 mg) Onset 0.5-1min, duration 6-10 min Avoid succinylcholine in patients with known ESRD, hyperkalemia, or crush injury as it is a depolarizing agent and will cause a surge in potassium – use rocuronium or vecuronium (0.6-1.2 mg/kg) in these patients
• Intubate
-Practice direct laryngoscopy with every case you are assigned to if anesthesia permits – it is a great way to get comfortable with the required maneuvers and to know what the vocal cords look like
-Familiarize yourself with using a Bougie for a difficult airway
- DO NOT let go of tube until secured
- Confirm placement – besides watching tube pass through vocal cords
- Use CO2 detector—should change to yellow after a few breaths
- Look for condensation in tube
- Listen for equal bilateral breath sounds, listen to the stomach
- Check O2 sats
- Obtain stat CXR
TRANSFER TO THE ICU!