Start with a free trial account for free content every month. Already a subscriber? Sign in.

Community Medicine Rants – Tape Measure Ventilation

Al Sacchetti, MD
00:00
10:57
Sign in or subscribe to listen

No me gusta!

The flash player was unable to start. If you have a flash blocker then try unblocking the flash content - it should be visible below.

Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN
00:00
01:09

No me gusta!

The flash player was unable to start. If you have a flash blocker then try unblocking the flash content - it should be visible below.

EM:RAP 2017 March Written Summary 580 KB - PDF

When setting the tidal volume, it’s not what they weigh, it’s what they should weigh based on height. The Italian Stallion recommends going low tech with a tape measure to get this right.

To view chapter written summaries, you need to subscribe.

Sign up today for full access to all episodes.

Maria B. -

Al , this rant was music to my ears. I'm a patient safety and QI fellow at Kaiser in Northern California and am working with RT to implement this region wide in the ED (agree, should be RT driven with ED/ICU backing). The NNT to save one life for LPV for all comers is 23 - if this were a drug we would all be clamoring for it. But it's not, and often invisible as we don't communicate about TVs in ml/kg of predicted body weight. Also, a fair segment of our patients in the ED already has ARDS on admission and we are under recognizing and under treating it (NNT for one life saved bumps up to 12 for these folks). To add fuel to the fire, it becomes a disparities issue as women, Asian, and Hispanic patients tend to be shorter and get their lungs blasted. But there's an easy fix in the ED - for volume control we have had success with a 350/450 ml protocol until a height can be obtained. It's 350 ml for female patients and 450 ml for male patients (based on 6 ml/kg predicted body weight for average American heights) with a rate of 20, chased by an ABG/VBG 15 min later. Like so many therapies, what we do in the ED really matters and we have this opportunity to set up patients for success. Tidal volumes are rarely dialed down in a timely manner even once they hit the ICU, and that's not even considering patients who are boarding in the ED. Let's recalibrate our settings and save some lives.

Alfred S., M.D. -

Marie: Thanks for your comments. We actually bought a tape measure ($8.95, measures in cm and inches) which the respiratory therapists keep at their work station in the ED. They measure the patient while we are doing the intubation so they have height already when it's time to put them on the vent. They use a simple table photocopied from a text book to get the predicted weight rather than do the actual calculations.

We recently presented some PI data at the hospital and found the since institution of this approach the use of LPV went from 20% to 75% for ED intubations. The outlying 25% were those with extreme conditions that needed settings outside the LPV ranges.

As an aside, the docs love it. They don't have to do any calculations and just make adjustments after the LPV is set up, the FiO2 is titrated down and an ABG is obtained.

Thanks again for your input.

Al

Maria B. -

Sounds like a smooth work flow that's making a huge difference! Your RTs are so on top of it for measuring during the intubation. Right now the order in our EHR is for RNs to measure height and that's probably a mistake (not my choice, political decision). We went with disposable paper tape measures because of infection control issues and RT badge cards for the TV/PBW chart as well as EHR support as not all of our EDs only intubate in designated resuscitation rooms. These are tiny variations on the same theme but workflow matters for successful implementation and remains site specific.

Alfred S., M.D. -

We are very similar, we intubate anywhere in the department. But it seems to work well with the RT's running the show. Please keep me posted on your program

Thanks

Al

To join the conversation, you need to subscribe.

Sign up today for full access to all episodes and to join the conversation.

To download files, you need to subscribe.

Sign up today for full access to all episodes.
Crashing Slowly Full episode audio for MD edition 238:10 min - 332 MB - M4AEM:RAP 2017 March German Edition Deutsche 73:21 min - 101 MB - MP3EM:RAP 2017 March Spanish Edition Español 89:05 min - 122 MB - MP3EM:RAP 2017 March Aussie Edition Australian 16:33 min - 23 MB - MP3EM:RAP 2017 March French Edition Français 25:15 min - 35 MB - MP3EM:RAP 2017 March Canadian Edition Canadian 28:50 min - 40 MB - MP3EM:RAP 2017 March Board Review Answers 262 KB - PDFEM:RAP 2017 March Board Review Questions 218 KB - PDFEM:RAP 2017 March MP3 Files 316 MB - ZIPEM:RAP 2017 March Written Summary 580 KB - PDF

To earn CME for this chapter, you need to subscribe.

Sign up today for full access to all episodes and earn CME.

6 AMA PRA Category 1 Credits™ certified by CEME (EM:RAP)

  1. Complete Quiz
  2. Complete Evaluation
  3. Print Certificate