Critical Care Mailbag - Albumin in Resus, Aspiration in DSI, RSI Mistakes

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Po H. -

Hi Scott, Rob,

I had an interesting and stressful case with an status asthmaticus patient. She cam POV unresponsive and with sats 50 to 60%. We planed for DSI using ketamine and tried albuterol without much improvement. She rapidly received epinephrine and solumedrol. She was "guppy breathing" with small tidal volumes and we had to assist with some bagging.

Here is the problem: We had some difficulty with high airway pressures so I'm sure we insufflated the stomach by going over 20 cm water which did result in some emesis. Besides cricoid pressure, possibly magnesium, and slowing down ventilations to decrease breath stacking any other suggestions?

Seems like asthma is different than our other scenarios because of the high airway pressures and consequences of breath stacking.

Po Huang
Boise, Idaho

Robert A. A., M.D. -

I am confused about whether it is standard to practice after pushing meds in RSI. I have been taught to not bag (and it says in this section of EMRAP, to "pause" after pushing meds). This makes no sense to me. I generally always bag during the one minute I am waiting for the paralytic to kick in. Comments? Thank you for thoughts!

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