Pacing Vs. Airway Management

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Hi Gavin,

Blast from the past! Hope you and all back home are doing 
well...
I'm siding with the Anaesthesiologist and ICU Consultant's 
answer on this one (ie. Forrest). My answer lies in your 
description of the case:

"55 year-old male patient with Hx of IHD and 
hypertension... defaulted for 6 months"
Everyone of these I've met in the last 15+ years has been 
fat and unhealthy and an airway nightmare and if flat on 
his back following collapse, is by definition already 
obstructed and hypoxic regardless of cause for collapse...

"His EKG shows a sinus rhythm of 110 with ischemia."
Academic at this stage, could be respiratory or cardiac

"While the paramedics are treating the patient"
So there are more than 1 pairs of hands and here in lies 
the key to my response

"he becomes unresponsive, the ECG shows 3rd degree HB and 
he has a BP of 80 systolic. He has very poor tidal 
volume."
This is pure myocardial hypoxia. (increasing myocardial 
ischaemic burden leading to conduction defect).

...But who cares!!! This is all academic, you have a 
luxury of 2 pairs of hands and thus simultaneous activity!

Paramedic 1) "Airway and Breathing" LMA or simple 
manoeuvre's and assist ventilation whilst at the same 
time, Paramedic 2) Slaps on pads and sets up pacing. Above 
should take no more than 1 min. Then get the guy onto a 
trolley fast and sit him slightly upright to get his gut 
off his chest and prevent any caval compression and "foet 
in die hoek boet."

If like me you have the luxury of providing critical care 
at the side of the road, then RSI, ETT, inotropes etc.

If you are alone with this guy, A,B,C (don't disagree with 
me, disagree with the ACLS world!)

Kind Regards

Dr. Jason van der Velde
Trauma Research Fellow in Anaesthesiology
Ireland


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