MV scenarios created by Jacob Riegelsberger.

1. Presented by: Jacob Riegelsberger
B.S., LP, NRP, CCEMT-P, FP-C

2.  2215hrs. 26 y/o male (182 lbs., height 5’7”) is Part-
Time employee of local Wendy’s fast food restaurant
found by a fellow coworker on the floor of the men’s
bathroom after not returning from his break. Patient
is U/U, GCS = 3 (E1,V1,M1). Drug paraphernalia to
include hot spoon and lighter on floor next to patient,
with syringe sticking out of patient’s RAC. Patient is
presenting with perioral and peripheral cyanosis. No
bleeding or signs of trauma appreciated. EMS arrived
7 minutes after call for 911.

3.  Vital Signs:
 RR = 6, shallow and irregular w/ periods of apnea.
 SpO2 = 87%, RA
 BP = 103/64
 HR = 50 BPM (matched w/ Radial Pulse)
 Interventions:
 Patient is ventilated w/ BVM + NPA + suctioning. IV access
unobtainable. Humeral IO being placed while another provider
administers 0.4mg IN, repeat in 1 min intervals to max of 2 mg.
with no change in patient’s mental status/GCS. No RSI protocol
available, gag reflex intact, BLS airway maneuvers utilized while
patient is being packaged for transport w/ destination of level 3
trauma center 45 minutes away.

4.  5 minutes into transport a loud “bang” is heard/felt by
the crew, driver pulls over to find right rear tire has
been punctured and is deflating. EMS crew calls for
HEMS to continue with transport.
 HEMS TT arrives, assesses patient and elects to PAI in
the ambulance before transferring patient to aircraft.
 Patient is placed on mechanical ventilator during 22
min flight to Level 1 trauma center.

5. BUN (mg/dL) 10
Creatinine (mg/dL) 1
HCO3
- (mEq/L) 24
Glucose (mg/dL) 79 mg/dL
Serum Chloride (mEq/L) 97
Serum Potassium (mEq/L) 3.6
Serum Sodium (mEq/L) 136

6. 

ABGs
pH 7.29
PCO2 (mmHg) 66
PO2 (mmHg) 62
HCO3
- (mEq/L) 24
CBC
WBC (/mm3) 5
RBC (/mm3) 5
Hgb (g/dL) 18
Hct (%) 42
Plt (/mm3) 250,000

7.  What are your oxygenation and ventilation goals?
 What medication considerations should you take for
the mechanically ventilated, post PAI patient?

8.  ?????

9.  6 y/o male patient (32 lbs) brought into tertiary care
center ED by EMS for having rummaged through
mother’s medicine cabinet. Suspected OD of daily
multi-vitamin gummies, Norco and ASA tablets
approximately 7 hours prior to call for EMS. Unknown
quantity consumed. Mother of patient did not want
medical attention due to not having insurance, but
patient progressively worsened. Patient presents as:
febrile, N/V, lethargy w/ decreasing GCS (13) and
increased respiratory rate/effort (55/min BPM) at time
of ED arrival.

10.  BP = 50/37
 RR = 55/min
 HR = 147 BPM, irregular w/ ectopy and intermittent
PVCs
 SpO2 = 84%, RA
 Temp = 101.4 F / rectal

11.  Bilaterally 20G IVs to ACs initiated. MD elects to PAI
w/ Etomidate and succinylcholine, places a 5.5mm
ETT and ventilated w/ hospital mechanical ventilator.
HEMS TT called for transfer to higher level of pediatric
services not available at local facility, with ground
transport time to exceed 1 hour.
 Toxicology report confirms 85 mg/dL serum ASA.
Activated Charcoal administered via NGT. Fentanyl
1mcg/kg administered q 15 minutes for continued
pain/sedation. A/P Abd + CXR obtained for
additional ETT verification w/ small radio-opaque
mass observed in lesser omentum.

12.  What are therapeutic ranges for ASA? Hint…it’s no
where near 85 mg/dL...
 What is the appropriate depth for this patient’s ETT?
 What are you considerations for continued sedation?
Is Fentanyl appropriate? Better options? Thoughts on
NMBA w/ this patient’s current pathology and
expected clinical course?

13.  Mode = AC + V
 Breath Type = VLV (see above)
 f = 12/min
 Vt = 60ml
 FiO2 = .21
 PIP = Variable 22 – 27 cmH2O
 Vte = 50ml – 55ml
 PEEP = 5 cmH2O

14. BUN (mg/dL) 10
Creatinine (mg/dL) 1
HCO3
- (mEq/L) 22
Glucose (mg/dL) 43 mg/dL
Serum Chloride (mEq/L) 104
Serum Potassium (mEq/L) 2.4
Serum Sodium (mEq/L) 148

15.  ABGs
ABGs
pH 7.58
PCO2 (mmHg) 14
PO2 (mmHg) 55
HCO3
- (mEq/L) 22
CBC
WBC (/mm3) 5
RBC (/mm3) 5
Hgb (g/dL) 16
Hct (%) 40
Plt (/mm3) 312,000
PT = 20 PTT = 90

16.  What are you initial considerations w/ this suspected
toxic pathology?
 What are your long term considerations w/ this
suspected toxic pathology?
 Are these vent settings appropriate for this patient?
What needs to be changed?
 When changing settings, what are your oxygenation
and ventilation goals?

17.  With this suspected toxic pathology (ASA and Norco overdose)
what is the expected clinical course (i.e. pathological path) of
this patient and what vent changes may be required to to keep up
with the developing pathology?
 What is the suspected culprit of the ectopic beats/PVCs?
 When considering the Oxyhemoglobin dissociation Curve what
clinical indicators point to a Left Shift? What clinical indicators
would suggest a Right Shift?

 How does your ventilator management change when shifting
from one to the other?

18.  HPI - 76 y/o female (134 lbs., height 5’2”) w/ multi-
lobar pneumonia/UTI arriving to rural hospital ED by
local EMS. Family members found the patient lying
on the bedroom floor (next to bed) at 0500hrs. Patient
states she was trying to get out of bed to use the
restroom but legs were too weak to support her,
lowering herself to the ground and calling for family to
assist her.
 Symptomology: productive cough, low-grade fever,
night sweats, general weakness x 3 days.
 History: HTN, COPD/Bronchitis, smoker for 30 years,
quit 10 years prior. No alcoholic elixirs.

19.  After arrival to ED the patient is started on antibiotics
(ABX) and is transported by ground ambulance (at
1300hrs later that day) to metropolitan facility 30 miles
away for higher level of care. En route, patient
condition deteriorates, warranting RSI w/ Ketamine.
Patient destination department upgraded to ICU.
Patient manually ventilated with BVT until arrival at
destination facility.
 Which mode and breath type are best for this patient,
considering age and severe pathology?

20.  Patient HOB elevated 30 degrees and placed on
mechanical ventilator by RRT. Additional IV access
gained, Foley catheter placed and aggressive fluid
management for suspected Sepsis (30ml/kg NS) with
current MAP in low 50s, continued sedation with
ketamine infusion 0.5mg/kg/hr. A/P CXR. Cultures
obtained. Pressors started for continued low MAP
post NS bolus x 2.

21.  Mode = SIMV + P
 f = 22/min
 Vt = ---
 Vte = variable between 310 ml and 360 ml
 PIP = 22 cmH2O
 PC = 15 cmH2O
 PEEP = 7 cmH2O
 FiO2 = .6
 EtCO2 = 21 mmHg

 Are these vent settings ideal? What, if anything, can be
changed?

22. BUN (mg/dL) 21
Creatinine (mg/dL) 1.1
HCO3
- (mEq/L) 10
Glucose (mg/dL) 67 mg/dL
Serum Chloride (mEq/L) 101
Serum Potassium (mEq/L) 24.8
Serum Sodium (mEq/L) 170

23. pH 7.2
PaCO2 (mmHg) 82
PaO2 (mmHg) 57
HCO3
- (mEq/L) 10
WBC (/mm3) 14,000
RBC (/mm3) 4
Hgb (g/dL) 14
Hct (%) 65
Plt (/mm3) 150,000
Serum Lactate 6.2

24.  What is causing the discrepancy between the EtCO2 and
PaCO2 values?
 How much Potassium (K+) shifting can we expect with the
current pH? With Ventilator Management in mind, how
do we correct K+ and pH? Which variable is ultimately our
goal to correct first, K+ or pH?
 What kind of Acidosis is this patient experiencing?
 What is the vasopressor of choice for this patient? Dose?
Desired/undesired effects? Long term
cautions/considerations?
 What are the best vent settings to “wean” this patient off
the vent?

25.  Transfer of 72 y/o male (214 lbs, height 6’3”) w/ TBI from
tertiary care center to level 1 trauma center with surgical
capabilities. HPI: Patient was grocery shopping with family
members and stepped off the curb in the parking lot,
losing his footing, and falling backward hitting his head.
Patient transported to hospital by EMS where patient was
confirmed to have a hemorrhagic bleed in the presence of a
basilar skull fracture. Foley catheter, bilaterally large bore
IVs, & 10F Ventricular Drainage Catheter with Cranial Bolt
was inserted into the left lateral ventricle for continuous
ICP monitoring, with a bulb syringe attached for drainage.
Patient transferred out to higher level of care not available
locally.

26.  IFR rotor-wing flight at 7,500ft. (due to poor weather
en route to receiving facility), w/ time en route
estimated at 72 min.
 What clinical considerations do you have for this
patient during transport, given the proposed altitude?
What other transport options can be arranged?

 Which is preferred?

27.  BP = 152/98
 RR = assisted (intrinsic at 8
BPM/shallow/irregular/periods of apnea)
 HR = 61 BPM
 SpO2 = 92%
 Temp = 35 degrees C.
 EtCO2 = 32 mmHg
 ICP = 24

28.  With consideration to this traumatic pathology in
mind, what pattern is seen in the VS? How does that
change your approach to this patient?
 What two medications should you be considering to
administer and/or asking for from the sending facility
if not carried on board your aircraft?

29. BUN (mg/dL) 10
Creatinine (mg/dL) 0.7
HCO3
- (mEq/L) 24
Glucose (mg/dL) 61 mg/dL
Serum Chloride (mEq/L) 97
Serum Potassium (mEq/L) 6
Serum Sodium (mEq/L) 92

30. pH 7.29
PaCO2 (mmHg) 33
PaO2 (mmHg) 65
HCO3
- (mEq/L) 24
WBC (/mm3) 5
RBC (/mm3) 5
Hgb (g/dL) 18
Hct (%) 37
Plt (/mm3) 350,000

31.  What vent settings are most appropriate for this
patient? Which mode and breath type for this
patient?
 What is ideal CPP for this patient?
 What lab value is most critically out of range, and why
is this? Is this an expected finding in the TBI patient?
 How doe we promote fluid excretion in these patients?
Does this need to be done judiciously and with care?

32.  54 y/o male w/ Dx of DKA by local EMS. Gentleman on
camping/hunting trip in rural South Texas, patient has
history of insulin dependent diabetes. Patient feeling
progressively unwell for last 36 hours. EMS assessment
includes: Patient GCS 3/A&O x 0, incontinent of urine,
“Fruity Pebbles” aroma originating from patient’s mouth.
At the scene, friends of the patient state he is normally very
compliant with his injections and has been injecting
himself as prescribed, they also state that the cooler he had
stored medications in ran out of ice two days prior. Patient
initially c/o of headache, fatigue, thirst and nausea and
feeling unwell as hours/day progressed.

33.  BP = 82/palp
 RR = 45/min, deep and regular
 HR = 122 BPM, regular, no ectopy
 SpO2 = 80%, RA
 Temp = 38 degrees C.
 EtCO2 = 20 mmHg

34.  What ventilator settings (mode and breath type) are
most appropriate for this patient?
 Is this patient a candidate for heavy sedation or
administration of NMBA?
 Which vent two vent settings are most important to
“match” for this patient?
 Why is the patient breathing so fast/deep?

35.  What do you expect the patient’s PaCO2 to be, if
obtained?
 What is the relationship between pH and K+, do you
expect this patient’s K+ to be high or low?
 What are your initial treatment priorities?
 What would you expect their Na+ levels to be, high or
low?

36. ?