Prolonged Field Care Podcast 53: Ventilating In The Prone

What happens when your patient has been given a cric or intubated but continues to decline… SpO2 continues to slowly drop despite taking control of the airway. You have placed your patient on a ventilator and slowly adjusted the PEEP up to 20cmH20… which quickly leads to hypotension. Do you go lower? Higher? Change volume or rate? You are out of bottled O2 and your oxygen concentrator does not seem to have much effect. The SpO2 continues dropping. Telemedicine is not available. You try positioning the patient by sitting them up. You try a couple other recruitment maneuvers you heard about.

Nothing is working.

What would Doug do?

Prone the patient???

Your patient may be suffering from ARDS, Acute Respiratory Distress Syndrome caused by a number of etiologies such as pneumonia or other lung injury. Carefully turning your patinet on their stomach may improve oxygenation by recruiting alveoli formerly compressed and “drowned” as demonstrated in the picture below. Positioning your patient on their stomach in the prone position must be practiced with anyone who will be helping you. Put someone else in a similar position and have the team with which you plan to help move the real patient do a couple rehearsals. You don’t want to flip them over only to lose your IVs, IOs and yank the airway out. Check out this Brazilian article which includes a proning checklist and some informative pictures and tips. You also don’t get an automatic win by flipping them on their belly and calling it a day. You will have to be even more vigilant about any potential complications with a dedicated airway person as is is a little harder to recognize a patient in distress if you are not used to it. You will also have to do more nursing care on the delicate skin of the face and other surfaces not normally on the down side: Shoulders, hips, knees tops of the feet. Put yourself in this position for a few minutes on a litter and you can quickly tell where the major pressure points will be. All of these complications increased along with the benefits of the study. While no prolonged field care patient should be on a bare litter, there is even more reason to move them to a mattress or other more comfortable padded surface.

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