Crashing On The Ventilator – EMCrit 16

In this post I link to and excerpt EMCrit Podcast 16 – Coding Asthmatic, DOPES and Finger Thoracostomy
December 23, 2009 by Dr Scott Weingart

EMCrit #16 tells us what to do when a patient on a ventilator is crashing.

Note  that if you have purchased the Resuscitation Crisis Manual [Not an affiliate link, I just think everyone should buy it], you will receive a free PDF copy that you can place on your smart phone, tablet or computer. Here are the relevant chapters for this problem:

  • Crashing On Ventilator – 11
  • High Peak Pressure: Volume Control Ventilation – 42
  • Hemodynamically Unstable Intubation – 45

Here is the podcast for EMCrit 16:

Here are excerpts:

The DOPE mnemonic gives you a path to figure out why a patient is desaturating.

If the pt is asthmatic, add an “S” to make DOPES

The “S” stands for Stacked Breaths–and it’s the first thing to address.

Address it by disconnecting the vent circuit. Don’t think about it, don’t dither, just disconnect the vent.

[If there has been breath stacking disconnecting the vent will allow the patient to exhale trapped air.]

“E” is for equipment. Attach a BVM hooked up to O2 [with an attatched PEEP valve] and you’ll eliminate ventilator equipment failures.

“D” is for tube displacement. Verify the tube with ETCO2, either qualitative or quantitative.

“O” reminds you to check for obstruction of the tube. See if you can put a suction cath all the way down.

If all of these don’t fix the problem, then consider “P” for pneumothorax.

Lung sounds are not always definitive. Throw on the [POCUS] if you have the time.

Otherwise perform bilateral finger thoracostomies. What the hell is that, you say? Listen to the podcast.


Is the tube mainstem, is there a ball-valve obstruction?
Consider reintubation
Consider Bronchoscopy

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