EMS brings in a 45 year old male with a PMHX of tobacco abuse who was rescued in a house fire.  The report is that a cigarette dropped on the patient’s couch while he was sleeping and caused a smouldering fire.  It resulted in a significant amount of smoke creation but very little fire damage in the house. The patient has no visible burns.  On arrival, the patient’s pulse oximetry on room air is 84%. He is alert and oriented but notes a sense of persistent dyspnea. His workup is significant for a lactate of 2.2 but otherwise benign.  Co-oximetry is normal without evidence of severe carbon monoxide poisoning. The patient does not display evidence of inhalational burns. The patient’s new hypoxia and dyspnea is worrisome so you planned admission to the hospital but wonder if you should give hydroxycobalamin empirically in case of occult cyanide toxicity.

Patient-ventilator asynchrony is underrecognized yet associated with increased mortality, ICU length of stay and duration of mechanical ventilation in critical illness. How do you diagnose and treat it? Hint: the answer is rarely deep sedation or paralysis!

EMS brings in a 67 year old male in a PEA arrest. ROSC is obtained after twenty minutes of downtime. He was intubated by EMS during transport. A colleague talks to the family and she lets you know that he was complaining of shortness of breath and chest pain for an hour before he had a witnessed cardiac arrest and that his PMH includes HLD and HTN. The respiratory therapist is asking for the ventilator settings.

A patient has arrived with increased work of breathing, hypoxia, and altered mental status requiring intubation.  After intubation, the patient stabilizes and their oxygenation improves. You know that both hypoxia and hyperoxia are bad for patients and that initial ED mechanical ventilation strategies are often continued after admission1.  How can you titrate the patient’s fraction of inspired oxygen (FiO2) to keep them safe from both hypoxia and hyperoxia?