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Case #42 Football Player Collapses


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#21 fiznat

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Posted 04 August 2008 - 04:02 PM

Any trach deviation or JVD?

Probably would dart him anyways. Let's do it already. ;)
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#22 Speed

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Posted 04 August 2008 - 05:54 PM

As we're fixing the pneumo we need to strip him and flip him. Make sure we rule out any penetrating trauma, really look for the cause you know. Note any free air (sub-q), paradoxical movement, rib fx's, if any, etc... Don't lag on the hx either; recent coughing, disease, surgery, etc...
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#23 Mike MacKinnon

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Posted 04 August 2008 - 08:01 PM

No trach deviation or JVD


Trach deviation is most often a post mortem finding tho, what CAN you feel in a pt who has an evolving tension pneumo?


No penetrating trauma etc
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#24 Speed

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Posted 04 August 2008 - 08:23 PM

No trach deviation or JVD
Trach deviation is most often a post mortem finding tho, what CAN you feel in a pt who has an evolving tension pneumo?
No penetrating trauma etc


Feel? Well, maybe an expanded affected side of the thorax, hyper-resonant on percussion, a weak pulse (might bump the mercury on inspiration), crepitus from air under the skin. From a displaced heart and > intra-thoracic pressure there could be bounding in the abdomen or some weird/atypical heart tones (guess that would be hearing though). You could "feel" a lack of excursion/recoil on the affected side. You could feel diaphoretic or cool skin maybe?
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Mike Williams CCEMT-P/FP-C

#25 ST RN/PM

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Posted 05 August 2008 - 12:31 PM

Mike,
You can feel da rice krispies......diaphragmatic hernia.... not a bad thought. There would be gastric sounds if there were enough of a herniation to obliterate breath sounds on the affected side....no? Steve
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Steve T. RN, PM

#26 JPatterson

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Posted 05 August 2008 - 01:44 PM

No trach deviation or JVD
Trach deviation is most often a post mortem finding tho, what CAN you feel in a pt who has an evolving tension pneumo?
No penetrating trauma etc


You can feel trachial tugging away from the affected side on inspiration before you will see any deviation.
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Jeff Patterson NREMT-P

#27 HELOSRCOOL

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Posted 05 August 2008 - 05:39 PM

Odd to have diaphram rupture on the right though, this is usually precluded by the liver on that side. I am not saying it doesn't happen though. Definitely need to expose for Rapid Trauma assess.

Sub Q air can be felt in many folks, but if this is a big guy it might take longer to show up due to increased muscle/tissue mass.
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Bill
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#28 Mike MacKinnon

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Posted 05 August 2008 - 08:29 PM

DING DING

YOU are the man.

There is, indeed, tracheal tugging.

So describe the next step


You can feel trachial tugging away from the affected side on inspiration before you will see any deviation.


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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#29 RoadieRN

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Posted 05 August 2008 - 10:53 PM

Odd to have diaphram rupture on the right though, this is usually precluded by the liver on that side. I am not saying it doesn't happen though. Definitely need to expose for Rapid Trauma assess.

Sub Q air can be felt in many folks, but if this is a big guy it might take longer to show up due to increased muscle/tissue mass.

Helo,
You're absolutely right with rarity of DH on the right. My thought process was just something else that could cause absent bs. Lord knows where this one is going to take us.

Fly safe everyone!
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Nick Crusius RN, BSN

Keep the rubber(or skid, if it applies) side down!

#30 ian

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Posted 05 August 2008 - 11:42 PM

I agree with every one that wants to perform immediate chest decompression.
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#31 Mike MacKinnon

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Posted 05 August 2008 - 11:44 PM

For the new ppl ...

Explain the process of needle decompression and why not just do a chest tube
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#32 RoadieRN

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Posted 06 August 2008 - 12:09 AM

So as far as the next step goes, I think, we start be needling the R chest 2nd intercostal space midclavicular line superior to the rib either the 2nd or 3rd rib. I'd use my 14 G 1.25in needle depending on the thickness of his chest. Also, I'd consider midaxillary same intercostal space, possibly a little lower depending on landmarks. With a 35 min ETA to our nearest facility, if the need arised again to needle the chest I'd do it again. If that doesn't work, I'd go to my Cook catheter. After I wiped the site, I'd make a 1-2 inch incision over the 2nd or 3rd rib near my old needle site. I'd set up my catheter with the introducer and one way valve. Next, I'd insert the setup til I hit the rib. After that, I'd slowly bring it superiorly over the rib into the pleural space. Once I knew I was in I'd advance the catheter until all of the holes on the catheter are in. After the last hole is in the skin, I'd advance the catheter an additional 4 cm. Then I'd cover it with a tegaderm and off we go.
Now if that doesn't work and we had a hemopneumo then I'd insert a CT into the 4th or 5th intercostal space midaxillary line. By going this high, you are more likely to avoid the liver(barring the unforeseen or undiagnosed DH.). Once again I'd grab my scalpel and make an incision big enough to get my index and middle fingers inside to hold the pleural space open prior to inserting the CT(for me about 3-4 cm). Next I'd insert my Kellys, puncturing the pleura. Once the pleura is punctured, I'd insert my finger into the hole, making sure I don't feel liver, spleen, or intestines. As part of my set up I"d already put my trochar on a pair of curved kellys and insert it along the angle of the rib until I'd get all of the holes inside the pleural space. I'd also keep the end of the CT clamped, in case it was a hemopneumo. Tape that bad boy down and we are off.
Mike, thanks for the refresher. It's been a while since I thought that all the way through.
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Nick Crusius RN, BSN

Keep the rubber(or skid, if it applies) side down!

#33 Speed

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Posted 06 August 2008 - 02:47 AM

The difference between dart versus thoracostomy is SPEED. This guy is crashing, and in what I call a "near arrest" situation (brain/hypoxia/cascade of other bad things). In two shakes of a lamb's tail he could be pink and happy, and I could slow back down to my normal pace (and if in I had the protocol & tube). What I would normally feel like in a guy like this is a reversible pneumo, so I would feel OK with a big long needle since hemodynamics have changed and looks like it is a tension (I carry two 3" 10g's, and if in a "crash" situation or real nasty chest I would use a Cook kit that might "pop out of no where???", then the regular old 2" 16's as a back up) . Aim for the apex, miss the vessels and nerves. Leaving them open to air bugs me unless we're coding 'em. Even though we're working below the carina I consider this "stuck at A". So the primary is is not in tact and I tend to treat similar traumas in similar directions (based on past "worst cases") and be prepared for the possibility of a real bad hemo and get past the airway and be on the way... just in case. This is pretty isolated, but still has potential.
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Mike Williams CCEMT-P/FP-C

#34 Mike MacKinnon

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Posted 06 August 2008 - 06:03 PM

Sweet good job guys.


Ok

So you pop in the needle and now can auscultate the lung inflating as the pt breathes.

Sat is now 98% on NRM

BP is now 190/100
HR is now 110

Pt still appears somewhat confused.... Hmm....
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#35 MSDeltaFlt

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Posted 06 August 2008 - 07:27 PM

Until proven otherwise, he's got a concussion. I'm betting during the exact time he got his lung dropped.
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain

#36 Speed

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Posted 06 August 2008 - 09:46 PM

Check FSBS, neuro assessment (physical and verbal, r/o concussion/axonal injury), body temp (lytes/ osmalality/hyperthermia/CVA), Signs of dehydration, sats/hypoxia/anoxic injury, assess for recent etoh/tox history, seizure hx, diet hx (malnourishment/supplements)...
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Mike Williams CCEMT-P/FP-C

#37 launchpad

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Posted 06 August 2008 - 11:15 PM

hey, fresh meat here. feel free to cut me up. first off, everyone wants to talk to the coach and family. weve been on scene long enough, what do they say? when did he likely blow a lung? is this traumatic (ribs feel right, bruise, etc. etc)? highschool so likely not a geographical sea level thing situation, like going from san diego to denver. second, and on somewhat of a side note, why does everyone think this kid is so big? all worried about dart length. im 6foot, 215, and i think that 3 incher would do fine.

so anyway, someone saved the day, and darted the chest. a,b temporarily good. i think its a case by case, and depends on your agency/protocols, but this kid bought a chest tube, and maybe a nap/ett (confusion?) might want/need to get that tube in before the ride. so a/b good for our purposes. c - hopefully the hr, bp will come back, specially the bp. if not, maybe thumped his ticker when he popped his lung??? keep an eye out for signs of bleeding and troublesome ecg changes.

confussion - now that im sure we have talked to people, is this kid a mongaloid? whats his baseline? did he indeed take a hit that anybody can think of? helmet condition - mostly looking for cracked foam/shell, proper fit (as near as you can figure), did he lose it in a pile-up? think back before this game, doesnt have to be an acute injury. so lets rule out the things we can fix, bg, o2, fluid, etc., and get out.

so finish up what we started with the dart, and what do bystanders say? detailed pe, show anything?

pad
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#38 schrodingers_cat

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Posted 08 August 2008 - 03:39 AM

At some point(like now)the kid needs c-spine.......altered LOC, distracting injury, MOI (he is a footbal player). Murphys' Law of co-existing injuries......
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#39 LWTRF14

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Posted 08 August 2008 - 05:30 PM

Hey all, just a thought, this player was described as a "Big boy"....Is he big as in body weight, or is he big as in muscle built....if its muscle, and this is just a side thought...is there a chemical floating around in the body that might have triggered something...A chemical that might cause muscle mass to build quickly....
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Earl F Bakke III, NR-EMT-P, CC-EMT-P, PNCCT

#40 MSDeltaFlt

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Posted 08 August 2008 - 09:18 PM

Oh he's probably "juicin", but you always treat the TBI until proven otherwise.
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain