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Case #44 13 Y/o With Resp. Distress.. Uh Oh...


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#21 Mike MacKinnon

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Posted 14 October 2008 - 10:41 PM

I can't believe this will end up being as simple as an anaphylaxis Rx. Stidor, face swelling, resp distress - could it all be that simple? I hear hoof beats - is it a horse or a zebra?

Percer has a very aggressive plan so far (IVx2?), and I could only hope he was my partner.

The onset - if it is anaphylaxis - is a little slow for an injection (bee sting) type reaction. Is she talk a new medication that would cause her to develop this new allergy? Or, maybe she did just get popped by a bee, and some weird underlying illness as been going on for a few weeks too. And, what does the T-cell leukemia have to do with anything, other then immune system problems. Very trick Mike. I'll get the Epi, benedryl, solu-medrol, and albuterol out, but I need more info.

For now:
Watch that airway and breathing.
Dig more into the history, last meal, meds, allergies. Any toxin exposures?
Any hives?

I look forward to more.



Last mean was 30 min ago

no meds

allx to peanut butter

Unknown if she had exposures

No hives ;)
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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

#22 Mike MacKinnon

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Posted 14 October 2008 - 10:42 PM

If it was a recurrence how would/could/will you know?

What are the implications?


I agree it sounds like the mediastinal mass is back and impinging on the airway and the SVC and other vascular structures. She also has SVC syndrome so the major vessels are being impacted. I would not be laying this girl flat, sedating and paralyzing her and messing with her airway unless she was dying. The anatomy is probably distorted and this is most likely going to be a difficult intubation from a lower airway standpoint. A surgical airway would probably not be of much benefit as the obstruction is probably too low. Laying her flat may totally obstruct her airway depending on where the mass is and it may also impede blood flow in the area making the situation even more "puckering".

Priority with this pt and her family is to keep calm and keep them calm especially the patient...lots of reassurance.
So for me for now I would start with the IV's and increase the O2.
If she becomes really anxious and it is increasing her respiratory distress I would give very tiny amounts of sedation or even just a touch of fentanyl to calm her otherwise just keep her as calm as possible.
Transport in a position that she is comfortable with and fly as low as possible.
Have the RSI ready to go only if she is about to code on you and have a cric kit ready even if possibly limited chance of success. (always be prepared, right?)
I think some steroids would be ideal in this situation but we don't carry them.
I don't think racemic epinephrine or atrovent would help much in this case but if she was starting to get worse I would definitely try that before thinking about intubation.
Basically intubation would be absolutely a last resort and only if she was near death.

"In the presence of severe symptoms of
cardiorespiratory compression such as, positional
dyspnoea, orthopnoea, stridor, syncope, and superior
venacava syndrome (SVCS), administration of GA may
be fatal.4,5,6 The profound hypoxia may also be due to
compression of great vessels in the presence of patent
airway.1,7,8 In high risk patients with mediastinal mass,
irreversible cardiorespiratory collapse can occur with the
use of sedative premedication, induction of anaesthesia,
with the use of muscle relaxants,2 initiation of intermittent
positive pressure ventilation (IPPV),9 simply by making
the patient supine,1 change of posture,7 and tumour
resection or manipulation.1,10 It is also possible that
tracheobronchomalacia i.e., softening of tracheal wall,
due to prolonged compression by mediastinal mass,
may potentiate the airway collapse, with the onset of
relaxation produced by anaesthesia or commonly after
tracheal extubation or emergence.2,11 Therefore, airway
management in patients with large mediastinal masses
with or without the evidence of airway obstruction poses
a difficult challenge to the anaesthesiologists."

Quoted from here.

Just my thoughts and the zebra is probably going to trample me but I gave it a shot.

Cheers.


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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

#23 Mike MacKinnon

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Posted 14 October 2008 - 10:44 PM

Soooo


While assessing you notice her lips are a little bluish.

Her sat is now 89% on the NRM

She is still awake but starting to get lethargic.

What now?
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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 Mike MacKinnon

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Posted 14 October 2008 - 10:44 PM

Soooo


While assessing you notice her lips are a little bluish.

Her sat is now 89% on the NRM

She is still awake but starting to get lethargic.

What now?
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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

#25 MSDeltaFlt

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Posted 14 October 2008 - 11:11 PM

Only breath sounds are biphasic stridor. Where do you hear the stridor loudest? Over the chest? Lower neck? Upper neck? With the stridor and the decreasing SATs along with the worsening cyanosis, we are losing her airway. I don't think intubation will be an option. We need to cric her. Some protocols are allowed to cut, some only to dart. Personally I'd like to cut her. Aggressive I know, but we are already behind the 8-ball.
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain

#26 mmssnb

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Posted 15 October 2008 - 03:40 AM

Ok, just to cover the allergy bases, her last meal was 30 minutes ago. What was it , and who prepared it?? ANy chance of cross contamination with peanuts? A friend share a snickers bar or something? What was she playing?
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#27 rfdsdoc

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Posted 15 October 2008 - 04:21 AM

The JVD in a kid is a give away for a mediastinal mass effect.
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Minh Le Cong
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RFDS Cairns base , Queensland, Australia

#28 Flightgypsy

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Posted 15 October 2008 - 05:37 AM

We won't know definitively whether the mass is back until we get a chest x-ray, CT and some labs. The implications are not good all the way around.

Looks like we are going to be dealing with a bad, bad airway situation.

Did any of the treatments like racemic epi help at all or have they not been tried at this point. I would really be trying everything to avoid intubation while I am preparing for a really bad scenario.

Ok, is there any possibility of nasally intubating this girl with some sedation? Much as I want to avoid giving her drugs I would really rather not paralyze her if we can avoid it. (I think we are heading there though!) Trying with a long and small enough tube to go as far down as we can to try and get past the obstruction.

I really don't want to lay this girl flat. Maybe we can try intubating with the HOB elevated as much as possible if we have to try oral intubation.

If we have to go for the surgical cric then I would probably opt for a regular ETT tube instead of a tracheostomy tube in the hope we can get past the obstruction. I think I would go for a smaller size like a 5.0 to try and get past the obstruction as we have a lot of narrowing by the sounds of the stridor. We want a size small but long enough. If we can do a surgical cric with her as upright as possible and someone holding her head up I think we will have more chance of success in case the mass is anterior to the trachea.

On the cardiovascular side I would open up the fluids wide open before I gave any medications, lay her flat or started messing with her airway. Have the epi ready to go as well as I think she will code on us with the slightest provocation.

Any chance we have some IV steroids on hand....really, really fast acting ones?????? (Please?)
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#29 Flightgypsy

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Posted 15 October 2008 - 05:45 AM

To answer your question Mike:
I am thinking the Mass is back because of her history of a mass, stridor indicating airway obstruction, SVC syndrome (puffy face, JVD) because the mass is obstructing the venous return to the heart and the fact that she hasn't been well for a few days so it is not an acute onset. If we can talk to her family I am sure there have been more subtle signs that have just hadn't been recognized. Hindsight is a wonderful thing.

That's just my thoughts but I may be totally wandering down a garden path again.
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#30 vtach1010

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Posted 15 October 2008 - 08:37 PM

What about the possibility of papilary muscle rupture related to cardiotoxic effects of the chemo depending on when she finished up
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#31 BamaFlightRN

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Posted 16 October 2008 - 03:20 AM

I just started checking the case out..sounds like everyone is really leary about gaining control of her airway. I understand the pucker factor and how difficult the airway could potentially be, but the initial report was inspiratory and expiratory stridor with severe respiratory distress. Right then, I think the airway is compromised and closing so then would be the time to intubate IMO. Now our airway is tighter and less likely to take a tube. I agree with agressive subq Epi and Racemic EPI treatments. Could be SVC syndrome but I think its something else. Something about the timing of it all. I would also consider solumedrol as well antihistimine. Gonna be hard to treat SVC syndrome in the field, but we can treat severe angioedema from exposure to peanuts if the exposure occured.
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#32 Jhobbs

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Posted 16 October 2008 - 04:33 AM

The Story:

You are kicked out on sat. at 6 pm for a 13 y/o girl who is reported to have resp. distress. This is a small town which is about 45 min by air from the nearest ER.

On Arrival:

You arrive on the scene of a playground where there is a 13 y/o girl surrounded by the volunteer FD people eagerly waiting for you to arrive.

There is a 13 y/o sitting up on the ground with a NRM mask of 12 L O2 on. She looks anxious and her eyes are darting back and forth. Her parents are there and look very concerned.

You are told she was just hanging around with her friends when she just had to sit down because she felt dizzy. Her mom was there and came over and decided to call 911.
Assessment:

On auscultation you hear biphasic stridor
She is tachypneic and has an SPO2 of 92% HR: 108 and BP 100/64

You notice her face is a little puffy and you can see JVD

History:

She was diagnosed 2 years ago with T-cell leukemia on the basis of blood smear and bone marrow aspiration of a small mediastinal bump which was treated and she has been in remission ever since.

Her mom tells you she has been displaying increasing symptoms of SOB over the past 6 days and they have an appointment in the city with her paeds oncologist about it.

Today she is "significantly" worse now than it has been.

Where to start?

Well it seems to me that the T-cell leukemia is now out of remission. I seems like the Thymus is becomming inflammed again, and will also increase the CSF. with the increase of the CSF this might be the reason for her anxiety. Or it could be all the Firefighters and ems staff. Or it could be because she is hypoxic after playing on the playground and the swelling of the thymus may be restricting her lung expansion. Oh well got to go got to have to go on a call. Will be back to comment later.
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#33 STPEMTP

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Posted 16 October 2008 - 02:28 PM

Hey Mike,

Is there abnormal swelling in her neck?? one side of the neck larger than the other? Any unilateral diminished breath sounds???

Sounds like we are heading down a path we all would like to avoid, intubating a patient with suspected mass impinging on the lower airways. I like Flightgypsy's idea of trying sedation assisted intubation over trying to go surgical on her. Really leary to go to the surgical option unless we are unable to get the tube into the trachea. I am thinking the mass is somewhere in the neighborhood of the carina vs somewhere on the trachea.



My thoughts on treatment
1. intubation, preferrably avoiding paralysis if possible
2. Keep patient on side or prone (maybe gravity will help decrease some of the compression on the airway. probably wishful thinking)
3. Steriods of choice (solumedrol 2mg/kg)
4. lasix 0.5mg/kg IV (may help relieve the pressure caused by the suspected SVC, Emedicine.com)
5. nebulized racemic epi/albuterol/other beta-2 agonists probably are going to have minimal effect due to mass "crushing" the airway vs being in the airway, but worth a shot due to long transport time.


I would do my best to keep the scene time as short as possible and start transporting to closest available ED, ideal would be somewhere that has cardiothoracic services. I would give the receiving facility a very early heads up so that they can get whatever equipment/personnel prepped and readied for our arrival.

great case so far Mike!

James Overkamp
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#34 rfdsdoc

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Posted 18 October 2008 - 08:29 AM

This is now very hard to decide.

The issue is that we are being backed into a corner, having to face a very difficult airway potentially.

In the OR, they would breathe her down with an inhalational anaesthetic gas like sevoflurane, and attempt a laryngoscopy, possibly with FOB backup, but definitely ENT surgical team backup ready to go with a surgical airway.

But we are not in the OR...

She gets IMI adrenaline now if I do not have IV access. My partner is drawing up ketamine and sux whilst I am getting IV access.
if the IMI adrenaline has not done anything by the time we setup for intubation and surgical airway then with the help of the firemen we would prepare a dual setup.

Best first pass attempt at laryngoscopic oral intubation under ketamine sedation. If view is reasonable but needs sux to pass tube then give sux.

If view is crap and no way can pass oral tube then BVM undere ketamine sedation , try a LMA if BVM not effective and start needle cric attempt. If that works and signs improve then go with that for transport. If it does not work then try to pass wire over needle if you have a seldinger cric kit. Last resort open cric or formal tracheotomy...ugly stuff.
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Minh Le Cong
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RFDS Cairns base , Queensland, Australia

#35 Mike MacKinnon

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Posted 18 October 2008 - 01:06 PM

Is there abnormal swelling in her neck?? one side of the neck larger than the other? Any unilateral diminished breath sounds???


You cant see any or palpate any.

Additionally, the EMT lays the girl flat as she isnt sitting up on her own. Her sats drop quickly to 80%.

Why did that happen? What could the mechanism of it be? If you understand the mechanism, what could then be done ?
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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

#36 Flightgypsy

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Posted 18 October 2008 - 05:39 PM

You cant see any or palpate any.

Additionally, the EMT lays the girl flat as she isnt sitting up on her own. Her sats drop quickly to 80%.

Why did that happen? What could the mechanism of it be? If you understand the mechanism, what could then be done ?



Ok, turn her on her side or as prone as possible maybe 3/4 prone while you are getting your drugs and gear set up. Prone will make it hard to intubate or surgically intervene but it may buy you some time if it relieves the compression of the trachea. It may also prevent her from coding. It seems like her sitting up was not helping a lot but it would still be better having her in an upright a position as possible. Elevate the head of the gurney as much as possible and have someone supporting her. Put towel rolls beside her head and tape it if you can.

I would still go with my previous suggestions for airway management and agree with Minh about giving as little sedation as we can get away with. We don't carry ketamine. I would be giving etomidate rather than versed for the RSI though for hemodynamic stability. I think we are going to have a lot of trouble with the intubation but if we can at least get a small size tube in there to help get air past the obstruction with PPV we may make it to the hospital. I would probably only attempt once via the oral or nasal route and then go fast to the surgical cric with a smaller size ETT and push it down as far as possible. A small ETT tube will still get more air in than a needle cric and prevent total collapse of the trachea.

I agree with giving some epi. If it doesn't help the airway it may at least prevent total cardiovascular collapse when we give her RSI drugs.
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#37 MSDeltaFlt

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Posted 19 October 2008 - 01:51 PM

You cant see any or palpate any.

Additionally, the EMT lays the girl flat as she isnt sitting up on her own. Her sats drop quickly to 80%.

Why did that happen? What could the mechanism of it be? If you understand the mechanism, what could then be done ?


Biphasic stridor tells me it's mechanical, not physiologic. So epi's not going to work.

If it's high, I'll cut. If it's low, it won't matter. So I can't.

I'm still stuck on where the stridor is and where the stridor isn't. Can't go any further, yet. Sorry.
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain

#38 Mike MacKinnon

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Posted 19 October 2008 - 03:05 PM

Stridor appears to be loudest over the sternal notch

Biphasic stridor tells me it's mechanical, not physiologic. So epi's not going to work.

If it's high, I'll cut. If it's low, it won't matter. So I can't.

I'm still stuck on where the stridor is and where the stridor isn't. Can't go any further, yet. Sorry.


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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

#39 MSDeltaFlt

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Posted 19 October 2008 - 03:28 PM

Stridor appears to be loudest over the sternal notch


Well, damn. Cuttin's out. You would say that, wouldn't you? We're just goin' to have to go with a smaller than normal tube. 1 whole size; maybe a size and a half. Paralyzing would probably be best. Put her completely down in order to pass it without any inadvertant rupture resulting in a glorified fuster-cluck.
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain

#40 mjcfrn

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Posted 20 October 2008 - 02:04 PM

Biphasic stridor tells me it's mechanical, not physiologic. So epi's not going to work.



OK, it's (presumably) primarily mechanical, but sometimes there is a component of airway edema present that racemic helps. In PICU, I've seen it help with mediastinal mass and vascular ring, buying a little time to get to the OR or just make a plan, etc. Did it once on transport on a kid with a known mediastinal mass, it got us to the house and kid was tubed in OR with anesthesia. Even a little bit of edema reduction in the airway goes a long way.....

Of course, knowing Mike, it won't help this time.....
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