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


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#41 Speed

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Posted 20 October 2008 - 03:43 PM

Ok, turn her on her side or as prone as possible maybe 3/4 prone


I'd like to see what some re-positioning (prone sounds good, or whatever would work to maybe take off any compression of or help "straighten out" the trachea and bronchi, maybe even some light pulling into a sniffing position or giving a cervical collar a try?) could do to possibly relieve the suspected obstruction prior to getting real aggressive, just to get a better idea of what's going on. Finding this out before intubation sounds better to me.
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Mike Williams CCEMT-P/FP-C

#42 Mike MacKinnon

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Posted 20 October 2008 - 05:20 PM

The stridor decreases and the sats increase to 90% in the prone position.....

How will you transport?

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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Mike MacKinnon MSN CRNA
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#43 Speed

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Posted 20 October 2008 - 05:40 PM

The stridor decreases and the sats increase to 90% in the prone position.....

How will you transport?


With a song in my heart and a smile on my face.
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Mike Williams CCEMT-P/FP-C

#44 MSDeltaFlt

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Posted 21 October 2008 - 12:21 AM

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.


"The stridor decreases and the sats increase to 90% in the prone position.....

How will you transport?"

Moving a pt with a compromised airway into a position which makes access to the airway tenuous at best in a vehicle at altitude fraught with 8-9 different stressors on a good day, not to mention with a confined space, is a recipe for disaster regardless of the outcome. Luck only counts in horseshoes and hand grenades, people. I don't like this.

Not losing your airway also includes not losing sight of your airway.
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Mike Hester, RRT/NRP/FP-C
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#45 Speed

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Posted 21 October 2008 - 01:07 AM

"Moving a pt with a compromised airway into a position which makes access to the airway tenuous at best in a vehicle at altitude fraught with 8-9 different stressors on a good day, not to mention with a confined space, is a recipe for disaster regardless of the outcome. Luck only counts in horseshoes and hand grenades, people. I don't like this.


So you want to put her on her back again? The options here are pretty limited. I wouldn't really want to leave her on scene, and I wouldn't want to obstruct her airway again. More than likely we moved the thymus off of her airway, I'd be comfortable focusing on a high-flow mask at 25 lpm with the valves taped shut, BVM for PPV on stand-by, maybe a neb in there at some point, and keeping her very comfortable and calm, maybe some very light sedation, more of a anti-anxiety "low dose". Comfort is the big idea here. The general population of 13 y/o females wouldn't be that hard to flip over even in a 206 (unless she's a really big girl?). Also, we're rallying back from deterioration (that's a good thing). She was running around playing just a few minutes ago?
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Mike Williams CCEMT-P/FP-C

#46 MSDeltaFlt

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Posted 21 October 2008 - 03:36 AM

"The stridor decreases and the sats increase to 90% in the prone position.....

How will you transport?"

Moving a pt with a compromised airway into a position which makes access to the airway tenuous at best in a vehicle at altitude fraught with 8-9 different stressors on a good day, not to mention with a confined space, is a recipe for disaster regardless of the outcome. Luck only counts in horseshoes and hand grenades, people. I don't like this.


High flow O2 does not exist with NRM in any situation regardless of liter flow. You might be giving her 60%, more than likely 40% FiO2. Nebs are not likely going to work on that mass. She needs oxygen but she has an obstruction. Sats are now 90% rolled over as apposed to their original 89% sitting up. On a pulse ox? It's semantics. Plus she's already lethargic; i.e.: limp, and you're still going to sedate her?!?

Now you can guarrantee her the O2 she needs by either giving her the 200-250 L/m of O2 she needs (impossible in an aircraft), or tube her. You go small. One whole size. Maybe one and a half size smaller than her body calls for. If her body size calls for a 6.0, go with a 5.0; maybe 4.5. At that short length of tube, you'll have to bury it deep. But it is feasible.

By the way, if we go with the prone thing-a-ma-bob and the fecal matter hits the rotary oscillator, how fast can you spin a limp 13 y/o around in an aircraft cot who is still strapped down with 3, maybe 5 point straps? Remember your FAR's.

Tube her.
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain

#47 rfdsdoc

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Posted 21 October 2008 - 11:53 AM

Arm chair anaesthetists

This is very difficult but I agree we have to make a call. Either way is very risky. Awake intubation even if she is limp/lethargic...how many have tried that in a 13 yo kid? How many goes are you going to try? Or are you going to keep doing it till she arrests?

Sure maybe have one go but not mutliple. It might be that the intubation is in fact fairly simple as the airway obstruction is below the cords. SO yeah MIke I agree have a go..but if it is crapville on your first laryngoscopy I'd be keen to bail, resume prone position and do whatever you need to maintain sats, BVM in the prone position with two persons if you can manage or in the lateral position if not.

Doing nothing has some merit. SaO2 are 90% in a prone position. First do no harm. AS much as it is painful to even corner yourself further it might be the least harmful thing to do at the moment.

Sure there is an airway problem but it is not a simple one to correct in the prehospital setting.

I got no brilliant ideas , but doing no more and going as is I could live with if it all turns to coronersville.

I would also not be critical of Mike having a go at intubation at this juncture even if he killed the patient trying to do it. I can see where he is coming from.
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Minh Le Cong
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MBBS(Adelaide), FRACGP, FACRRM, FARGP, GDRGP, GCMA
RFDS Cairns base , Queensland, Australia

#48 Speed

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Posted 21 October 2008 - 01:10 PM

[quote name='MSDeltaFlt' post='13675' date='Oct 20 2008, 10:36 PM']High flow O2 does not exist with NRM in any situation regardless of liter flow. You might be giving her 60%, more than likely 40% FiO2. Nebs are not likely going to work on that mass. She needs oxygen but she has an obstruction. Sats are now 90% rolled over as apposed to their original 89% sitting up. On a pulse ox? It's semantics. Plus she's already lethargic; i.e.: limp, and you're still going to sedate her?!?[/quote]

The neb. With stridor and probably some other underlying sounds I can't absolutely rule out other things, and yes it would be more or less trivial, and no it wouldn't help with the suspected obstruction, but I don't see it hurting (except maybe driving up the need for O2, then no we shouldn't if HR climbs more than what I would like to see). Sedate her if she needs it, that is if her mental status is driving up her need for O2. If she's limp and whatever and doesn't appear to need it, well no of course. I would like to give her a moment to see if her mental status rebounds, not long though. With the flow and mask augmentation, for me that would be for a small amount of airway pressure/resistance (tight mask and coaching). Or you could tube her, I'd like to see her response for a bit though (just to know where we stand, the suspected dx is just a suspect right now).

[quote]Now you can guarrantee her the O2 she needs by either giving her the 200-250 L/m of O2 she needs (impossible in an aircraft), or tube her. You go small. One whole size. Maybe one and a half size smaller than her body calls for. If her body size calls for a 6.0, go with a 5.0; maybe 4.5. At that short length of tube, you'll have to bury it deep. But it is feasible.[/quote]

If you wanted to tube her now I would most definitely wouldn't argue with you. I really wouldn't expect anything but a normal intubation?

[quote]By the way, if we go with the prone thing-a-ma-bob and the fecal matter hits the rotary oscillator, how fast can you spin a limp 13 y/o around in an aircraft cot who is still strapped down with 3, maybe 5 point straps? Remember your FAR's.[/quote]

I guess I missed a post or two, didn't realize she was lethargic; yes tube her if she's not improving pretty quickly. If she's awake and able to talk, moving air OK, and on and on; I wouldn't be afraid to carry a normal size 13 y/o girl prone with the plan of flipping her if she deteriorated again. I'm sure I could do it within the confines of a part 135 flight (within reason secondary to her size of which I can't see in this simulation). I've done it before at the site of erupting vomitus.
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Mike Williams CCEMT-P/FP-C

#49 fiznat

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Posted 21 October 2008 - 03:06 PM

So prone position changed the sats from 89 to 90% and resulted in a subjectively "less" stridor? Is that a good enough trade for flipping this girl over and compromising visualization of the patient, airway access, possibly increasing stress, etc etc?


As far as intubating this patient, if we believe that this is a mechanical obstruction located at some place inferior to the chords (as evidenced by the stridor position), what are we accomplishing with ETI? Will a tube pushing air just above the obstruction be more effective than where we're at now? What about just trying to BVM this patient and see how well it is tolerated/what effect it has on mental status/oxygenation.


I'd be interested to see what this patient is doing for ETCO2.
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#50 RoadieRN

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Posted 21 October 2008 - 05:33 PM

So prone position changed the sats from 89 to 90% and resulted in a subjectively "less" stridor? Is that a good enough trade for flipping this girl over and compromising visualization of the patient, airway access, possibly increasing stress, etc etc?
As far as intubating this patient, if we believe that this is a mechanical obstruction located at some place inferior to the chords (as evidenced by the stridor position), what are we accomplishing with ETI? Will a tube pushing air just above the obstruction be more effective than where we're at now? What about just trying to BVM this patient and see how well it is tolerated/what effect it has on mental status/oxygenation.
I'd be interested to see what this patient is doing for ETCO2.

I've been sitting this one out and watching and learning from everyone here. Really out of the box kind of case here, Mike. I imagine the number of times any of us have seen this has been in the ICU environment with everyone possible toy at your disposal. I imagine seeing this in the field would have the requiste shart stain behind us as we walked in the door. This patient is very complicated and you have quite a few dilemnas here. For starters, this patient's airway is about as tenuous as they get. Prone is where she likes, but your patient access is quite difficult. You have to rely on your pulse ox and ETCO2(if you have the noninvasive airway kind). In my experience that can be very finicky at best in the air. If push came to shove, I would do a DAI and only paralyze if I couldn't pass the tube d/t patient not tolerating the tube and if I had a great view of the cords. However, there is a possiblity of passing the tube and being unable to ventilate w/no other option. Since taking away her airway would likely be catastrophic, I am more leaning toward some racemic epi nebs, sq epi if it is an allergic rxn, and crossing my fingers.
As far as the whole part 135 thing goes, why do the feds gotta be a PIA like that?! I'm totally joking bear in mind. In all serioiusness, I would position our patient where she likes it the most and tolerates it the best. It puts us between a rock and a hard place, but that is why we get paid the big bucks, right? I'd prop her with pillows and blankets or whatever else I could find to get her comfy and head on down the road. It is what is best for her and she ultimately needs definitive care, not us mucking with airway anymore than necessary. I would only intubate if I've exhausted all other possibilities and she is about to code.
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Nick Crusius RN, BSN

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

#51 Speed

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Posted 21 October 2008 - 10:00 PM

It puts us between a rock and a hard place, but that is why we get paid the big bucks, right?


Exactly
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Mike Williams CCEMT-P/FP-C

#52 Mike MacKinnon

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Posted 22 October 2008 - 12:12 AM

Soo.....


I will give you 3 course of action options then once you have come to a consensus Ill tell you what actually happened to this patient


Course #1: Put her prone and fly her like that

Course #2: RSI her

Course #3: Attempt an awake intubation.

The tools you have avaliable are:

ILMA, King LT, Combitube, Bougie, Lightwand, Needle Cric kit, Full cric kit and retrograde intubation kit
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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

#53 Speed

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Posted 22 October 2008 - 01:22 AM

Soo.....
I will give you 3 course of action options then once you have come to a consensus Ill tell you what actually happened to this patient
Course #1: Put her prone and fly her like that

Course #2: RSI her

Course #3: Attempt an awake intubation.

The tools you have avaliable are:

ILMA, King LT, Combitube, Bougie, Lightwand, Needle Cric kit, Full cric kit and retrograde intubation kit


Is she still groggy/lethargic/obtunded/<LOC? Glasgow?
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Mike Williams CCEMT-P/FP-C

#54 MSDeltaFlt

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Posted 22 October 2008 - 01:48 AM

Soo.....
I will give you 3 course of action options then once you have come to a consensus Ill tell you what actually happened to this patient
Course #1: Put her prone and fly her like that

Course #2: RSI her

Course #3: Attempt an awake intubation.

The tools you have avaliable are:

ILMA, King LT, Combitube, Bougie, Lightwand, Needle Cric kit, Full cric kit and retrograde intubation kit


With biphasic stridor at the sternal notch, ILMA, King LT, Combitube, Bougie, Lightwand are out. Smallest feasible tube would be too big to pass over.

Retrograde is more than likely out due to location of stridor making it a mute point.

Awake intubation will be difficult with her being conscious (able to manipulate glottis) with a compromised airway.

RSI with Atropine to prevent brady. You can even do this with her head elevated. Use a SMALL tube.
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain

#55 Mike MacKinnon

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Posted 22 October 2008 - 03:34 AM

Is she still groggy/lethargic/obtunded/<LOC? Glasgow?


Groggy yes.

Opens eyes to voice, alert to pain
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Mike MacKinnon MSN CRNA
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It's what we know for sure that just ain't so" - Mark Twain

#56 BackcountryMedic

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Posted 22 October 2008 - 04:43 AM

RSI. Best 1st pass success.

Use the Bougie (doc today at AMTC recommended it for every intubation, not just the hard ones - 'cause they're all hard in the field).

Back up with the ILMA, KING, and Cric. I don't think any of the other stuff will do any good.

I would use a cuffed tube here. The pt is boarderline between the cuffed vs. uncuffed debate. In this case my hope is that positive pressure will be a better dynamic for this airway as opposed to negitive pressure (push past the obstruction as opposed to pulling through). A cuff will help seal the airway and keep the flow in the right direction.
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#57 Speed

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Posted 22 October 2008 - 04:50 AM

OK, if she was just groggy, stayed responsive to voice, cognitive of surroundings, maintained a cough/gag, and SpO2 was climbing > 95% I would maintain what I had:

Course #1: Put her prone and fly her like that

If the sats never got above 90%, "looked asleep", lost her gag, and/or deteriorating I wouldn't let that sit for 45 min of transport and would go with knocking her down:

Course #2: RSI her w/ good BLS airway

Normal intubation attempt
LMA or King on stby (primary back-up)
Surgical cric (secondary back-up)
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Mike Williams CCEMT-P/FP-C

#58 Speed

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Posted 22 October 2008 - 05:02 AM

And flip her back over to prone if I intubated. You could get creative with a KED and suspend her torso/rib cage instead of letting it rest on the cot to further relieve the obstruction from a suspected space occupying lesion or gland if things got real bad.
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Mike Williams CCEMT-P/FP-C

#59 chris_rn2006

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Posted 22 October 2008 - 05:15 AM

New poster so please be patient but I do not agree with the 3rd option of awake intubation. I could see something going wrong with that very quickly. Especially since she now opens her eyes to voice and is alert to pain. I just think that it would be to hard to get the airway established with that route. The fact that her sat drops when she is on her back worries me about the RSI also, but the risk of a compromised airway scares me. I have to say though if she increasing with being in the prone position I would transport her that way with the intubation equipment handy just in case. Keeping the Bougie even closer because I am a fan of it. With the back up of the King airway.
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#60 chris_rn2006

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Posted 22 October 2008 - 05:16 AM

New poster so please be patient but I do not agree with the 3rd option of awake intubation. I could see something going wrong with that very quickly. Especially since she now opens her eyes to voice and is alert to pain. I just think that it would be to hard to get the airway established with that route. The fact that her sat drops when she is on her back worries me about the RSI also, but the risk of a compromised airway scares me. I have to say though if she increasing with being in the prone position I would transport her that way with the intubation equipment handy just in case. Keeping the Bougie even closer because I am a fan of it. With the back up of the King airway.
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