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


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#81 Will Wingfield

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Posted 26 October 2008 - 02:31 AM

I think the answer Mike's looking for has already been presented quite a bit..... I say "roll her". If a non-depol NMBA had been given I'd also say "reverse her"

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#82 BrianACNP

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Posted 26 October 2008 - 05:17 AM

I really think a right-sided thoracotomy would allow access to the airway structures so that you could manually relieve the obstruction. The only thing killing her is a blocked airway. If I had the capabilities, and in the scenario that McKinnon has presented, I would definitely try to keep her from dying, hopefully as bridge to sternotomy and definitive repair (I'm guessing thymectomy unless you found it to be a tumor), since it's been allowed to progress without treatment to a life-threatening situation.


It's not gonna give you the access into the mediastinal area that you're looking for. Not right away for those who even know are experienced in doing thoracotomies.


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#83 fiznat

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Posted 26 October 2008 - 07:35 PM

Would a very deeply-placed tube help to add more structure and patency to that airway when the mass started pressing down? Even if you are right mainstem, at least there could be something of an airway, and I can't imagine the mass would compress the tube completely.....
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#84 MSDeltaFlt

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Posted 26 October 2008 - 10:53 PM

With anesthesia doing the procedure and all the toys they needed at their disposal (incuding a bronch), I believe they might have tried that. Hence my retort to one of my last posts.
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Mike Hester, RRT/NRP/FP-C
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#85 mjcfrn

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Posted 28 October 2008 - 08:46 PM

Someone mentioned stenting her airway open with CPAP. I was wondering if an LMA might have been a possible bridge. No, it wouldn't have gotten past the obstruction, but it would be a way to provide PPV, stent airway, decrease the work, etc.

I would love to hear from you smart folks as to whether or not it might have been a therapeutic option. Thanks.
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#86 Speed

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Posted 29 October 2008 - 07:45 PM

It's not gonna give you the access into the mediastinal area that you're looking for. Not right away for those who even know are experienced in doing thoracotomies.
Brian


You would have to open the mediastenum pleura rapidly to identify(probably by feel) the thymus and carina(throw the bougie all the way down and feel for it) and manually relieve any stenosis of the airway. I say right because it would give better access to provide a "rescue" in a crash airway situation. If you were going in knowing you were going to remove some of the thymus left would probably be the approach if not sternotomy or complete clam shell. Yes, you'd have to know what you were doing???


and I can't imagine the mass would compress the tube completely.....


More than compressing the tube, I'd foresee some possible "kinking" or resistance (possible perforation) depending on how angulated the airways were from displacement, maybe relieved by a more rigid and well lubed tube, maybe?
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Mike Williams CCEMT-P/FP-C

#87 Mike MacKinnon

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Posted 29 October 2008 - 08:13 PM

heh

lots of good additions.

As for opening, it is likely the patient would be dead by the time you relieved the pressure.

The right mainstem idea makes sense, except that the tumor can actually occlude the ETT itself. In the OR you might considered an Armored tube which cannot be compressed.

Best option for these patients is to always keep them breathing on their own. Anything that takes away their own intrinsic ability to maintain the airway can result i death. Scary buisness.
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Mike MacKinnon MSN CRNA
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#88 Speed

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Posted 30 October 2008 - 04:06 AM

As for opening, it is likely the patient would be dead by the time you relieved the pressure.


True
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#89 JPatterson

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Posted 04 November 2008 - 05:18 PM

what about a bifurcated ETT? I have seen them used in the OR and it allows each lung to be ventilated independently. Definitely not something that we carry or do, but if anesthesia in a large center is doing it, that could help...
I think that I would have trialed NIPPV before intubation.
Thank you for these cases...
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Jeff Patterson NREMT-P

#90 EDMEDIC

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Posted 07 November 2008 - 12:54 AM

again, a great case! I can't wait for the next exciting adventure in medicine....LOL, Brian
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Brian EMT-P/CC
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