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Case #49 When Bad Goes To Worse.


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#1 Mike MacKinnon

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Posted 17 September 2009 - 12:27 AM

Welcome back to the good times of case studies ;)


You are kicked out on a trauma call in a rural area. MVA with 3 passengers in one vehicle caused by blown tire at highway speeds.

The local EMS has already triaged the patients and only has one that meet flying criteria (mine anyway).

You arrive to see a vehicle which has clearly rolled 2-3 times. It is a mess.

The driver is your patient who is a 46 y/o woman found unconscious on the scene, the other 2 patients are children with minor scrapes and bruises.

You find the mom on a backboard clearly in resp. distress. The local crew has been giving her O2 100% NRM and has attempted Nasal intubation X 2 without success. You see some vomit on the ground beside her (no blood).

The information you are given is:

46 y/o female

A&O x 1 (person) she is perseverating and clearly SOB.

Hx: Unknown but children said their mom does not take any regular medications except for blood pressure.

VS: BP: 160/100 HR: 120 Sat: 89%

What do you do?
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

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It's what we know for sure that just ain't so" - Mark Twain

#2 RN_mike

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Posted 17 September 2009 - 01:00 AM

I 'll take a shot at it first..

Sat of 89% and distress needs to be addressed.

What are her lungs sounds?
work of breathing?
chest wall stable?
Obvious penetrating injuries?
JVD?

Based on the mechanism it seems she would have some kind of internal injuries which explains the tachycardia. Once we have treated obvious life threats her airway needs to be secured.

Plan:

Airway needs to be secured RSI with Etomidate and Succ, pretreat with Lidocaine for ICP.

Breathing rate slightly elevated 20-22 per minute.

Circulation: Two large bore IV's.
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Michael L. Howlin RN

#3 AdamMedic11

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Posted 17 September 2009 - 01:19 AM

I'll give it a try.

Initially:

Airway: Vomit, decreased level of consciousness.
Breathing: Increased work of breathing. Low O2 sats.
Circulation: HTN

Plan: Would do a quick once over. Getting a good picture of mental status. Listen to lung sounds make sure they are equal. Feel for any chest injuries. With a decreased level of consciousness and vomiting, she is probably heading towards a ETT. However, I definatly want to makre sure that there isn't something I can do really quick that would improve pt status, i.e. needle chest, blood sugar.

I would set someone to work on an IV, get good access, try to do a BG with that if there was time. I would RSI with Etomidate and Anectine, no Lido. Use Versed and Zemuron to keep her down. Once we get airway established I would do a more focused assessment. See if anything stands out in that.

My concerns would be her tachycardia and HTN. Granted she just got two atemps at nasal-tracheal intubation and may just need time to rest. She's a sick gal and I would definatly be trying to minimize my scene time.

Adam
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#4 Gila

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Posted 17 September 2009 - 01:22 AM

I want to do a rapid exam to identify life threats prior to thinking about RSI. This would also include an airway assessment. (LEMONS exam, etc.) Can we identify a cause of the respiratory distress? Do we need to consider needle decompression? If we intubate and ventilate a pneumothorax could potentially become much worse. In addition, was a BGL obtained?
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#5 JClayborne

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Posted 17 September 2009 - 03:21 AM

I would probably start managing her airway as my partner got started on the rapid trauma assessment and a complete set of vitals. I am all about delegation so lets get the medic(s) on scene to start working on IV access. So we will continue 100% and quickly assess --Is the airway clear, specifically do we need to suction or remove teeth from back there? Do we have bilateral lung sounds and/or JVD? Weve got tachycardia and dyspnea refractory to O2 in our trauma patient so a pneumothorax is an obvious concern. Dart her if indicated and move on. I would prepare for RSI with Succinocholine and Etomidate, if readily available I would use Lidocain as well. Intubate, confirm, reconfirm, secure, and have the EMT on scene take over ventilation asking him to bag only until the chest rises and try to keep that number at ETCO2 35. So if weve intubated we have at least one IV and hopefully more. My partner has done an amazing trauma assessment Im sure. So lets find out the results of that and manage anything critical and see what injuries weve got. She is already secured to a backboard so this is probably I good point to get moving.
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JClayborne, NREMT-P, FP-C

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#6 TexRNmedic

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Posted 17 September 2009 - 05:55 AM

Let the FNG give it a shot. I will pretty much echo what everyone else has said up to this point but want a little more info and want to think a bit about the patho.


1. Type of vehicle? Restrained? How was she extricated? Did the vehicle strike anything on the wipe out? Body habitus? Were the kids appropriately triaged by the ground crew and ok for ground? How exactly is she perseverating (speech, motor activity etc)? How far am I from the Level 1 hospital?

2.Rapid trauma assessment and delegate a few tasks to the ground crew (IVs, BLS airway management, suction, already BB and c-spined).
-Why is she so dyspneic and hypoxemic? Differentials-aspiration, pneumothorax, flail seg, diaphramatic issues, thoracic vascular trauma. Lung sounds? Expose the chest-Stable chest wall? Any bruising, abrasions or seatbelt markings?
-Is her behavior from a neuro insult or hypoxemia? The HTN makes me think neuro but she has a history of HTN. Tachycardia has me concerned but she is hypoxemic and just had a guy trying to shove a 7.5 tube down her nose. On scene my heart rate would probably be about 120 too.

3. Treatment- To start, a good dose of Jet A. She needs a short scene time and a quick flight. Airway is at risk with the emesis and I expect her LOC isn't going to get much better. NRB isn't working either. Let's secure an airway and quickly address any emesis in the airway and/or pneumothorax. Pretreat with lido. Sedation and paralytic of choice. I need my assessment data to decide how I'm going to treat any injuries. The MOI and presentation is making lean towards a TBI. Unless I suspect she has a nasty thoracoabdominal bleed or long bone fractures, I'm going to allow for some significant HTN. Gotta perfuse the grey stuff. Some mild hyperventilation would be indicated. If I think this is an isolated head injury, I'd give a dose of mannitol once in the air, 1 gram per kg. I'd like a look at her 3-lead ecg. Do I see anything weird that would make me think her heart got a good thump too? Based on the title of the study and the patient's presentation, I'm guessing she will decompensate quickly and I'd like to have all my bases covered.

Sounds like she had her bell rung and needs a trip through the CT.
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Wes Seale
Houston , TX

#7 Doc1490

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Posted 17 September 2009 - 06:56 AM

I'll give this one a shot, but this is my first time posting so please be gentle.....

First things first, I want to know about the scene. I'd take a quick peek at the vehicle to look for damage patterns (i.e. starred windshield, any vehicle intrusion, etc.) or find out if she'd been ejected.


Moving along to primary survey....

A: She's obviously going to need an airway, but I'm concerned about increasing her ICP further after an episode of emesis and two attempts at nasal intubation. Despite her sats being low and the low level of consciousness, I'm going to take a few seconds to do a quick airway assessment before going to RSI. First off, I'd throw in an NPA and try assisting ventilations with BVM to see if she can be ventilated easily and if we can get her sats >90%. If she didn't have palpable anatomy for a surgical cric and had any predictors of a difficult intubation, I may delay RSI if it's a short enough flight to the trauma center (<10 minutes). Since I'm sure that's not going to be possible (these scenarios are never that easy), I'll go for RSI with lidocaine, etomidate for induction (maybe some fentanyl too), a defasiculating dose of vec (it's in my protocols, but I know the debate goes either way on this one), sux, and some benzocaine spray. I'd definitely limit my number of attempts to 1, maybe 2 if I was sure I could get it. Definitely be ready to go surgical airway. After a definitive airway is established, I definitely want an NG/OG to decompress the stomach...Don't want more vomiting to spike ICP higher.

B: Auscultate lung sounds, look for assymetric chest movement/flail segments/JVD, etc. High index of suspiscion for a pneumo/hemothorax. Be ready to needle the chest immediately (and possibly place a chest tube, depending on your protocols). Once the airway is established and patient is on the vent, go for high FiO2 and no PEEP. If at all possible, I'd try to limit PIPs to low 20s.

C: Assess for exanguinating external hemorrhage, penetrating trauma to thorax/abdomen, significant orthapedic injuries (especially pelvic fractures)

D: Do a quick nuero prior to RSI. Initial GCS, movement/sensation in extremities, check pupils; watch out for seizures

E: Make her naked, but be sure to keep her warm (expose in the ambulance if feasible). I probably wouldn't roll her to check the back unless ground EMS didn't check or there was some bleeding whose source I couldn't find.

Overal plan: IV X 2 (big), intubate, OG/NG, watch for pnuemo/hemo, keep her warm, throw her on the monitor (12 lead for sure), check BG, minimize stimulation once intubated, keep an eye out for the zebra

Concerns: low LOC, MOI, low Sp02, HTN, Tachycardia
Working DDx:
-TBI
-pulmonary/cardiac contusion
-pneumo/hemothorax
-pre-existing medical condition causing the crash (AMI, seizure d/o, CVA, etc.)

Any thoughts/input would be much appreciated...be gentle.
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Brendan McGurk, BSEMS (on 12/19/09), NREMT-P, CCP

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"You begin saving the world by saving one person at a time; all else is grandiose romanticism or politics. -Charles Bukowski

#8 Canis doo

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Posted 17 September 2009 - 03:00 PM

[quote name='TexRNmedic' date='Sep 17 2009, 12:55 AM' post='19080']
I will pretty much echo what everyone else has said up to this point but want a little more info and want to think a bit about the patho.
1. Type of vehicle? Restrained? How was she extricated? Did the vehicle strike anything on the wipe out? Body habitus? Were the kids appropriately triaged by the ground crew and ok for ground? How exactly is she perseverating (speech, motor activity etc)? How far am I from the Level 1 hospital?

2.Rapid trauma assessment and delegate a few tasks to the ground crew (IVs, BLS airway management, suction, already BB and c-spined).
-Why is she so dyspneic and hypoxemic? Differentials-aspiration, pneumothorax, flail seg, diaphramatic issues, thoracic vascular trauma. Lung sounds? Expose the chest-Stable chest wall? Any bruising, abrasions or seatbelt markings?
-Is her behavior from a neuro insult or hypoxemia? The HTN makes me think neuro but she has a history of HTN. Tachycardia has me concerned but she is hypoxemic and just had a guy trying to shove a 7.5 tube down her nose. On scene my heart rate would probably be about 120 too.
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
ETA to scene time differentials. How long it took us to get there. What is the inital scene size up, what is the tone of the scene. What could have changed from point of injury to our arrival.

Respiratory sufficiency is a must. Are there any obvious JVD, subcutaneous empysema, pneumomediastinum, BVM quality/resistance. Any change in YOUR or PARTNER'S Ventiation, SPO2/tachycardia prior to RSI or during pretreatment. IV or IO as needed if not established PTA
Quick GCS RTS est. GCS<that optimal same for RTS

Intubate
Vec .01mg/kg
Lido 100mg;cricoid pressure
Rapid trauma while pretreatment
Etomidate 3mg/kg
Succ 1.5mg/kg
Then
Ativan 1mg PRN Consider if needed
Zemuron 1mg/kg SAA

Standard post-intubation care.
Head Midline, secured padded
OG Tube 14/16/18fr
IV TKO pressure is good but is she compensating? lets not exacerbate the bleeding, if any.
Ok reevaluate. Has any thing changed??? Look at MOI/NOI PDOF. What are her potential injuries. I've gotten in the habit of a good vehical investigation as we are prepare to head to the ship. PDOF is invaluable.
Children state she takes "blood pressure meds". Beta Blockers? ACEI? ARRBS?Diuretics?α2 adrenergic agonist?
That Tachycardia could be really high given what meds she takes. Therefore impeding compensation.

Thinking TBI, obviously. Cardiac contusion or tamponade? Pelvic FX, pneumo-whatever/hemo-something.Possible trachealbronchial disruption or aortic injury.
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Jason Howard LP, FP-C
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#9 Mattw

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Posted 17 September 2009 - 03:06 PM

So far everyone seems to be on the right track. While looking at the scene I would probably quickly check the car to see if there are any obvious signs of controlled substance use in the vehicle. I am very concerned about airway at this point and would be leaning towards RSI depending on any other life threats that I find during my rapid assessment. Any significant fractures? Femurs and Pelvis intact? I would be working very hard to minimize my time on the ground. My first look is telling me that this lady needs a trauma team and possibly a neurosurgeon.
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#10 JLP

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Posted 17 September 2009 - 06:40 PM

I haven't seen anything about a LEMON score - before I screw around with any sedatives or relaxants I want to be sure that I can intubate once she's down. If she's fully immob'd, turn her to the side, suction out what you can, bag with 2 NPA's to get sats up immed.

Check BGT - preferably delegate that, it's a straightforward skill our BLS land guys can all do.

Check eyes for nystagmus, deviation, evidence of seizing, treat with benzos if present

Auscultate - is a/e present and equal bilat? tension pneumo is very unlikely with the pressure but if there is loss of breath sounds and JVD or tympanic sounds, needle the chest.

What's the flight time? Under 10-15 minutes, we're gone, do it all in the air. Longer, assess for facilitated airway with/without paralytics. That BP suggests good old versed, fentanyl should be fine for sedating and if LEMON is less than 2 from what you can see, SUX. Be prepared for difficult airway, have trachlight, bougie, Airtraq or glidescope out and ready. Have cric site landmark and kit out. After 2 failed nasal ETT attempts the airway is likely a swollen mess.

2 big lines, if no obvious veins go IO, no hesitation. If legs are messed up go for humeral head. All else fails, have someone hold the head, move the collar and go EJ.

46 year old female, I'm guessing 65kg, go with 6.5 mg versed, 65mcg fentanyl, heavy topical lido and 100mg IV lido.

anything on head, neck, chest, abdo, pelvis, legs inspection? If there are focal signs (eye deviation, unequal pupils, etc) AND the BP is still 160 systolic, consider mannitol or 3% saline. DO not use if MAP less than 100-ish, the ICP necessitates a higher MAP to permit a decent CPP.

That BP is high and the pulse is 120, check bilat BP's and check whether all limbs are the same temp, could be aortic injury with compensatory tachycardia. If so I am very reluctant to mess with trachea as the injury is often in the arch sitting over the trachea, do not want to disturb that.

What does ECG show?
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#11 MSDeltaFlt

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Posted 17 September 2009 - 07:03 PM

Welcome back to the good times of case studies ;)
You are kicked out on a trauma call in a rural area. MVA with 3 passengers in one vehicle caused by blown tire at highway speeds.

The local EMS has already triaged the patients and only has one that meet flying criteria (mine anyway).

You arrive to see a vehicle which has clearly rolled 2-3 times. It is a mess.

The driver is your patient who is a 46 y/o woman found unconscious on the scene, the other 2 patients are children with minor scrapes and bruises.

You find the mom on a backboard clearly in resp. distress. The local crew has been giving her O2 100% NRM and has attempted Nasal intubation X 2 without success. You see some vomit on the ground beside her (no blood).

The information you are given is:

46 y/o female

A&O x 1 (person) she is perseverating and clearly SOB.

Hx: Unknown but children said their mom does not take any regular medications except for blood pressure.

VS: BP: 160/100 HR: 120 Sat: 89%


What do you do?


You did not give us a gurgle airway, but you did give us workable VS which makes us stuck on "B" and "D". What is her BGL? Since her SOB is obvious, is the reason why she's SOB also obvious? What are her pupils? Her scalp doesn't crack on palpation, does it? This is a mother in her mid-upper 40's with at least HTN. I'm thinking osteoperosis and possibly hormonal changes going on as well making her sick as well as traumatized. Just my thoughts.
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Mike Hester, RRT/NRP/FP-C
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#12 PhilMoney

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Posted 17 September 2009 - 07:38 PM

Hooray for Case Studies!!!!!

I agree with most of what everyone is saying.

Are we sure that this is our only pt??? "Rural" EMS = good intentions but maybe not the best training. Are these kids hurt? If so, scramble another helo; if not, then kudos to FR.

Was mom restrained? ejected? driving??? Ambulatory prior to arrival of HEMS? Did she crump while FR's were there?

Vehicle intusion, bent steering wheel, airbags, anything remarkable about the car.....Pull out the iPhone and start snapping pics for the recieving MD.


I would ask FR's why the nasal intubation was unsucessful (nicely of course)...was it an anatomy thing, obstruction (vomit?)

Treatment wise I would pretty much do the same as all the other posters but wouldnt rush so quickly to intubate....NPA's and BVM might get the sats up to help a little. Dart her if necessary, chest tube perhaps....needle decomp will probably be the best for now.

Monitor really only needs to go on if I'm giving RSI meds or I have extra time enroute (and i can reach her lower extremities).

Differential.....
Cardiac/ pulmonary contusion...... heart tones?????
Pneumo--maybe not so much with that BP
Tamponode----also not likely with BP (although ICP increase to componsate bleed=HTN)
Aortic dissection/ anuerysm
scrambled eggs (head injury)--- eyes PERL???

Cant wait for more!
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Matt P. B.S., A.S., CCEMT-P, FP-C

#13 TexRNmedic

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Posted 17 September 2009 - 10:03 PM

Hooray for Case Studies!!!!!

I agree with most of what everyone is saying.

Are we sure that this is our only pt??? "Rural" EMS = good intentions but maybe not the best training. Are these kids hurt? If so, scramble another helo; if not, then kudos to FR.

Was mom restrained? ejected? driving??? Ambulatory prior to arrival of HEMS? Did she crump while FR's were there?

Vehicle intusion, bent steering wheel, airbags, anything remarkable about the car.....Pull out the iPhone and start snapping pics for the recieving MD.
I would ask FR's why the nasal intubation was unsucessful (nicely of course)...was it an anatomy thing, obstruction (vomit?)

Treatment wise I would pretty much do the same as all the other posters but wouldnt rush so quickly to intubate....NPA's and BVM might get the sats up to help a little. Dart her if necessary, chest tube perhaps....needle decomp will probably be the best for now.

Monitor really only needs to go on if I'm giving RSI meds or I have extra time enroute (and i can reach her lower extremities).

Differential.....
Cardiac/ pulmonary contusion...... heart tones?????
Pneumo--maybe not so much with that BP
Tamponode----also not likely with BP (although ICP increase to componsate bleed=HTN)
Aortic dissection/ anuerysm
scrambled eggs (head injury)--- eyes PERL???

Cant wait for more!


Matt, I'm going to be a bit of a critical care snob and guess they couldn't get the nasal intubation because the patient is A&Ox1. Awake enough to try to protect her airway. She probably gagged on the tube enough to vomit. I'm sure that helped elevate her BP and I'm sure it didn't do her ICPs any favors either. Which brings up a good question, have the ground-pounders given any meds to aide in the nasal attempts? Wondering if that might be an "out of left field" reason for some of the AMS we are now seeing.

BTW- Going for the difficult airway algorithm and ready to skip over to failed airway algorithm. Preoxygenate with BLS airway management. Have my King LT and surgical airway kit handy. I'd rather drop a King tube on this lady than cut her. However, I'm also worried about laryngospasm with AMS and crud potentially in the airway. I usually prefer just to sedate for intubation but in this case I'd pretreat with IV and topical lido, etomidate 0.3mg/kg, and succinylcholine 2mg/kg. Get ready to suction like crazy and expect some trouble.
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Wes Seale
Houston , TX

#14 mjcfrn

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Posted 17 September 2009 - 10:58 PM

Agree with above. Suggest adding neurogenic pulmonary edema to the list of potential pathophys we're dealing with here.....


and happy to see more case studies! Yay!!
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#15 viking563

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Posted 18 September 2009 - 12:08 AM

Id like to do quick head-to-toe, especially lung sounds, any paradoxical chest movement?, respirations regular or irregular?;
A: Start bagging, with 2 NPAs, don't want to sound like I'm rushing to RSI, but would have to do it prior to leaving because we can't pull over to do it later if needed. etomidate 0.3mg/kg, 1.5 mg/kg lido pretreatment, succinylcholine 1.5 mg/kg; no more than 2 attempts then going to combitube as backup and surgical cric as last resort. confirm with ETCO2, and other method(LS,EDD), after placement, 2-5 mg versed, 1 mg/kg of roc.
B: Needle decompression if signs of tension pneumo, stabilize flail chest if needed.
C: EKG, Two large IVs, TKO for now, bolus as needed. Chem BG off IV start. Can have ground crews start if available to assist.

As short as possible for my scene time

Possible:
TBI(my guess would be epidural, but I'll let the ct scan tell me), Pulmonary contusion, tension Pneumothorax, flail chest
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Matt, NREMT-P

#16 Mike MacKinnon

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Posted 19 September 2009 - 03:27 AM

Sorry for the delay, it has been a busy week!

Lung sounds are severe wheezing (very little air movement)
Chest wall stable
BS: 175
No obvious trauma
Visual airway clear

Vehicle was a Lexus SUV
All restrained
All self extricated
She was repeating the same thing over and over again "Kids OK?" and "hard to breathe". Now she is hardly moving any air.
No noted particulars about the vehicle.
Scene calm and collected.

No 'obvious' signs of substance abuse.

LVL 1 trauma 45 min by air.

3 lead normal (but generally useless anyway)

BVM does not seem to help, you cannot get air in.

Saw these doses and wondering where they came from?

I'm guessing 65kg, go with 6.5 mg versed, 65mcg fentanyl, heavy topical lido and 100mg IV lido.


Why so much versed and so little fent. Also, what is the topical lido for and why the IV lido?


Ok so would you use Suxx on this patient? Why, why not?

How many would attempt to intubate without paralytic, why or why not?

In the mean time, her sat is 75%.
Her BP is now 75/50
HR now 140
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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

#17 TexRNmedic

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Posted 19 September 2009 - 04:16 AM

Sorry for the delay, it has been a busy week!

Lung sounds are severe wheezing (very little air movement)
Chest wall stable
BS: 175
No obvious trauma
Visual airway clear

Vehicle was a Lexus SUV
All restrained
All self extricated
She was repeating the same thing over and over again "Kids OK?" and "hard to breathe". Now she is hardly moving any air.
No noted particulars about the vehicle.
Scene calm and collected.

No 'obvious' signs of substance abuse.

LVL 1 trauma 45 min by air.

3 lead normal (but generally useless anyway)

BVM does not seem to help, you cannot get air in.

Saw these doses and wondering where they came from?
Why so much versed and so little fent. Also, what is the topical lido for and why the IV lido?
Ok so would you use Suxx on this patient? Why, why not?

How many would attempt to intubate without paralytic, why or why not?

In the mean time, her sat is 75%.
Her BP is now 75/50
HR now 140


So the assessment is basically negative for trauma and neuro is grossly intact (pupils, motor function and sensation)?
Looks like we are getting clued in on a case of reactive airway with some narrowing pulse pressures. Dang medical problems sneaking in on my trauma patient. Gonna entrain some nebs (xopenex 1.25mg sounds good and may need to repeat). A little squirt of solu-medrol 125mg isn't contraindicated in trauma. If she doen't look like a tamponade too I'd consider some epi 0.1 mg SIVP and may repeat it if it worked to open her up. I might cautiously give a little fluid bolus to see if it helps with the asthma and BP. If I can't find anything else going on with her, I'd like to see if I can treat the bronchoconstriction before tubing her. If I have ketamine available for intubation I'd use as it will help open her up (2mg/kg). I really want to evaluate her airway before knocking her down. If I see a laryngospasm in the future I'd paralyze her. I'm guessing she will be easy to tube but a bear to ventilate. If it really does look like a tamponade (narrowing pressures, jvd, low gain ecg etc), the long flight is going to require me to fix it now and she is going to get stuck in the chest. Same thing with the airway, long flight ahead. Need to do what I can to get things under control and get ourselves on the road, err over the road. I'm looking for quick interventions that the ground crew can help with and then scoot are way to the hospital.

With all that said, if TBI is still in the picture, I can't forget to manage that as well. If my assessment shows an abnormal neuro exam (other than the sequlae from the hypoxemia) I'd get her intubated as stated above and in my first post. I'll think about giving the mannitol once the airway opens up a bit and the BP recovers. Not perfusing the brain much at 75/50 especially with a head injury.

Looking forward to reading everyone else's take. Thanks for letting me join in and exercise a few neurons!
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Wes Seale
Houston , TX

#18 Doc1490

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Posted 19 September 2009 - 08:59 AM

The picture definitely just got more interesting/crappy....The fun question is which came first, the hypoxia or the AMS? At the moment, however, a few immediate questions before addressing the immediate life threats (hypoxia/airway&breathing/hypotension)...

1) Any abnormal neuro findings beyond perseverating/A&Ox1? Pupils? Grip strengths/movement of extremities?
2) Any JVD? How about chest excursion? Stable chest wall, but is movement equal bilaterally? Looking for any sign of a tension pneumo or tamponade.
3) Heart tones (if feasible, depending on noise level at scene)?
4) How does she look for intubation purposes (i.e. short/thick neck? small mouth?)?
5) Any sign of anaphylaxis? Angioedema? Uticaria? How's her pallor?
6) Any dialysis shunt/fistula? Maybe the "blood pressure pill" is the tip of her medical history iceberg. Renal failure would be the only reason (besides a crappy airway assessment) that would keep me from using sux.

My immediate plan of action would be to needle the chest (bilaterally or whichever side has markedly decreased breath sounds) unless there are any obvious signs of anaphylaxis. Worst case scenario, we'll be unnecessarily doing a needle thoracostomy and she'll be getting bilateral chest tubes. That being said, a patient presenting with severe respiratory distress, tachycardia, hypotension, inability to ventilate, and narrowing pulse pressures after a significant trauma sure sounds like a tension pneumo.

If I didn't see immediate improvement with the decompression (or signs of a pericardial tamponade), I'd start moving down the anaphylactic reaction/reactive airway disease differential. Starting with some IV benadryl (50mg; can't really hurt may help with sedation), I'd start fluids wide open through both (hopefully 14G) PIVs or IOs. I'd also go with some Epi in this case (feel free to crucify me, I'm going out on a limb). If the decompression didn't help, I'm thinking anaphylaxis or reactive airway disease is probably the biggest life threat. Either way the Epi would help (I'd go with 0.3mg of 1:10,000 IV/IO or 0.3mg of 1:1,000 IM/SQ depending on protocol). Some solumedrol might be nice. I'd also start a nebulizer of Xopenex (if available) or Albuterol while preparing for intubation.

Regarding intubation, I'm still deeply concerned about some sort of TBI. Accordingly, I don't want to spend much time on the intubation and I don't want the patient to fight the tube. Unless there's some sort of nasty airway predictor (thick/short neck, etc.), I'd undoubtedly go for paralytics. Again, I'd stick with Etomidate, Lidocaine, defasiculating dose of Vecuronium, some Fentanyl, and Sux.

Once I had the patient tubed, I'd LOVE to get her on waveform capnography so I could look for the sharkfin waveform (bronchospasm). As far as vent settings, I'd go for 100% FiO2, no PEEP, I-time of something like .8 seconds (less if bronchospasm became part of the working diagnosis). If the patient's sats didn't start to improve, I'd add PEEP and allow higher PIPs to ensure adequate ventilation. Beyond that, I'd definitely shoot a 12 lead and beat feat to the trauma center. If the patient remained hypotensinve (I'm hoping/assuming we corrected the hypoxia/difficult ventilations with intubation) after some volume and the epi/benadryl/etc., I'd hang either dopamine or dobutamine (prefer dobutamine based on the HR, but I could be wrong on this one).

I'm sure there are a host of presentations that I'm missing that could be causing the wheezing, difficult ventilations, and hypotension, so please feel free to point out the error of my ways.



.....Just a closing thought....Did the ground crew use Latex gloves/equipment?
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Brendan McGurk, BSEMS (on 12/19/09), NREMT-P, CCP

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#19 cardiomedic

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Posted 19 September 2009 - 09:48 AM

I think she rolled her vehicle over because she was drinking a beer, not because she was intoxicated, but because she swallowed a bee nesting in the heavenly pure taste that can only be appreciated by drinking PBR through a straw! Anaphylaxis is her problem...

By the way, seriously, I have two questions.

1) Why all the pretreat with Lido. Studies have proven that Etomidate blunts the ICP increases from laryngoscopy and Succinylcholine. Why still Lido???

2) Have you ever been in a car wreck, with multi-trauma? Have you ever been intubated?? It hurts and not one post-intubation intervention listed above includes fentanyl. Small pet peave of mine...some opiates have anxiolytic properties, however, giving them a hypnotic alone, without analgesia, only makes them forget how much it hurt, and doesn't take care of their PAIN!!! My two cents and pet peave. Remember...When the need to forget, Remember Versed. When they need to be sedate, Remember Fentanyl. I like Ativan better, because it seems to last longer and has less vasoactive effects.

Thanks for returning Mike and hope life is treating you all well...FLY SAFE!
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#20 LearRRT-CCEMTP

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Posted 19 September 2009 - 04:13 PM

Once I had the patient tubed, I'd LOVE to get her on waveform capnography so I could look for the sharkfin waveform (bronchospasm). As far as vent settings, I'd go for 100% FiO2, no PEEP, I-time of something like .8 seconds (less if bronchospasm became part of the working diagnosis). If the patient's sats didn't start to improve, I'd add PEEP and allow higher PIPs to ensure adequate ventilation. Beyond that, I'd definitely shoot a 12 lead and beat feat to the trauma center. If the patient remained hypotensinve (I'm hoping/assuming we corrected the hypoxia/difficult ventilations with intubation) after some volume and the epi/benadryl/etc., I'd hang either dopamine or dobutamine (prefer dobutamine based on the HR, but I could be wrong on this one).



I'd like to address the above vent management with a teaching point. Where did you come up with a Ti of 0.8 because there is no mention of Rate, VT, RCT, I:E Ratio, or FR? The focus needs to be on I:E ratio not Ti. I realize that Ti is a component of I:E ratio but when you pull settings out of thin air it's not a great situation for the patient. Cowboying vent settings may work 80% of the time but what about the other 20% and maybe this is one of them. When clinicians pull settings out of the air patients have issues, they may not be apparent until hours later in the ICU but they happen. Rate, VT, RCT, I:E Ratio and Flowrate are all mathematically connected! We all should be doing the math to properly manage a ventilator. In this case a proper I:E ratio is important to prevent air trapping but a unnecessarily shortened I:E ratio can also be an issue. As you reduce the I:E Ratio, the Ti is also shortened, this increases the flowrate thus increasing the turbulence in the airways. RAD benefits from smooth laminar flow. In this situation, I would have hopefully had a vent with graphics and would have optimized the I:E Ratio by looking at the flow waveform or the flow-volume loop. If I did not have graphics, then I would have done an expiratory hold maneuver and measured my total PEEP for air trapping and would have optimized my I:E based on that. Expiratory hold maneuvers can be performed on most any vent either via an exp hold control or by manually performing it.

As for the PEEP, I realize your concern was with increased intrathoracic pressure and a cardiac injury but 5 cmH20 is only replacing the physiologic PEEP. Any negative effects (rare) of 5 cmH20 PEEP would also have been counteracted by the reduced Mean Paw from the prolonged I:E Ratio. Besides, if this is RAD without cardiac injury then you may be significantly increasing the PEEP to equal air trapping to evacuate CO2.

F = Frequency
VT = Tidal Volume 8 - 12 ml/kg (ARDS Network 5 - 7 ml/kg)
RCT = Respiratory Cycle Time 60 Seconds / F = RCT
I:E Ratio = Based on pathophysiology 1:2 Normal
Ti = Inspiratory Time RCT / (Sum of I:E ratio) = Ti (seconds)
FR = Flow Rate VT (L) / Ti (Sec) = FR (L/Sec) X 60 seconds = FR (Lpm)


Example: F = 14, VT = 500 ml, Desired I:E ratio 1:3

F = 14 bpm

VT = 500 ml or 0.5 L

RCT = 4.28 seconds RCT = 60 sec / F 60 / 14 = 4.28 seconds

I:E Ratio = 1:3

Ti = 1.07 seconds Ti= RCT / (Sum of I:E Ratio) 4.28 / (1+3) = 1.07 seconds

FR = VT (L) / Ti (sec) = FR (L/Sec) X 60 = FR (Lpm) 0.5 L / 1.07 sec = 0.47 L/sec X 60 sec = 28 Lpm


This may look complicated but anyone who has taken my workshop can tell you after a couple days practice, you can run through these in about 30 seconds. That's 30 seconds to ensure proper parameters and a reduction in ventilator complications!
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