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Case #49 When Bad Goes To Worse.


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#21 JLP

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Posted 19 September 2009 - 05:17 PM

Great to get the feedback from the boys'n'girls with the years on.

This sounds like it might be bronchospasm secondary to airbag deployment (forgot about that, treated a status asthma from a minor MVC a few years ago). Start piling salbutamol (sorry, Canuck-ism, that's albuterol for you in the US), get a BLS person to load up 0.3 epi for SC admin if you need it.

Given current status, no choice but to intubate. Percuss chest, look for JVD, to rule out tamponade and bilateral pneumo. Honestly, with a sinking BP and no air movement I'll just needle both sides of the chest, if I'm wrong it creates a minor pneumo, not my biggest worry.

For tubing, fentanyl and versed are out due to BP (by our directives. Personally I have never seen fentanyl knock BP down much, but I don't set the rules where I work). Etomidate is a possibility but only if you have a good LEMON score b/c I'm not using etomidate if I wouldn't want to follow with SUX if the patient gets severe masseter spasm. If the patient is sinking fast, can open up enough and I'm confident I can tube quickly, I will intubate after liberal topical lido alone in a pinch if there is no result from chest needles and albuterol. An evil thing to do to someone but it beats respiratory failure and cardio collapse.

Follow-up, definitely pain control after ett - my throat hurt after waking up from an elective ETT several years ago, I can only imagine how much it hurts to be awake after we bashed the cords doing an emergent ETT. Fentanyl is my choice for that, sedation with versed if BP permits. Post-ETT paralytic only if the patient is really hard to manage AND we absolutely, positively have to keep patient down, such as a tough vent (ideally more sedation, more pain control, less muscle relaxant).

Drop a whack of albuterol down ett.

Open up the fluid bolus if she doesn't immediately get a rise in BP from chest needles (if the pneumo signs were there). Even if she has a TBI, hypotension will make her brain a whole lot more damaged than extra fluid will, b/c with an increasing ICP from TBI she will need a good MAP to have any cerebral flow at all.

As for venting:

If she turns out to be pneumothorax which resolves with thoracentesis, vent conservatively, say PC 15-20/5, SIMV to let her breathe rather than have all breathes being positive pressure, aim for a volume of 4-6/kg as long as you keep sats as high as pos, pref >95%, rate 16-20, start at a normal I:E but be prepared to reduce the pressure and go with a longer I time to enhance oxygenation. If it looks more like bronchospasm, shorten the I time, keep the volumes about the same, PC 20/3-5 but be willing to go up on the pressure, give here a nice long E time to reduce air trapping as long as sats stay good. If it is bronchospasm, be ready to decompress as anyone with status bronchospasm is a high risk of blowing pneumos when on PPV.

What does the ECG look like? Wide QRS? PVC? arrhythmia?
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#22 Flightgypsy

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Posted 20 September 2009 - 12:01 AM

There are the hooves......

Pretty difficult situation. Lot of possibilities. I'm wondering if she aspirated a large chunk of something when she vomited while she was unconscious. Her visual airway may be clear but it may be lodged further down. Otherwise I am thinking pretty much along the lines of everyone else's differentials. The low BP does tie in more with anaphylaxis although from what, I am not sure. Maybe something to do with the airbag deployment? The low BP may be just before she codes from hypoxia though. She doesn't have any history of asthma so I don't think it is that.
The thought of neurogenic pulmonary edema is a good one as she obviously has a head injury but she doesn't sound like her lungs are wet so much as obstructed.

I think I would be reluctant to use a paralytic unless I had to because it may cause complete airway collapse and obstruction. Unfortunately her BP doesn't lend itself to too much sedation either. I would open up her fluids while getting airway equipment set up. If her BP isn't responding to that I would give a dose of epinephrine (could be life-saving to give if she is having an anaphylactic reaction) and once I had her BP up you could give sedation for the airway. As for the airway that is a little tricky. I would want to do direct laryngoscopy and see if I could see any obstruction or swelling but she would definitely need something for the gag reflex. Don't need her vomiting anymore. If you have lido spray I would use that. I think that we don't really have much time before she goes unresponsive though. My plan would definitely be to be prepared for a cric and go for it sooner rather than later especially if I did use a paralytic. If you do see something in her airway remove it with the Magills or it might come out when we start CPR like we will be any moment! ;)

Once we have an airway secured then I would reassess her chest. She has no obvious signs of trauma to her chest and initially had wheezing which leads me away from a tension pneumo. Just to check though, did she have any JVD, tracheal shift or unequal chest rise? If her initial assessment had led me to think pneumo then I would have darted her before messing with her airway.

Definitely get the airway secured before we transport her but once we have an airway I would be moving quickly. I will worry about the vent settings once I get her intubated and have a better idea of what we are dealing with. If it is anaphylaxis hopefully the dose of epi helped. I would probably give her a dose of Benadryl if her BP was improved. If the fluids don't really help her BP and she starts getting worse with her lungs then I would back off on the fluids. As long as we have a reasonable BP after her airway is secure then I would give her at least some Fentanyl and add Versed when she has a better BP.

Just my musings on the matter.
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#23 Canis doo

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Posted 20 September 2009 - 04:03 AM

Summary,
46yof presented rollover MVA Driver stated she was wearing her seatbelt. Can you confirm that? Do you see seat belt abrasions, ecchymosis?
Alert on scene now unconsious. Epidural ????
A&O x 1 (person) she is perseverating and clearly SOB. Now she is wheezing? Pulmonary contusions. Reaction to the powder from airbag?

Since she was the driver wearing seatbelt. what injuries could she have?
Wheezing, Hard/can't to ventilate persistant low SPO2. I'm thinking Laryngeal trauma. So should I use SUX's?? Hmmm. Up to this point sounds like she is way past RSI. CRASH/DIFFICULT airway.
Due to the Laryngeal trauma Needle Cricothyrotomy or Tracheostomy. Then give her the best Go-Fast-Juice you can. Divert to the closest facility of performing Tracheostomy, unless you are authorized to perform.
So we Have successfully placed a tracheostomy tube. Lets get started on that BP. If you are getting ventilations and Spo2 is better what are her lungs sounds now. Did she break a clavical, giving her a pneumothorax which has tensioned.



Oh as for PAIN meds post-trauma and intubation. IS A MUST. GIVEN SAID HEMODYNAMIC PARAMETERS. I forgot to post that earlier

SCRUB ABOVE___________________________________________________________________________
________________________________

.....Just a closing thought....Did the ground crew use Latex gloves/equipment? HMMMM. Brendan nailed it!!!! Gotta hate those unknown latex allergies

BVM inline 1-2mg EPI. If not able then CPAP(low) or NEB with inline Epi.
IV fluids WO on pressure bags. IV EPI 0.3mg-0.5mg
Benadryl 50mg
Cimetidine 300mg
Methylpredinisone 250mg
Phenergan 6.25mg-12.5 PRN

Neo-synephrine, Levophed, or EPI infusion if needed
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Jason Howard LP, FP-C
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#24 MSDeltaFlt

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Posted 20 September 2009 - 04:03 PM

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


One of the side effects of succinylcholine is anaphylaxis. Her lungs have already shut down. You can't bag her and her sats are dropping. Her MAP is 67 and since her BP is dropping, so is her MAP. We don't want it getting much lower than 60. Need to keep perfusing the brain. So, for these reasons I would not want to use Suxx, sedation, or analgesia on this woman. I'd consider crash tubing her with some Rocc, if I had it, or some Vecc. Regardless of which I'd use my most experienced airway person and have my back ups already set up and in quick arm's reach. Because if she crashes, she'll crash hard and quick. She'll drop like rock.
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Mike Hester, RRT/NRP/FP-C
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#25 MSDeltaFlt

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Posted 20 September 2009 - 04:09 PM

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!


Actually it ranges from 20-45 secs, but who's counting?

These setting are for volume cycled ventilation. As tight as she is, Dave, what would you say about going with pressure ventilation and maintaining PEEP for inline nebs?
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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 TexRNmedic

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Posted 20 September 2009 - 06:12 PM

David, I love talking about vent settings. I'm glad you mentioned the impact of inappropriate setting on the patientís long term outcome in the ICU later. These patients require careful management or are at great risk for ALI and a near impossible wean. I've seen way to many folks "power bagged" into the hospital and put on the "standard" settings (something like AC R 14, TV 600, PEEP 5, fiO2 100%) even if it is only for the first couple of hours. We wonder why they end up with barotrauma, horrible looking chest x-rays and end up buying a trip to the OR for a trach.

My opinion for setting up this gal and managing her would be AC-PRVC R12, TV 6ml/kg, peep 5, p limit 20 with fiO2100%, IE 1:3. I don't want this gal to have any work of breathing, so I'm not a big fan of SIMV in this situation. The calmer she is and the less work of breathing the less oxygen she is consuming. Means less O2 I need to get into her right now. She needs nice smooth inspiratory flow (get the o2 in) and plenty of time to exhale (co2 out). Hence the flow modulation in PRVC and 1:3 ratio. Need to be very careful what kind of pressure I'm giving or we will cause some iatrogenic trauma (I'm not a big fan of giving someone a pair of chest tubes and a few extra days lingering in the ICU because of poor management early on, just not acceptable patient care at this level). We already know she is headed towards respiratory acidosis with a nice and high co2 level and hypoxemic. What is going to kill her first? The low O2. She isnít too far away from coding as it is. Slow down the rate and give some time for the air to get where it needs to be and keep the volumes under control to keep from pounding her airway with a high flow and pressures. I want to watch O2 sats, ETCO2, PIP and Pplat. Hopefully my vent and monitor have waveform graphics on them. I want to watch them to make sure a full breath is getting in and I'm getting a good exhalation without causing any barotrauma (keeping Pplat <30). If my RAD interventions work and she opens up a bit I'll add a little more TV and bump the rate up a bit to help blow off some CO2 and correct the acidosis. I'll bump up the peep 2cm at a time to overcome trapped air. Obviously a lot of this depends on how she responds to the initial and subsequent settings. My goal is to get her on the best settings to start with and then know how to change as the patientís condition develops. For ongoing sedation fentanyl (25-50mcg IVP) and versed (1-2mg IVP). I prefer to start with small doses and work my way up. It is hard to take back what youíve given and you can always give a little more. I may paralyze with roc if she starts consuming too much o2 when induction meds wear off.

As far as induction goes, we all pretty much agree the etomidate is the drug of choice. I like ketamine in RAD for its known benefits, and often able to intubate without paralytics. I might try it before intubation with etomidate, sux and lido (if it looks like her condition will allow) to help her relax, comply with BVM ventilations and give time for the meds to work. Might be able to prevent an intubation to begin with. She is tight, but might not be beyond the point of no return. I would give succinylcholine, as she is a traumatized patient who has already vomited once, at risk for doing it again, as well as having laryngospasm and I want her to be still and comply with the invasive ventilations. Tubing her is of no benefit if I canít ventilate. Other than benadryl, I've already pretreated for any potential of anaphylaxis. It is going to take a few minutes for her to respond to everything Iíve done and we still need to get her loaded. By the way, I'm guessing her BP looks that way because she has trapped all the air in her chest she can and intrathoracic pressures are all jacked up. Correct this and Iím guessing her BP and HR might just come back a little closer to normal.

As far as lidocaine goes, everywhere Iíve worked has it in the protocols. I asked one of the docs in the neurosurg ICU and they said there is more evidence for its use than against it. They said they would rather have both lido and etomidate mitigating ICP spikes than only one. I tend to agree.

Enough of me running on and on. Humbly submitted to those with more years in a helicopter than I have as a nurse.
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Wes Seale
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#27 Gila

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Posted 20 September 2009 - 10:29 PM

I dunno, we have yet to establish an airway. I am also curious about an air bag related injury. However, nothing was said about airway swelling, angioedema, or stridor. If this is the case, placing an airway may be exceeding difficult. Additionally, if we are going to use lido for premedication, do we really have a patient who is going to tolerate a several minute wait? We are not exactly doing well with positive pressure mask ventilation. We may even be sliding down into a crash airway if in fact she does not have something we can rapidly correct. Failed airway is a real scenario, and we have yet to even give our induction agent and paralytic.
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Christopher Bare
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#28 sflower

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Posted 20 September 2009 - 11:00 PM

To add to Gila's comments. As was stated by Mike earlier, BVM is not effective and you can't get air in. That's not indicative of asthma. So, is there angioedema? Stridor? Uritcaria? Could her "blood pressure med" be Lisinopril? Could she be finally having a rx to it? Again, angioedema? Her airway issues could be related to the airbag with the powder that is expelled when the airbag deploys. Although there were nasal attempts X2 without success, and given the fact she is now 75% SpO2 and unable to ventialte with a BVM, you are now in a failed airway scenario. You have past the difficult and crash airway. You have a very narrow window to establish an airway. You could induce her and attempt oral, or drop a King, etc., but given that she is becoming profoundly hypotensive and hypoxic, and you can't ventilate with a BVM, sounds like a scalpel is indicated.
Giving Benadryl is questionable at best given the current situation. It's ABC's, and B doesn't stand for Benadryl. Solu-Medrol as previously posted is useless right now. You're looking at 4-6 hours for effects to begin, she has bigger iissues presently. She is hypotensive and Benadryl has a side effect of hypotension. Epi? Sure, 0.3 sq can't really hurt and at the rate she is decompensating, she's going to be getting alot more Epi than 0.3 sq.
Bilateral chest darts without a secured airway is a bad idea. Single sided is one thing, but you can make her airway issues much worse by darting both sides without an ETT or other airway. Chest decompression is indicated in a tension pneumothorax, although she is hypotensive, tachycardic and hypoxic, from the given scenario and lack of chest wall trauma, a true tension pneumo doesn't seem logical. However, I've been wrong before. Priority #1 right now is securing her airway and getting some fluids on board. As far as dealing with her tight lungs or possible allergic/ana rx's, that can be dealt with later. In line nebs, IV Benadryl once her BP improves a little, etc. A bolus of Jet A will help as well.
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Scott Flower
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#29 LearRRT-CCEMTP

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Posted 21 September 2009 - 01:45 AM

Actually it ranges from 20-45 secs, but who's counting?

These setting are for volume cycled ventilation. As tight as she is, Dave, what would you say about going with pressure ventilation and maintaining PEEP for inline nebs?




Mike,
If I was venting her and I had a decent transport vent like a LTV or iVent then I would be utilizing PCV. I would use PCV not PC-SIMV as someone mentioned. I personally do not believe in SIMV pressure or volume in adults. If they need a rate then ACV, PCV, or PRVC if they can breath spontaneously then PSV. But that comes from training with Neil MacIntyre at Duke. But even with PCV these formulas are appropriate. They would just eliminate the flow calculations and set Vt but everything else (F, RCT, I:E, Ti) are the same. However I have found many transport clinicians tend to shy away from PCV for some reason.
Take Care,
Dave
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David W. Garrard, BHS, RRT, RCP, CCEMTP, PNCCT, CFC
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#30 LearRRT-CCEMTP

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Posted 21 September 2009 - 01:54 AM

David, I love talking about vent settings. I'm glad you mentioned the impact of inappropriate setting on the patientís long term outcome in the ICU later. These patients require careful management or are at great risk for ALI and a near impossible wean. I've seen way to many folks "power bagged" into the hospital and put on the "standard" settings (something like AC R 14, TV 600, PEEP 5, fiO2 100%) even if it is only for the first couple of hours. We wonder why they end up with barotrauma, horrible looking chest x-rays and end up buying a trip to the OR for a trach.

My opinion for setting up this gal and managing her would be AC-PRVC R12, TV 6ml/kg, peep 5, p limit 20 with fiO2100%, IE 1:3. I don't want this gal to have any work of breathing, so I'm not a big fan of SIMV in this situation. The calmer she is and the less work of breathing the less oxygen she is consuming. Means less O2 I need to get into her right now. She needs nice smooth inspiratory flow (get the o2 in) and plenty of time to exhale (co2 out). Hence the flow modulation in PRVC and 1:3 ratio. Need to be very careful what kind of pressure I'm giving or we will cause some iatrogenic trauma (I'm not a big fan of giving someone a pair of chest tubes and a few extra days lingering in the ICU because of poor management early on, just not acceptable patient care at this level). We already know she is headed towards respiratory acidosis with a nice and high co2 level and hypoxemic. What is going to kill her first? The low O2. She isnít too far away from coding as it is. Slow down the rate and give some time for the air to get where it needs to be and keep the volumes under control to keep from pounding her airway with a high flow and pressures. I want to watch O2 sats, ETCO2, PIP and Pplat. Hopefully my vent and monitor have waveform graphics on them. I want to watch them to make sure a full breath is getting in and I'm getting a good exhalation without causing any barotrauma (keeping Pplat <30). If my RAD interventions work and she opens up a bit I'll add a little more TV and bump the rate up a bit to help blow off some CO2 and correct the acidosis. I'll bump up the peep 2cm at a time to overcome trapped air. Obviously a lot of this depends on how she responds to the initial and subsequent settings. My goal is to get her on the best settings to start with and then know how to change as the patientís condition develops. For ongoing sedation fentanyl (25-50mcg IVP) and versed (1-2mg IVP). I prefer to start with small doses and work my way up. It is hard to take back what youíve given and you can always give a little more. I may paralyze with roc if she starts consuming too much o2 when induction meds wear off.

As far as induction goes, we all pretty much agree the etomidate is the drug of choice. I like ketamine in RAD for its known benefits, and often able to intubate without paralytics. I might try it before intubation with etomidate, sux and lido (if it looks like her condition will allow) to help her relax, comply with BVM ventilations and give time for the meds to work. Might be able to prevent an intubation to begin with. She is tight, but might not be beyond the point of no return. I would give succinylcholine, as she is a traumatized patient who has already vomited once, at risk for doing it again, as well as having laryngospasm and I want her to be still and comply with the invasive ventilations. Tubing her is of no benefit if I canít ventilate. Other than benadryl, I've already pretreated for any potential of anaphylaxis. It is going to take a few minutes for her to respond to everything Iíve done and we still need to get her loaded. By the way, I'm guessing her BP looks that way because she has trapped all the air in her chest she can and intrathoracic pressures are all jacked up. Correct this and Iím guessing her BP and HR might just come back a little closer to normal.

As far as lidocaine goes, everywhere Iíve worked has it in the protocols. I asked one of the docs in the neurosurg ICU and they said there is more evidence for its use than against it. They said they would rather have both lido and etomidate mitigating ICP spikes than only one. I tend to agree.

Enough of me running on and on. Humbly submitted to those with more years in a helicopter than I have as a nurse.




Tex,
Very reasonable vent management. In these situations I have actually RSI'ed the patient then allowed them to come up out of the paralysis so that they had some spontaneous effort then put them on pure high level pressure support. The pure pressure support allowed them to regulate their own I:E ratio since they are not going to take another breath until they have exhaled to their comfort zone. With high level PS (20 - 30 - even done 40 before) their is no WOB, actually the patient is breathing more physiologically and their comfort level is higher. With them setting their own I:E they clear their CO2 quicker and normalize their pH. I have had many patients like this do beautiful with this line of treatment. However if they do need a rate then PCV is an outstanding way to go! I am waiting for the day we get PRVC on transport vents! I love that mode! The VersaMed iVent 201 from GE has what I call a "poor man's" PRVC with it's adaptive Flow in AC-volume mode. Hopefully Pulmonectics will one day offer PRVC on it's next line of vents.
Take Care,
Dave
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David W. Garrard, BHS, RRT, RCP, CCEMTP, PNCCT, CFC
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#31 LearRRT-CCEMTP

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Posted 21 September 2009 - 02:08 AM

Sounds like a possible myocardial contusion with associated congested heart failure. With such decreased lung sounds it's possible all you would be hearing is wheezes. Interesting case, can't wait to hear more about it!
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David W. Garrard, BHS, RRT, RCP, CCEMTP, PNCCT, CFC
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#32 MSDeltaFlt

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Posted 21 September 2009 - 04:24 AM

Mike,
If I was venting her and I had a decent transport vent like a LTV or iVent then I would be utilizing PCV. I would use PCV not PC-SIMV as someone mentioned. I personally do not believe in SIMV pressure or volume in adults. If they need a rate then ACV, PCV, or PRVC if they can breath spontaneously then PSV. But that comes from training with Neil MacIntyre at Duke. But even with PCV these formulas are appropriate. They would just eliminate the flow calculations and set Vt but everything else (F, RCT, I:E, Ti) are the same. However I have found many transport clinicians tend to shy away from PCV for some reason.
Take Care,
Dave


Yeah, mine doesn't have P-A/C mode. I wish it did, but growing up in the MA-1 days one learns to make due. I would also use PSV if they breathed spontaneously enough. All in all, though, I like pressure modes best when PIP's are an issue. That and multiple inline nebs titrated to Vte and HR.

The reason, I believe, most transport clinicians tend to shy away from PCV is because of their focus. Most have been trained and trained and trained again on airway and circulation. Just look at all of the intubation and cardiovascular threads on this website alone among others. But not so much on breathing and disability.

Which is why I think this case is going to be awesome. Her pulmonary status is going to play a big part in this case and I think it's going to make all of us, especially me, really have to think. As in your thoughts on myocardial contusion and CHF manisfesting with "cardiac asthma". Trauma induced cardiogenic shock is a possibility here. So far it fits. I'm digging this case. Can't wait to see what happens.
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain

#33 Mike MacKinnon

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Posted 21 September 2009 - 11:13 PM

[quote]1) Any abnormal neuro findings beyond perseverating/A&Ox1? Pupils? Grip strengths/movement of extremities?[/quote]

None.

[quote]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.[/quote]

No JVD, bilat lung sounds,

[quote]3) Heart tones (if feasible, depending on noise level at scene)?[/quote]

Noisey Wheezing, barely moving air


[quote]4) How does she look for intubation purposes (i.e. short/thick neck? small mouth?)?[/quote]

Looks like a good airway

[quote]5) Any sign of anaphylaxis? Angioedema? Uticaria? How's her pallor?[/quote]

Nope, pallor pale now.

[quote]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.[/quote]

Nope

[quote]My immediate plan of action would be to needle the chest (bilaterally or whichever side has markedly decreased breath sounds)[/quote]

Both sides markedly decreased.

So still wanna needle?

Any special intubating choices?

You have intubated. You go to bag and get ALOT of resistance
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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

#34 Mike MacKinnon

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Posted 21 September 2009 - 11:15 PM

No angioedema
No stridor, just wheezing and little air movement



To add to Gila's comments. As was stated by Mike earlier, BVM is not effective and you can't get air in. That's not indicative of asthma. So, is there angioedema? Stridor? Uritcaria? Could her "blood pressure med" be Lisinopril? Could she be finally having a rx to it? Again, angioedema? Her airway issues could be related to the airbag with the powder that is expelled when the airbag deploys. Although there were nasal attempts X2 without success, and given the fact she is now 75% SpO2 and unable to ventialte with a BVM, you are now in a failed airway scenario. You have past the difficult and crash airway. You have a very narrow window to establish an airway. You could induce her and attempt oral, or drop a King, etc., but given that she is becoming profoundly hypotensive and hypoxic, and you can't ventilate with a BVM, sounds like a scalpel is indicated.
Giving Benadryl is questionable at best given the current situation. It's ABC's, and B doesn't stand for Benadryl. Solu-Medrol as previously posted is useless right now. You're looking at 4-6 hours for effects to begin, she has bigger iissues presently. She is hypotensive and Benadryl has a side effect of hypotension. Epi? Sure, 0.3 sq can't really hurt and at the rate she is decompensating, she's going to be getting alot more Epi than 0.3 sq.
Bilateral chest darts without a secured airway is a bad idea. Single sided is one thing, but you can make her airway issues much worse by darting both sides without an ETT or other airway. Chest decompression is indicated in a tension pneumothorax, although she is hypotensive, tachycardic and hypoxic, from the given scenario and lack of chest wall trauma, a true tension pneumo doesn't seem logical. However, I've been wrong before. Priority #1 right now is securing her airway and getting some fluids on board. As far as dealing with her tight lungs or possible allergic/ana rx's, that can be dealt with later. In line nebs, IV Benadryl once her BP improves a little, etc. A bolus of Jet A will help as well.


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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 Mike MacKinnon

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Posted 21 September 2009 - 11:15 PM

100% wheeze and little to no air movement.

Sounds like a possible myocardial contusion with associated congested heart failure. With such decreased lung sounds it's possible all you would be hearing is wheezes. Interesting case, can't wait to hear more about it!


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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 TexRNmedic

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Posted 22 September 2009 - 03:55 AM

100% wheeze and little to no air movement.



Just as an interesting point. Just had a patient with vague PMH with similar presentation to the case study (just no MVC). Turns out she had just had her flu vaccination about 30 minutes prior, started feeling short of breath, started driving to the ER and had to pull over and call. Usual RAD/anaphylaxis meds didn't work fast enough, so she ended up RSIed. Opened up with some continous entrained nebs, solu-medrol, bendadryl and epi. With this case study fresh in my mind, kind of made for an interesting encounter.

So Mike, no band-aid on her shoulder from a recent vaccination?
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Wes Seale
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#37 Gila

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Posted 22 September 2009 - 04:06 AM

I would look at bilateral pleural decompressions. Perhaps I am off; however, I am willing to deal with the consequences of iatrogenic pneumos than miss something. Especially since we have intubated and started PPV. Want to look at gastric decompression as well. What did her belly look like? Any possibility of a diaphragmatic rupture?
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Christopher Bare
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#38 scottyb

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Posted 22 September 2009 - 04:46 AM

Hi Mike,

I concur with everyone else's treatment modalities; just wondering what BP med this pt. is taking, unless someone else already asked and I missed it...

Gute Nacht!
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Scott Bild RN, FP-C

#39 Flightgypsy

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Posted 22 September 2009 - 05:48 AM

At this point I would be throwing the med bag at her. Hard to differentiate at this point whether it is anaphylaxis or a severe asthma attack although I am leaning towards the anaphylaxis. I would be giving her continuous in-line nebs, SQ or IV Epi, Benadryl, Magnesium sulfate and if all else fails head to IV Terbutaline. Unfortunately I don't carry steroids or Atrovent or I would give those as well. I would also request that the pilot fly as low as it is safe to.

Vent settings have already been discussed with preferably some kind of PC mode, long expiratory time (I:E around 1:5), PEEP of at least 5 and if able to measure her auto PEEP and match it or higher, 100% FiO2 at this point, a higher rate, smaller volumes with lower PIP's, etc.

I don't think I would be needle decompressing her at this point as the last thing she needs is a pneumo if she hasn't already blown one.

Glad we could get her airway at least. Have we started coding her yet?
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#40 Gila

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Posted 22 September 2009 - 05:59 AM

At this point I would be throwing the med bag at her. Hard to differentiate at this point whether it is anaphylaxis or a severe asthma attack although I am leaning towards the anaphylaxis. I would be giving her continuous in-line nebs, SQ or IV Epi, Benadryl, Magnesium sulfate and if all else fails head to IV Terbutaline. Unfortunately I don't carry steroids or Atrovent or I would give those as well. I would also request that the pilot fly as low as it is safe to.

Vent settings have already been discussed with preferably some kind of PC mode, long expiratory time (I:E around 1:5), PEEP of at least 5 and if able to measure her auto PEEP and match it or higher, 100% FiO2 at this point, a higher rate, smaller volumes with lower PIP's, etc.

I don't think I would be needle decompressing her at this point as the last thing she needs is a pneumo if she hasn't already blown one.

Glad we could get her airway at least. Have we started coding her yet?


I could be off; however, people have stated they would treat for anaphylaxis, yet the patient is not improving. Would we not consider a pneumo as a potentially correctable problem? All the info I have thus far is telling me we are killing her with the asthma approach.
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Christopher Bare
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