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Case #49 When Bad Goes To Worse.


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#41 MSDeltaFlt

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Posted 22 September 2009 - 03:03 PM

All that wheezes is not asthma. However, here it sounds to me that her lungs are still shut down. They're shut completely down at this point and they need to be opened up. In line continuous nebs definitely with PCV with optimum PEEP to splint the airways open. We need to be extremely careful, though, that we don't drop a lung or two (if not already dropped) or start blowing her up head to toe with SQ air. Remember we're still stuck on "B". We're way beyond SQ Epi here. We need IV Epi. We are at a place on this scene flight where we just might be delivering a cadavar instead of a pt.
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Mike Hester, RRT/NRP/FP-C
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#42 Canis doo

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Posted 22 September 2009 - 03:12 PM

Since I tried my best to kill her and she is persisitant on living, The only thing else i can think of is Bilateral Pulmonary Embolism. Sudden short of breath, failing SPO2 despite ventilating. She definately fits the criteria
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Jason Howard LP, FP-C
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#43 Gila

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Posted 22 September 2009 - 03:30 PM

Problem being, we cannot ventilate. Pulmonary embolisms are great at producing dead space; however, this inability to ventilate is not charateristic of a pulmonary embolism. Like wise, I am not looking at a ventilator strategy just yet. We cannot even bag this patient effectively.
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Christopher Bare
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#44 Canis doo

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Posted 22 September 2009 - 03:45 PM

Since I tried my best to kill her and she is persisitant on living, The only thing else i can think of is Bilateral Pulmonary Embolism. Sudden short of breath, failing SPO2 despite ventilating. She definately fits the criteria

Adding that since this is my new suspicion and I have only treated her accordingly with intubation, given her recent "trauma" I would get on the horn and call the recieving facility and ask for consult due to significant risk factors if wrong.

We only carry Streptpkinase. I know its not the preferred drug but any embolism that causes this much hemodynamic instability must be treated.
Start heparin theray at 60u/kg or 4000-5000 IVP. then 1000u/hr, 20ml/min

IV bolus to support Blood pressure but limit as much as possible.
Dopamine infusion
Continue on bronchodilator therapy.
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Jason Howard LP, FP-C
You have enemies? Good. That means you've stood up for something, sometime in your life. ― Winston S. Churchill

#45 LearRRT-CCEMTP

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Posted 22 September 2009 - 03:46 PM

I am still leaning towards myocardial contusion with associated congestive heart failure. Yes we only have wheezes but they could be cardiac wheezes. I would be reluctant to needle her chest at this point.
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David W. Garrard, BHS, RRT, RCP, CCEMTP, PNCCT, CFC
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#46 Gila

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Posted 22 September 2009 - 04:05 PM

Adding that since this is my new suspicion and I have only treated her accordingly with intubation, given her recent "trauma" I would get on the horn and call the recieving facility and ask for consult due to significant risk factors if wrong.

We only carry Streptpkinase. I know its not the preferred drug but any embolism that causes this much hemodynamic instability must be treated.
Start heparin theray at 60u/kg or 4000-5000 IVP. then 1000u/hr, 20ml/min

IV bolus to support Blood pressure but limit as much as possible.
Dopamine infusion
Continue on bronchodilator therapy.


I am not sure. You need to be certain this is a PE before heading down the path of lysis with a trauma patient. Additionally, we cannot ventilate this patient. You can typically ventilate a PE patient; however, the dead space created by the embolism prevents perfusion and gas exchange. However, it seems we cannot even ventilate the alveoli at this point.

I would be willing to go along with medications; however, several folks have already talked about this, and the patient continues to spiral downward. As stated, I could be off; however, I am still looking at decompression.
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Christopher Bare
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#47 Speed

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Posted 22 September 2009 - 05:10 PM

Has anyone tried suctioning yet? Maybe you could notice some change that would help rule some things out? Maybe the return matter could also give some clues?
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Mike Williams CCEMT-P/FP-C

#48 LearRRT-CCEMTP

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Posted 22 September 2009 - 11:12 PM

Good point Speed, I assumed we suctioned when we tubed her but I guess never assume. I think Pulmonary Embolism is an extremely low probability. If that was the case, active gas exchanging tissue would have been turned into pathophysiological deadspace. You CAN ventilate deadspace! It's shunting that results in decreased compliance thus difficult ventilation............ Please Mike, next round of info!
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David W. Garrard, BHS, RRT, RCP, CCEMTP, PNCCT, CFC
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#49 Speed

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Posted 23 September 2009 - 01:51 PM

Good point Speed, I assumed we suctioned when we tubed her but I guess never assume. I think Pulmonary Embolism is an extremely low probability. If that was the case, active gas exchanging tissue would have been turned into pathophysiological deadspace. You CAN ventilate deadspace! It's shunting that results in decreased compliance thus difficult ventilation............ Please Mike, next round of info!


Looking back that's all I could see standing out, maybe Mg+ along with the attempts at bronchodilation. I think one important factor is the blown tire, to me that means nothing was probably going until she was tossed around. The anti-hypertensives of course give us a task of ruling out CVA (don't think so) and MI(but triggered by and MVA??? not so much but have an extra hand run an ecg). Obviously she is losing her ventilatory capacities rather quickly, so I have to mainly think trauma. What could be taking up space in her chest: blood (hemo/pericard), air (pneumo), bowel contents (diaphragm) and causing isolated bronchoconstriction or an airway reaction in the developing wheezes. Rule out traumatic asphyxiation (look at hers eyes and skin, and she'd probably already be dead). , things like that. The suction thing is really just a shot in the dark going down those pathways. It would be good to know exactly when the vomiting happened in correlation to nasal intubation attempts. Have to wait and see what pops out and gives the best clues.
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Mike Williams CCEMT-P/FP-C

#50 wynnefredd

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Posted 23 September 2009 - 09:22 PM

Does she have any subcutaneous air on her chest or neck? Could she possibly have torn her trachea or transected one of her bronchi? Is there equal chest expansion when you bag her? Have we completely ruled out tension pneumo?
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#51 JLP

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Posted 23 September 2009 - 11:24 PM

Looking back that's all I could see standing out, maybe Mg+ along with the attempts at bronchodilation. I think one important factor is the blown tire, to me that means nothing was probably going until she was tossed around. The anti-hypertensives of course give us a task of ruling out CVA (don't think so) and MI(but triggered by and MVA??? not so much but have an extra hand run an ecg). Obviously she is losing her ventilatory capacities rather quickly, so I have to mainly think trauma. What could be taking up space in her chest: blood (hemo/pericard), air (pneumo), bowel contents (diaphragm) and causing isolated bronchoconstriction or an airway reaction in the developing wheezes. Rule out traumatic asphyxiation (look at hers eyes and skin, and she'd probably already be dead). , things like that. The suction thing is really just a shot in the dark going down those pathways. It would be good to know exactly when the vomiting happened in correlation to nasal intubation attempts. Have to wait and see what pops out and gives the best clues.


Good point about the traumatic asphyxia - back when I was a BLS ambulance driv - I mean, attendant - I did a call for a guy who was slowly compressed about the belly by a huge tire from a construction vehicle. He was alive but with the bloodshot eyes and flushed head and neck, but he got progressively harder to bag until he could not be ventilated at all (at which point he coded). Bowel sounds in the left side of his chest (not initially audible at scene).

The suction is also a good point - I had a patient two years ago who threw a mucus plug so large it completely clogged the tube, could not be BVM'd and no breath sounds, and he promptly arrested before we could clear it, then got a pulse back after we got the ET clear (he was pretty fragile to start with).
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#52 EDMEDIC

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Posted 25 September 2009 - 06:55 PM

Hi all, interesting case so far! Well we accomplished the "A" airway, but "B" seems to be an issue. We need alveolar recruitment for ventilation or all we "really" have is a PVC tunnel to her bronchus. I would be for doing a bilateral decompression I think at this point. I wasn't really crazy about that prospect before she was successfully intubated. What does her EtCO2 / Capno look like post ETI? We don't do prehospital "lysis" in my area, but /c her trauma history I can't imagine even thinking about lysing her! What a catastrophe that could end up being...she's catastrophic enough now as it is. Decompression, possibly going /c some IV epi and in-line nebb'd beta-adrenergics is the way to fly. Speaking of flying, let's burn some jet fuel and get this gal on her way to the trauma center. If we have airway and PIV access, the rest can be done enroute. IMHO, Brian
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Brian EMT-P/CC
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#53 Mike MacKinnon

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Posted 26 September 2009 - 06:42 PM

no band aids ;)

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

#54 Mike MacKinnon

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Posted 26 September 2009 - 06:42 PM

would you decompress someone with wheezes and no obvious trauma?

No air movement but wheezes ;)

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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Mike MacKinnon MSN CRNA
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#55 Mike MacKinnon

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Posted 26 September 2009 - 06:45 PM

persistent nebs and sq/iv epi seem to relieve the wheezes slighly.

See next post.


All that wheezes is not asthma. However, here it sounds to me that her lungs are still shut down. They're shut completely down at this point and they need to be opened up. In line continuous nebs definitely with PCV with optimum PEEP to splint the airways open. We need to be extremely careful, though, that we don't drop a lung or two (if not already dropped) or start blowing her up head to toe with SQ air. Remember we're still stuck on "B". We're way beyond SQ Epi here. We need IV Epi. We are at a place on this scene flight where we just might be delivering a cadavar instead of a pt.


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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

#56 Mike MacKinnon

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Posted 26 September 2009 - 06:59 PM

suctioning attempts shows she is clear.

Update:

She is intubated without difficulty class 1 airway. 7.5 Ett, 21 at teeth.

Hard to ventilate, lots of pressure. No obvious trauma

little to no capnograph tracing

Wheezing

Little to no air movement

Now pts vitals have changed:

HR now 50
BP now 60/30
Sat now unattainable

What now?

Good point Speed, I assumed we suctioned when we tubed her but I guess never assume. I think Pulmonary Embolism is an extremely low probability. If that was the case, active gas exchanging tissue would have been turned into pathophysiological deadspace. You CAN ventilate deadspace! It's shunting that results in decreased compliance thus difficult ventilation............ Please Mike, next round of info!


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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

#57 Mike MacKinnon

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Posted 26 September 2009 - 07:07 PM

Speed & delta suggested

Mag and bronchodilators (and some others suggested nebs).

Why?


suctioning attempts shows she is clear.

Update:

She is intubated without difficulty class 1 airway. 7.5 Ett, 21 at teeth.

Hard to ventilate, lots of pressure. No obvious trauma

little to no capnograph tracing

Wheezing

Little to no air movement

Now pts vitals have changed:

HR now 50
BP now 60/30
Sat now unattainable

What now?


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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#58 ST RN/PM

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Posted 26 September 2009 - 07:11 PM

Well, I'm gonna jump in....presumably to miss the boat and go splashing into the drink, but here goes.......
In discussion, so far, all previous posters have addressed the same things that I would, so I haven't posted. She is wheezing, her sats are dropping, and she is difficult to bag. Because I know Mike's case studies, this is something really off the beaten path. My feel from the get-go is that this accident was precipitated by a medical event, as a blown tire would occur if she had an event that caused either a loss of consciousness or a near-syncopal episode behind the wheel. I think something happened, she drifted towards a curb/side-of-the-road, and launched her car in the air, causing rollover. She is hypoxic, with tight lungs, and perseverating. The first instinct is to say.....she's dying from hypoxia. I would do as others have stated, intubate her, in-line nebs, epi, mag. sulfate, even try terbutaline...see how she responds......i am not convinced that she has a traumatic injury, and we are clearly in dire straits here....she is dying from hypoxia......Jet A.................!
PS... major pucker!!!
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Steve T. RN, PM

#59 TexRNmedic

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Posted 26 September 2009 - 08:29 PM

Well, I'm gonna jump in....presumably to miss the boat and go splashing into the drink, but here goes.......
In discussion, so far, all previous posters have addressed the same things that I would, so I haven't posted. She is wheezing, her sats are dropping, and she is difficult to bag. Because I know Mike's case studies, this is something really off the beaten path. My feel from the get-go is that this accident was precipitated by a medical event, as a blown tire would occur if she had an event that caused either a loss of consciousness or a near-syncopal episode behind the wheel. I think something happened, she drifted towards a curb/side-of-the-road, and launched her car in the air, causing rollover. She is hypoxic, with tight lungs, and perseverating. The first instinct is to say.....she's dying from hypoxia. I would do as others have stated, intubate her, in-line nebs, epi, mag. sulfate, even try terbutaline...see how she responds......i am not convinced that she has a traumatic injury, and we are clearly in dire straits here....she is dying from hypoxia......Jet A.................!
PS... major pucker!!!




Major pucker here too. When all else fails I'm going back to the basics here (although not alot of time to problem solve, maybe a minute before she arrests). Maybe we really haven't moved passed A for airway. Not getting any O2 in or CO2 out. What is causing the wheezing? One way or another there is some significant thoracic airway obstruction. We have treated the heck out of airway constriction (nebs, epi, steroids, mag,etc.). She has probably responded with dilation as much as she can. I just don't think we are dealing with bilateral pneumos or bronchial tears. Only other thing has got to be foreign body in the airway. She must have something pretty solid near the carina. We've already suction with nothing coming back. I'm going to throw a hail mary pass and main stem my ETT. Try venting a couple of breaths. If it doesn't work I'll pull back to a normal position and hope I've shoved whatever it is into the right main stem and just one lung ventilate. AT this point one lung is better than none. We've thrown all the drugs at this lady we can. And at this point I would go ahead and have someone needle the chest. Honestly don't think it will do much to help but I don't think it will hurt at this point. I am going to be really embarrassed if my patient died from a piece of gum stuck deep in her trachea. Meds haven't worked and if this doesn't work, I'm stumped.

BTW. How close are we to a hospital with a cxr and/or a bronchoscope? My suspicion of trauma is very low and I would not have a problem riding 5 or 10 minutes with the ground crew to a really good non-trauma rated community hospital where we can look in this galís chest and fix it. She is going to be in cardiac arrest pretty quick if my above interventions donít work and will welcome the extra set of hands on the way to the hospital.

Looking forward to ya'lls comments on my treatment plan :-)
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#60 MSDeltaFlt

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Posted 27 September 2009 - 12:43 AM

Speed & delta suggested

Mag and bronchodilators (and some others suggested nebs).

Why?


Mag Sulfate is a smooth muscle relaxer... aka an IV bronchodilator. We need to counter act this woman's wheezing from both sides; both directly by inline nebs, and through the back door with IV bronchodilators such as epi and mag.
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain