[pureadrenalin]

Okay, not an overactive participant here, but, I want to just get everyones feelings on this seeing as many of you are all well experienced clinicians, and I was mildly baffled as to the actual cause. And I ahve not caught up with the MD on duty to figure it out.

Presentation.

57 Y/O-Female presents to ED by FD Paramedics.

C/C-Severe respiratory distress beginning 30min prior to 911 activation.

HX- HTN/DM2/Hypercholesteremia

Meds-Insulin,Glyburide, Metformin, HCTZ, Lipitor

S/Sx-Diff. Breathing with full acc. muscle usage, cyanosis of lips and nailbeds are dusky, skin is mottled. Overall doesn't appear to be perfusing well. PT appears to be tiring quickly.

V/S- B/P-150's/70's P-140's(Sinus tach) RR-40+ being assisted with BVM and 100%o2, very shallow. Pulse ox initially was 96 on room air per meds on scene, but have not been able to get one. Co2 via sidestream cannula is in the teens, holding between 15-20.

MD on duty elected to RSI patient due to apparent failing airway. PT setaded with 50 of Etomidate, and paralyzed with 100 of Succ's. Intubation was done with glidescope per hospital protocol, 7.0ET was placed. Literally, and I mean, literally as soon as BVM was attached with EZCap and first breath was given, there was a fountain of blood. It filled up the BVM, as well as it's replacement. Pt subsequently decompensated rapidly, coded into VF, and eventually was called after thirty minutes.

I feel that this was probably a massive PE, and something ruptured somewhere...but..where the hell did all the blood come from with no signs of hemoptysis prior to intubation. Is that even possible with a PE?

[SerendepitySaki]

the more i read, the more i was thinking PE... sounds like you had the same conclusion...

as for the blood, EtOH Hx? varices? mallory weiss? those are the chip shots...i'm sure folks plenty smarter than me will chime in with a few more....

autopsy?

[SerendepitySaki]

PS: i hope you don't think i didn't enjoy your pathway question....

despite my initial response, i thought your approach was much more focused and disciplined than many, and making a snap judgement from limited interactions with you, i suspect you are very much well on your way to being an awesome flight-medic!


complacency kills and attitude = altitude.

[Jwade]

SerendepitySaki, on 28 March 2011 - 07:04 PM, said:

the more i read, the more i was thinking PE... sounds like you had the same conclusion...

as for the blood, EtOH Hx? varices? mallory weiss? those are the chip shots...i'm sure folks plenty smarter than me will chime in with a few more....

autopsy?

1. 50 of Etomidate? Holy crap, how much did she weigh?

2. BMI?

3. As Sean stated, ETOH? Varices are plausible given the limited info.

4. What color was the blood?

5. PE is obviously in the logical differential here, Autopsy will pin it down for sure.

6. During my time working in the Operating Room, I assisted on a handful of cases where people had erosions into their IVC and bled out, even though we cracked their chest and cross-clamped pretty much no chance.

7. A PE in and of itself generally will not cause rupture.

8. Undiagnosed TAA?


Respectfully,
JW

[MSDeltaFlt]

Until the autopsy is performed my guts says this. Either

1. PE and the BVD moved a large clot making the pt bleed out or

2. Still PE and the blade ruptured a varices making the pt bleed out.

I'm leaning towards #1 since the pt was stuck on "B" for the chief complaint.

[pureadrenalin]

I wasn't worried about that. I sincerely do appreciate your vote of confidence though!

ETOH yes, severity of abuse I don't know, but I would suspect high, other than the fact she came from an impoverished area of the city as do most of our patients. Varicies I did not think of, though, the blood was all up the tube. Which is what caught me off guard..just leads me to feel that it wasn't GI tract in nature.

I'm not back until Thursday which is when that group of docs should be back on duty. I'll have to find out if an autopsy was done.

[pureadrenalin]

JW, about 130kg as a rough estimate. We have a very large, obese, African American population here. That's actuallly a pretty typical weight in Milwaukee.

Blood was bright red, appeared arterial.

[Jwade]

pureadrenalin, on 28 March 2011 - 07:40 PM, said:

JW, about 130kg as a rough estimate. We have a very large, obese, African American population here. That's actuallly a pretty typical weight in Milwaukee.

Blood was bright red, appeared arterial.

I am originally from Detroit, and worked the streets there. So, I know all about the " Population" LOL......


From my experience in the Operating Room, varice blood will tend to be dark in nature, so I would lean towards more along the lines of ruptured TAA of some sort. Would have been a really interesting autopsy.

Few more questions:

1. Liver Issues?

2. Portal Hypertension?

3. 50 still seems pretty overkill IMO.

JW

JW

[JClayborne]

Bronchitis is the most common cause of massive hemoptysis but given the sudden onset of dyspnea and the lack of a chronic history I am leaning away from that as the cause. The sudden onset and tachycardia had me thinking pulmonary embolism as well. I appreciate the fact that she has accessory muscle use and such but I don’t like that she isn’t hypotensive and doesn’t have the hypoxic SPO2 I was expecting. I wouldn’t expect even a massive PE to result in fatal hemoptysis so quickly. If I had to make an “educated guess” I still think PE is the primary cause of the dyspnea. However, I am thinking bronchus or tracheal rupture as the cause of the massive hemoptysis or something related to the intubation / direct positive pressure ventilation. This is an interesting case. I’ll be interested to read more on it. Thanks!

[old school]

JClayborne, on 29 March 2011 - 12:17 AM, said:

The sudden onset and tachycardia had me thinking pulmonary embolism as well. I appreciate the fact that she has accessory muscle use and such but I don’t like that she isn’t hypotensive and doesn’t have the hypoxic SPO2 I was expecting. I wouldn’t expect even a massive PE to result in fatal hemoptysis so quickly. If I had to make an “educated guess” I still think PE is the primary cause of the dyspnea. However, I am thinking bronchus or tracheal rupture as the cause of the massive hemoptysis or something related to the intubation / direct positive pressure ventilation.

Exactly. As I read the initial post, the whole way through I was thinking "PE". But the second-to-last paragraph that mentioned massive hemoptysis threw me a little.

As JClayborne stated, I'd guess the initial dyspnea was due to a PE, and the blood was from an unrelated rupture.

And John, 50mg of Etomidate isn't really that much. I've routinely given 40 to large patients and I remember once giving 80 when the dude was still talking to me after 40.

[Jwade]

old school, on 28 March 2011 - 09:14 PM, said:

Exactly. As I read the initial post, the whole way through I was thinking "PE". But the second-to-last paragraph that mentioned massive hemoptysis threw me a little.

As JClayborne stated, I'd guess the initial dyspnea was due to a PE, and the blood was from an unrelated rupture.

And John, 50mg of Etomidate isn't really that much. I've routinely given 40 to large patients and I remember once giving 80 when the dude was still talking to me after 40.

Standard dose # .3mg/kg would = 39 of Etomidate not 50 @ 130kg. Given the OP said the weight was estimated, i agree that 50 could be in the realm of needed. The MDA in my family just said she gives .2-.6 mg/ kg for Anesthesia Induction but prefers to stay on the lower side versus the overdose side when possible.


I hope we get some answers on the autopsy, very interested to find out what ruptured.

Respectfully,
JW

[old school]

Jwade, on 29 March 2011 - 01:45 AM, said:

Standard dose # .3mg/kg would = 39 of Etomidate not 50 @ 130kg. Given the OP said the weight was estimated, i agree that 50 could be in the realm of needed. The MDA in my family just said she gives .2-.6 mg/ kg for Anesthesia Induction but prefers to stay on the lower side versus the overdose side when possible.


I hope we get some answers on the autopsy, very interested to find out what ruptured.

Respectfully,
JW

Well, despite the published doses, things in the real world don't always work out the way the textbook says they will.

I don't really see what the etomidate dose had to do with the outcome.

I agree, its an interesting case.

[pureadrenalin]

Thanks for the input everyone. I was just as baffled. Never knew about the bronchitis thing. Gonna have to learn about that.

Ill see if I can ever figure this one out, and if an autopsy was done.

[fltpuke]

pureadrenalin, on 28 March 2011 - 09:24 PM, said:

Okay, not an overactive participant here, but, I want to just get everyones feelings on this seeing as many of you are all well experienced clinicians, and I was mildly baffled as to the actual cause. And I ahve not caught up with the MD on duty to figure it out.

Presentation.

57 Y/O-Female presents to ED by FD Paramedics.

C/C-Severe respiratory distress beginning 30min prior to 911 activation.

HX- HTN/DM2/Hypercholesteremia

Meds-Insulin,Glyburide, Metformin, HCTZ, Lipitor

S/Sx-Diff. Breathing with full acc. muscle usage, cyanosis of lips and nailbeds are dusky, skin is mottled. Overall doesn't appear to be perfusing well. PT appears to be tiring quickly.

V/S- B/P-150's/70's P-140's(Sinus tach) RR-40+ being assisted with BVM and 100%o2, very shallow. Pulse ox initially was 96 on room air per meds on scene, but have not been able to get one. Co2 via sidestream cannula is in the teens, holding between 15-20.

MD on duty elected to RSI patient due to apparent failing airway. PT setaded with 50 of Etomidate, and paralyzed with 100 of Succ's. Intubation was done with glidescope per hospital protocol, 7.0ET was placed. Literally, and I mean, literally as soon as BVM was attached with EZCap and first breath was given, there was a fountain of blood. It filled up the BVM, as well as it's replacement. Pt subsequently decompensated rapidly, coded into VF, and eventually was called after thirty minutes.

I feel that this was probably a massive PE, and something ruptured somewhere...but..where the hell did all the blood come from with no signs of hemoptysis prior to intubation. Is that even possible with a PE?

After reading the post, it's not all that difficult to rule out and etiology not associated with the airway. MW tears, varicosities, other GI bad juju things do not bleed up the airway to the point that the blood will "fill up the BVM and it's replacement". That leaves us with a bad respiratory culprit.

The patient was VERY negative pressure ventilating and, to the point that it was taken away, was able to maintain a pretty high negative thoracic pressure. Take that away with Anectine and a large dose of Etomidate and she relaxes the thorax and opens the well spring. I'm not inclined to think that the induction / intubation had anything to do with the hemorrhage, it just gave the blood a path of least resistance. I would GUESS that the patient had some sort of pulmonary vascular erosion into the alveolar sac. Those vitals (at first blush, and with only one set listed) don't make my Spidey Senses think PE. I'm not seeing the tachycardia WITH the hypotension AND hypoxia. The ETCO2 was not a true airway captured reading so the hypocapnea is a red herring.

It seems that this unfortunate patient already had her fate sealed before anybody came to help her. It is certainly an interesting case and I, like others here, would be most interested to hear the post mortem findings.

As always,

My .02 worth
Actual mileage may vary
Tax, tag, tile extra
Professional driver on a closed course

Please be safe friends

Jeff

[SerendepitySaki]

i'm more than down with just about everything said so far, but,

just as an "oh by the way..."

with regards to airway and varices...and without going into subjective appearance of the blood.... i have personally seen patients with confirmed ruptured varices (and no other bleed sources) that made Linda Blair's performance in the Exorcist look totally amateur hour....literally liters on the bed/floor...that being said, i'm not wedded to any particular hypothesis...just throwing it out there...

like oldschool was saying, frequently the "exam of real life" differs from textbook/certification exam presentation... always a tightrope act when trying to reach a differential dx through index of suspicion...

lots and lots of good ideas and valid possibilities here...and plenty that i like MORE than my chip shot varices/M-W options....sure hope there are autopsy results....

[shock360j]

Just my two-cents: The elevated RR and hypocapnea, along with an adequate SPO2, would lead one to believe the patient was ventilating and oxygenating ok (if you believe the SPo2 of 96% on room air) and potentially rules out any VQ mismatch (PE, ect). The bright red bleeding may be from a rupture of the patients pulmonary artery, which would have resulted in severe dyspnea and a fountain of blood following the intubation.

[Tmed725]

Had a case years ago at a patients home that sounds sim. Initial CC on Disp was Resp diff. When we arrived the patient was in a pool of blood on the kitchen floor in arrest. I was taking large clots out of the airway with magills and when I intubated the patient I could not even get air into the tube. Partner re-intubated with same result. I did a DL with tube in place as confirmation and the tube was in the right hole. Turns out the patient had a recent DX of lung tumor and aparently it erroded into a major pulmonary vessle. His lungs were full of blood litteraly.

[Rescue7RN]

I'm going to agree with everyone that this is most likely a PE. There was no further mention in the OP of the confirmation of tube placement. If it was indeed in the trachea then all of this talk of GI bleeding/causes is mute. There would have had to have been some sort of tracheal-esophogeal fistula, and more than likely the patient would have had further complications sooner. If the tube was in the esophogus and there was GI bleeding then there are other major issues here. As for the blade "breaking" the varicies, in my experience varicies are usually very distal, and related to portal hypertension, not far up in the proximal esophogus. The reason for the PE I believe is in the symptoms. HR elevated, RR increased. The patient may have been hyperdynamic at this point and that is why there is no hypotension at that time. As for the ETCO2 being low there is increased dead space because of the physical clot. Because of this there is a lower reading because the CO2 can't be fully exhaled because of the physical clot and the V/Q mismatch.

My 2 pennies.

[BrianACNP]

Tmed725, on 29 March 2011 - 02:09 PM, said:

Had a case years ago at a patients home that sounds sim. Initial CC on Disp was Resp diff. When we arrived the patient was in a pool of blood on the kitchen floor in arrest. I was taking large clots out of the airway with magills and when I intubated the patient I could not even get air into the tube. Partner re-intubated with same result. I did a DL with tube in place as confirmation and the tube was in the right hole. Turns out the patient had a recent DX of lung tumor and aparently it erroded into a major pulmonary vessle. His lungs were full of blood litteraly.

Yep....actually this was my thought after reading the case in its entirety. Had a similar case just within the last two weeks of a patient with known lung CA treated with radiation (last year) and chemo most recently. Admitted for surgery. Postop, Intubated for respiratory failure, became progressively more hypoxic, then died when he bled profusely through his ETT. We surmised that he bled from a prominent vessel that the tumor eroded through, although we have no autopsy to prove it.

I'm curious as to whether there was any recent history to suggest a lung malignancy.


Brian

[onearmwonder]

So I am curious... I don't think you mentioned if you ever noticed if the Doc ever obtained secondary ETT conformation since there was so much blood during the initial ventilations. Was the tube actually in the trachea? Were you able to judge the carefullness of the intubators technique? How long did they stay in with the blade? Just curious... Interesting case...

Matt