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Case #36 The Inadequacy Of The Requesting Description Can Kill.


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#41 Mike MacKinnon

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Posted 10 February 2008 - 10:28 PM

You pull the NPA back but the high pitched stridorous sound continues...

Sats are still in the 80's HR now 120.

What now? whats that noise?
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Mike MacKinnon MSN CRNA
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#42 bertmict

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Posted 10 February 2008 - 11:23 PM

Bert

Never downplay your BLS skills. All good ALS is 100% based on a solid BLS foundation. One of the biggest frustration among medic instructors (myself included) is how quickly they look down upon (and forget) basic BLS skills which are NEVER unimportant!

You can certainly get the patient out the door with the cadre of help here. The rotor wont hold the patient tho (too rotund). He wont be walking out in his current condition but likely on a board.

Have to stay in the house until we manage the current airway emergency but afterward moving would be ok.

Unfortunately the closest airfield is farther than the closest facility away so no luck there!


Thank goodness we can utilize the help then. After two shoulder surgeries, I do not want another one!!

As far as progression of the case....the stridor could be something that got shoved down with the NPA placement, whether it was his tongue, adipose tissue or a smokie covered in Jack Daniels BBQ sauce. This could also be anaphylaxis related to the feast, meds given by us or by the family PTA (ASA?). Maybe we (he) would benefit from some Etomidate and he would relax enough to take a peak at the airway, so we can see if there are any occlusions. Who knows if our Magills will be long enough for this guy. At the same time, if we see vocal cords, suction and then pass an ETT. I, like others, think that to best ventilate this patient, he will have to be sitting up some, to keep some weight off his chest. I hope the VFF have a tarp on one of their vehicles.

I understand the need to secure the airway, but we also have at least 90 minutes of drive time, so we need to start that way. After all, after having been in the confines of a Rotor, the ambulance is going to feel like a hospital room, when it comes time to doing some work.
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#43 chris

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Posted 11 February 2008 - 12:00 AM

Looking at the picture there is no way in you know where am I going to try to cric this guy. If you can bag him up I would go with that. I would reposition him to optimize air movement. I am thinking he is going to need an NG to suck out all the crud you can before he pukes once we are out of the house. If he does not bag up I would try to tube him. That is a really unpleasant thought when you think of cric.
Anyway once airway is fixed you can load him up (Sawzall anyone for the door?) and then move out smartly for the nearest tertiary care center.
I like the idea of doing a posterior 12 lead. I still think you need to do something about the b/p although it may drop some once you start moving air easier. Labatalol push to start with for b/p control. Nipride drip if that does not help. I would give him 10-20 mg of Lasix if his lungs are wet. Not too much as the current thoughts I have seen is to use just a little lasix to get the diuresis going then some Nitro to open him up.
Too bad about the A star. Not going to be a pleasant 90 min journey. Any other service with a bigger helicopter that could do an intercept??????

Great case study so far!
Chris
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#44 rfdsdoc

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Posted 11 February 2008 - 02:22 AM

Hey Folks

Just catching up to this month's case as have been away. No chance it is that Tako-Tsubo cardiomyopathy " broken heart syndrome"?...hahahahaha

Anyway Whilst mIke has already indicated this is a classic EKG for PE, I agree with recent posts that a posterior MI must also be considered.
Either way he has a potentially treatable condition to thrombolytics: STEMI or PE.

But his problem now with the acute stridor is laryngospasm, probably due to the NPA being pushed too far or it pushed some vomit onto his cords.

First line is some positive pressure ventilation with a BVM to see if the laryngospasm can be relieved. If not then your options are very limited : paralyse him and try to intubate or BVM OR knife his neck, fentanyl IV may also relieve the laryngospasm.

Let me stress paralyse this guy is fraught with danger. He likely has sleep apnoea and will desaturate quicker than you can blink and you already are in a hypoxic state!. Keeping this guy spontaneously breathing is the safest option. I would keep him sitting up as much as possible, trying to maintain his own airway. He is doing that at the moment albeit not very well but if you paralyse him then I doubt you could rescue ventilate him let alone knife his neck. The surgical airway option here is zero.


The best airway intervention for him is a blind nasal intubation whilst he is still breathing under topical anaesthesia and sedation. Gotta go but will write some more!@
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#45 rfdsdoc

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Posted 11 February 2008 - 06:42 AM

I meant to emphasise that we treat his laryngospasm first with BVM in a sitting position with two persons, then try some sedation such as IV fent/midazolam, and finally if all else fails to relieve the laryngospasm then a dose of SUX and my preference rather than try DL is to insert a ILMA such as a Fastrach whilst still in the sitting position and rescue ventilate with that. Once Sats back up then could try a blind intubation via the fastrach whilst still under the effect of the dose of Sux. I have just seen so many times people struggling to do DL on patients like this and forgetting how quickly desaturation occurs. In the heat of the moment we tend to persist too long in our DL attemtps in these patients.

If you did not have an ILMA then a standard LMA or really any supraglottic device is better than letting the guy die of hypoxia.


As to treating his PE I'm not sure if anyone has mentioned starting IV heparin but that would be useful for PE and STEMI. SO I would do that. I agree with others in getting his BP down with some IV nitrates or labetalol. Does anyone carry tenecteplase on board as we do? Would I lyse him in the prehospital setting? He has chest pain of short duration, EKG signs of either submassive PE or posterior STEMI, he is unstable with low sats ( if this is a STEMI then this indicates pulmonary oedema/acute LVF which in itself indicates a huge MI and impending cardiogenic shock, if it is a PE then this indicates submaissive or massive PE and impending arrest)... I'd load the IV heparin and draw up the tenecteplase.

If we got 90 minutes via road and not much chance of getting him in the helicopter then I would faviour giving him the lysis in the house. A guy this unstable needs better stabilisation before you get going on a 90 min road trip.

SO lysis, treat his pain with some IV morphine or fentanyl, oxygen mask , keep him sitting up and awake, if you need to sedate him for transport then keep him sitting up as best as you can, if needed drop a LMA or King LT in under etomidate or whatever and ventilate him with that. As long as he is sitting up then he is at low risk of aspiration even with a LMA etc inserted. The big NO- NO is to try to do traditional RSI and DL on this guy, lie him down etc.... that is a good way to kill him. I tried this once and never again, after the 170 kg man I did RSI on ( drunk and combative with a stab wound to his chest that needed thoracostomy for tension pneumo) went into asystolic hypoxic arrest as I visualised his epiglottis after 30 seconds of apnoea. lUckily he was resuscitated with two person BVM and one dose of IV adrenaline and he had the nerve to come back 2 weeks later to thank me for saving his life!
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Minh Le Cong
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RFDS Cairns base , Queensland, Australia

#46 BackcountryMedic

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Posted 11 February 2008 - 10:21 AM

Could the neck and strider be angioedema (Ludwig's Angina)?
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#47 BackcountryMedic

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Posted 11 February 2008 - 03:26 PM

I wrote the last at 0300 this morning, when I sat bolt up right and murmured 'Ludwig's Angina'. I do my best think while asleep.

What was the unknown bottle of HTN med?

Sure, I don't doubt he has a PE, but could his current acute problem be the angioedema? Did he have some C/P and took extra HTN med thinking it would work for an AMI? Does the family think his neck is bigger then normal? I mean - jump Jesus on a pogo stick - the guys ear is completely buried by his expanding neck. I've never seen anyone THAT fat (but I don't work in NASCAR country).
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#48 Speed

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Posted 11 February 2008 - 03:43 PM

OK... so I'm looking at this photo and I have to ask are you or real? Is this just an example, or is this the actual neck that we're working with? This guy looks like he's got more going on there than just obesity and adipose, damn? Anyway, yeah, as long as I could work with him breathing and "sat's" in the high 90's, but obviously you're going somewhere else with this. Basically if I can leave him alone and upright and he's maintaining; I will. If not I think a nasal intubation would be my first attempt at improving "sat's", if that's unsuccessful I'd go with an attempt at visualization/bougie/tube (I'd keep him at 45 degrees, use lots of blankets, towels, and pillows to position his mouth/larynx/trachea in a straight line). I'd start with Etomidate only (try that first) and if I needed to paralyze him I would. If I couldn't visualize anything; throw in a King airway. If it all failed I'd be forced to attempt a surgical airway. I'd probably start with a needle into the membrane, wire, over the wire introducer / tube. Like I said, I would try to avoid all that, but I can't let his "sat's" stay low. I would like to talk to the wife about her feelings and his wishes as far as a DNR. If you have heparin give it. As soon as I could get an airway I'd want to transport to the closest hospital and treat everything else (BP) on the way.
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Mike Williams CCEMT-P/FP-C

#49 Speed

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Posted 11 February 2008 - 03:47 PM

OK... so I'm looking at this photo and I have to ask are you or real? Is this just an example, or is this the actual neck that we're working with? This guy looks like he's got more going on there than just obesity and adipose, damn? Anyway, yeah, as long as I could work with him breathing and "sat's" in the high 90's, but obviously you're going somewhere else with this. Basically if I can leave him alone and upright and he's maintaining; I will. If not I think a nasal intubation would be my first attempt at improving "sat's", if that's unsuccessful I'd go with an attempt at visualization/bougie/tube (I'd keep him at 45 degrees, use lots of blankets, towels, and pillows to position his mouth/larynx/trachea in a straight line). I'd start with Etomidate only (try that first) and if I needed to paralyze him I would. If I couldn't visualize anything; throw in a King airway. If it all failed I'd be forced to attempt a surgical airway. I'd probably start with a needle into the membrane, wire, over the wire introducer / tube. Like I said, I would try to avoid all that, but I can't let his "sat's" stay low. I would like to talk to the wife about her feelings and his wishes as far as a DNR. If you have heparin give it. As soon as I could get an airway I'd want to transport to the closest hospital and treat everything else (BP) on the way.


Actually let me back track on that a bit. It might be worth getting his BP down to see if that resolves the dyspnea and distress so I wouldn't have to deal with the airway...maybe if I was that lucky? But with the PE I don't think that would make much difference.
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#50 Mike MacKinnon

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Posted 11 February 2008 - 03:48 PM

hehehe

While thats not the 'actual' person it is a real patient in an OR ;)


OK... so I'm looking at this photo and I have to ask are you or real? Is this just an example, or is this the actual neck that we're working with? This guy looks like he's got more going on there than just obesity and adipose, damn? Anyway, yeah, as long as I could work with him breathing and "sat's" in the high 90's, but obviously you're going somewhere else with this. Basically if I can leave him alone and upright and he's maintaining; I will. If not I think a nasal intubation would be my first attempt at improving "sat's", if that's unsuccessful I'd go with an attempt at visualization/bougie/tube (I'd keep him at 45 degrees, use lots of blankets, towels, and pillows to position his mouth/larynx/trachea in a straight line). I'd start with Etomidate only (try that first) and if I needed to paralyze him I would. If I couldn't visualize anything; throw in a King airway. If it all failed I'd be forced to attempt a surgical airway. I'd probably start with a needle into the membrane, wire, over the wire introducer / tube. Like I said, I would try to avoid all that, but I can't let his "sat's" stay low. I would like to talk to the wife about her feelings and his wishes as far as a DNR. If you have heparin give it. As soon as I could get an airway I'd want to transport to the closest hospital and treat everything else (BP) on the way.


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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

#51 rfdsdoc

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Posted 11 February 2008 - 07:29 PM

if you wanna try a surgical airway do it awake under local or even some sedation like etomidate...I would avoid trying it after your failed intubation with sux!
you could drop a lma or king lt in and ventilate whilst a surgical airway attempt is made.
but you are in definite tiger country here looking at major neck dissection, I doubt even a Melker needle crico kit would be long enough for this neck. remember he also has a PE ,MI & knifing the neck with questionable chance of success before you start heparin is asking for trouble!
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#52 LZone

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Posted 12 February 2008 - 01:57 AM

You pull the NPA back but the high pitched stridorous sound continues...

Sats are still in the 80's HR now 120.

What now? whats that noise?



Now why would this happen? I'm sure that I am incorrect but here are a few theories. How about laryngospasm secondary to hypocalcemia? It's unrelaible especially with his size but could you elicit a Chvosek or Trousseau sign? I cant imagine that someone could have some sort of localized infection brewing on top of everything else. Otherwise he has some sort of partial airway blockage, he's probably living with sleep apnea/Pickwickian syndrome for sometime, but he is now awake...although lethargic, from the booze, hypoxia or both?. Is his plummeting saturation holding or are we looking at a situation that will soon spiral terminally downward?

Other than that I got nothin'. But I'm sure I will learn.
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#53 BamaFlightRN

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Posted 12 February 2008 - 02:32 AM

I have been following along....It seems like we have to be thinking along with our initial treatments how we are going to transport...Will he fit in the aircraft..If not have someone gathering the equipment neccessary for the transport in the ambulance...Would another aircraft be available that could transport the patient? My first thought with the stridor would be to pull the NPA, if the patient is indeed more awake and talking he shouldnt need it..I would give the guy a quick dose of subq epi, If this improved the stridor, attempt a nasal intubation with him as awake as possible. Wouldnt do anything to compromise the airway further such as paralytics or RSI. Follow the subq epi with racemic epi breathing treatments if the stridor doesnt improve. I wouldnt dare give a thrombolytic without a chest xray and a definitive diagnosis of PE, gut feeling will not hold up in court. I feel like we need to clear and control the airway, obtain IV access and get out of dodge the best way we have available..Cant wait to hear more.
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#54 rfdsdoc

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Posted 12 February 2008 - 06:55 AM

would you give heparin and aspirin without a cxr?
thrombolysis is done on clinical history & EKG alone before cxr, cardiac enzymes ,when the clinical picture is appropriate .
it is a risk benefit call I agree and should not be done lightly.
90min is a long time to wait for a cxr if you are having a posterior STEMI!
if you don't normally give prehospital lysis I agree don't start now. but I do have that option and would in this case.in PE I only give lysis when the BP or Sats are low and not improving on usual treatment. oh and when they arrest from their PE....

I have been following along....It seems like we have to be thinking along with our initial treatments how we are going to transport...Will he fit in the aircraft..If not have someone gathering the equipment neccessary for the transport in the ambulance...Would another aircraft be available that could transport the patient? My first thought with the stridor would be to pull the NPA, if the patient is indeed more awake and talking he shouldnt need it..I would give the guy a quick dose of subq epi, If this improved the stridor, attempt a nasal intubation with him as awake as possible. Wouldnt do anything to compromise the airway further such as paralytics or RSI. Follow the subq epi with racemic epi breathing treatments if the stridor doesnt improve. I wouldnt dare give a thrombolytic without a chest xray and a definitive diagnosis of PE, gut feeling will not hold up in court. I feel like we need to clear and control the airway, obtain IV access and get out of dodge the best way we have available..Cant wait to hear more.


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Minh Le Cong
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RFDS Cairns base , Queensland, Australia

#55 Mike MacKinnon

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Posted 12 February 2008 - 09:37 PM

Minh (rfdsdoc), buddy you are a wicked clinician. No 2 ways about it.


About laryngospasm

Laryngospasm is an uncontrolled/involuntary muscular contraction (spasm) of the laryngeal cords. It may be triggered when the vocal cords or the area of the trachea below the cords detects the entry of water, mucus, blood, or other substance. It is characterized by stridor and or retractions. Commonly, this happens in pts who are sedated or lethargic. If you have ever heard of a "dry drowning" where the kid is floating on the top of the water and has little or no water in their lungs that is what has happened. It can be so severe that the pt cannot breath whatsoever and can die of asphyxia. nasty stuff.

Except Minh :P Someone tell me what is a major complication (especially in this case) due to layrngospasm?
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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 Flightgypsy

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Posted 12 February 2008 - 10:36 PM

Death????
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#57 RoadieRN

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Posted 13 February 2008 - 01:29 AM

Death????


Now that's funny right there. I don't care who you are. :P
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Nick Crusius RN, BSN

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#58 GravyMedic

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Posted 13 February 2008 - 01:51 AM

Now that's funny right there. I don't care who you are. :P


Im jumpin in pretty late here, but better late than never. great case so far.

Not really sure what you're looking for with complication of laryngospasm, but it makes for a hell of tough time passing the tube. So, difficult intubation? Little lido on the cords will help relax em.
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#59 MSDeltaFlt

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Posted 13 February 2008 - 04:56 AM

Laryngospasm. With the scene as Mike described, I'd lean towards aspiration. Major complication would probably be a complete and irreversible airway shut down. Combi, King, and LMA is a definite no joy. It's intubation or cric. Christ Almighty I'd hate to be the one charting this one. I'm getting writer's cramp just thinking about it.
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#60 newBfltrn

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Posted 13 February 2008 - 03:35 PM

Minh (rfdsdoc), buddy you are a wicked clinician. No 2 ways about it.
About laryngospasm

Laryngospasm is an uncontrolled/involuntary muscular contraction (spasm) of the laryngeal cords. It may be triggered when the vocal cords or the area of the trachea below the cords detects the entry of water, mucus, blood, or other substance. It is characterized by stridor and or retractions. Commonly, this happens in pts who are sedated or lethargic. If you have ever heard of a "dry drowning" where the kid is floating on the top of the water and has little or no water in their lungs that is what has happened. It can be so severe that the pt cannot breath whatsoever and can die of asphyxia. nasty stuff.

Except Minh :P Someone tell me what is a major complication (especially in this case) due to layrngospasm?


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