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


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#101 rfdsdoc

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Posted 22 February 2008 - 02:04 AM

Hey folks

You gotta know when to hold, know when to fold, know when to walk away, know when to run....

I guess when you look at it we are all gamblers in this line of work, arent we?

Just trying to stay light hearted in what is an obviously shitty situation!

I am gambling that the cause of this airway obstruction/failure is something as simple as body positioning combined with recent paralysis. I do not believe the obstruction is anything more complicated or sinister than that. I do not believe it is recurrent laryngospasm as he is paralysed. Would he have suddenly developed a laryngeal tumour or haematoma or fracture in the last 5 minutes? Has he suddenly aspirated a hot dog..I don't think so. If his airway anatomy is normal then why cut him until you can prove that it is not a functional obstruction due to body position?

He had a reasonable patent airway when we arrived and everything we did to mess with it made things worse. I think doing more complicated things to the airway just does not fit with the recent history of airway complications i.e why do more when you have not tried doing less!

Does anyone honestly think that this man has a complete airway obstruction that can only be solved with surgery? Think of all the compete airway obstructions you have attended and does it fit this picture here?

The emergency literature tells us that a surgical airway on a cadaver ( ie not bleeding) by trained surgeons takes on average 100 secs from go to woe(read Levitan's excellent treatise on this ) . It is going to take about 10 seconds to reposition this guy into a sitting position and reattempt BVM with two persons. If you really want you can stick in oral and nasal airways to assist this effort. Don't worry about laryngospasm at this point as he is paralysed and about to die anyway.


Speed I think your surgical airway plan is a good plan but the timing is off that's all.
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Minh Le Cong
Medical Officer
MBBS(Adelaide), FRACGP, FACRRM, FARGP, GDRGP, GCMA
RFDS Cairns base , Queensland, Australia

#102 chris

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Posted 22 February 2008 - 02:34 AM

I am really ready for the next part of this case. What happened???
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#103 Mike MacKinnon

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Posted 22 February 2008 - 01:25 PM

hehe

Ok

So there are 2 distinctly different options but here is what happened and we will go from there.

The cric was attempted with a 16 gauge long needed used to guide the cut after trachea was punctured / identified.

Cric was attempted using the inserted IV as a guide without success. Membrane could not be identified.

Pt was repositioned in a semi sitting position with a few blankets/pillows behind his back to extend his head a little, an OPA was placed as the pt is basically non responsive. A large tegredem is placed over the patients nose and mouth with holes put where the nares and mouth are (this creates a better seal plastic on plastic) and an EMT is assigned to hold the mask to the pts face as tight as he can while the crew ventilated him. They managed to get the sat up to 92% for the trip.

En route the patient coded on 2 seperate occasions since the ride was almost 90 minutes.

He did have a PE and a severe aspiration pnemonia. Never regained consciousness and expired in the ICU 3-4 days later. Turns out that he also had genetically deviated trachea which was extremely anterior. On intubation in the trauma room the pt was unsuccessfully attempted 2 times with a glidscope and then dont with the Fibreoptic.

Nasty nasty...

What could have been done differently?
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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

#104 BackcountryMedic

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Posted 22 February 2008 - 04:41 PM

A large tegredem is placed over the patients nose and mouth with holes put where the nares and mouth are (this creates a better seal plastic on plastic) and an EMT is assigned to hold the mask to the pts face as tight as he can while the crew ventilated him. They managed to get the sat up to 92% for the trip.


This is pure genius! I'll be putting it in my 'toolbox'.
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"If everybody is thinking alike, then somebody isn't thinking" - Patton

#105 Mike MacKinnon

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Posted 22 February 2008 - 05:15 PM

hey BC

yah it works well. It is something I use for pts with beards as well. Works good. :)
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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

#106 chris

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Posted 22 February 2008 - 08:14 PM

That is a great idea, using the tegaderm. I really don't think you could have done anything differently. The guy was screwed from the git go. You know he had a crummy airway if you could not tube him with a glide scope. :) :D
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#107 Speed

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Posted 22 February 2008 - 08:43 PM

Gee thanks Mike! My butt's a little raw after that one. Most definitely a "two cigarette" flight, I guess: ride, on this one. Anyway, I would've avoided the NPA. After going back through and reading it all (which I should've done earlier) I'm just noticing the dose of the IM succinylcholine you gave, that's a smarter way of doing that. I was assuming a standard IV dose... bad excuse I know. The atypical larynx explains why the LMA didn't work. Getting a tube through the LMA sounded nice, but I guess in all honesty I couldn't have done that in the first place since I don't carry them. It would have been a King airway. If all of the non-invasive attempts, ET, and King weren't working I'd still have tried to place a tube in the cric', maybe that's a flaw on me, that's just something that's always worked for me and I've come to depend on it. Mind you the flying doc has something when he speaks of positioning. I think positioning is everything when it comes to a BLS airway, visualizing cords, and even more critical in a morbidly obese person. A surgical airway is really the last thing I want to do, but if I start getting that feeling that the "ship is sinking" I won't hesitate.
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Mike Williams CCEMT-P/FP-C

#108 rfdsdoc

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Posted 22 February 2008 - 11:40 PM

Hey folks
Back in civilisation and just caught up on the case conclusion.

I think the EMS crew did a remarkable job in keeping him alive and are to be congratulated for managing a difficult job reasonably well. The only lesson which I am sure they will never repeat is messing with a high risk airway in the first place.

The fact that they were even able to locate the trachea with a needle is impressive. If they had SPeed there he could have passed a guide wire down and done a percutaneous cric!

The more I do prehospital work the more I realise that less is more. That is doing less on scene is in fact achieveing more good for your patient. I mean look at what happened to Lady Diana ...

A few of my retrieval colleagues would have a go at me for saying such a thing but that is my experience and clearly what this case demonstrates.

Once again thankyou Mike for an excellent learning case study and to the forum for the stimulating discussion.

We do not have anything similar to this forum in Australia (which is sad) so as an international guest I appreciate the spirit of equal sharing and participation.

All the best till next time
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Minh Le Cong
Medical Officer
MBBS(Adelaide), FRACGP, FACRRM, FARGP, GDRGP, GCMA
RFDS Cairns base , Queensland, Australia

#109 Mike MacKinnon

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Posted 22 February 2008 - 11:43 PM

Hey mike


Dont worry, i would have went the same route as you did. The only reason I think differently now is from all the controlled "tests" ive been doing on positing in to OR in relation to obstruction. Really, I was a solid airway guy before anesthesia school but I didnt really think much about positioning beyond the basics. While i dont think anesthesia has made my airway skills any better I do think I consider other things (which in not-sick patients is easy to do) like positioning that i would not have before.

I agree with you about Minh, he is on his game ;) AU is lucky to have you bub.
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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

#110 Ridgegirl

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Posted 23 February 2008 - 12:58 AM

Thanks for another great case. Morbidly obese patients should never be placed flat. I have learned some basic but valuable ramping techniques from a dear CRNA friend of mine which have allowed me to be successful with some very difficult intubations. Positioning is the key to success!
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Michele Guthrie, RN, CFRN, CCRN, CEN, NREMT-P

#111 STPEMTP

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Posted 24 February 2008 - 06:37 PM

Thanks for another great case Mike.
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#112 Mike MacKinnon

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Posted 24 February 2008 - 09:25 PM

Im glad people like the cases, i LOVE doing them. I learn an incredible amount reading the replies from a stellar group of clinicians here!
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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

#113 wvmountaineer

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Posted 25 February 2008 - 03:44 AM

Im glad people like the cases, i LOVE doing them. I learn an incredible amount reading the replies from a stellar group of clinicians here!



The most I learn from these case presentations is how little I actually know!
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Those who think they know it all are more dangerous than those who admit they don't.

#114 ucdust

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Posted 18 September 2008 - 04:33 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?

I would stick with BLS and simply reposition his airway.
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