# OK try this...



## piranah (Feb 21, 2008)

you have a 32 yr old male with crushing chest pain but gets worse when he inspires...his respirations are shallow but adequate at 24 BPM........hes got a pulse of 92 and normal.....skin is reddened but dry...he is GCS of 15.. and everything else is within normal ranges..no history of any cardiac condition and nor family history...this is the first time he has ever been truly sick or in pain medically speaking......what are some possibilities


Next one is a 25 yr old male who was involved in a MVA  he was unrestrained and has hit his throat on the steering wheel..he has crushed trauma to his crycoid cartiladge and has a compromised airway...he cannot be intubated....what are your options?

i like these two...


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## skyemt (Feb 21, 2008)

well, you are describing a pain that is "pleuritic" in nature... coupled with his young age, makes cardiac much less likely, i think...

was it sudden onset? or gradual?
does any position ease the pain?
does he feel it move anywhere?
has there been any trauma lately?
are you saying the breath sounds are clear bilaterally?


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## pumper12fireman (Feb 21, 2008)

On your chest pain pt., any recent use of drugs? i'd also like to know if there was any recent trauma? Also, what was he doing prior to onset of s&s?


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## Ridryder911 (Feb 21, 2008)

piranah said:


> Next one is a 25 yr old male who was involved in a MVA  he was unrestrained and has hit his throat on the steering wheel..he has crushed trauma to his crycoid cartiladge and has a compromised airway...he cannot be intubated....what are your options?
> 
> i like these two...



If it was a true "crushed cricoid cartilage", then intubation could be considered contraindicated and actually can be lethal as well as ventilating with high pressure resources. The problem arise that most cannot detect fractured cricoid until attempting intubation.  Performing a "crich" would even be considered controversial and even possibly causing more dangerous, the *one and only true treatment* is a surgical tracheotomy. 

Some resources* suggest that one might be able to intubate, but again very high risks, poor success to be expected, and again tracheotomy is suggested.

R/r 911


*Management of tracheal trauma;William E. Hurford, MD and Ruben Peralta, MD _Canadian Journal of Anesthesia_6/21/2003


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## piranah (Feb 21, 2008)

yes ...the pain is pleuretic in nature...and to the throat PT, i woul see if the surgical tracheotomy would be my consideration.......great guys... exactly what i was looking for...


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## ffemt8978 (Feb 21, 2008)

Moved to appropriate forum


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## bonedog (Feb 21, 2008)

Young people with pleuritic chest pain, stats say 20% have a PE.

Airway = rock and hard place, do what you must time h34r:


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## firetender (Feb 26, 2008)

Ridryder911 said:


> If it was a true "crushed cricoid cartilage", then intubation could be considered contraindicated and actually can be lethal as well as ventilating with high pressure resources.


 
I'm wondering if an unvisualized nasal-trachael intubation would be a possibility.


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## Ridryder911 (Feb 26, 2008)

firetender said:


> I'm wondering if an unvisualized nasal-trachael intubation would be a possibility.



It would not really matter. Since the fracture site is the lower portion of the airway or anterior trachea itself, just superior of the tracheal rings. The problem arises since this portion is where needle crichoidthyrotomy is performed and hence that procedure would as well be futile. The only option is perform an true tracheotomy just inferior of the crichoid membrane at just superior of sternal notch. The old procedure of surgical opening with horizontal cut 1/2" and rotating the handle and inserting either ETT or true tracheotomy fitting. Of course not many want or have performed this procedure in the field setting, nor alike myself want to if possible. 

R/r 911


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## bonedog (Feb 28, 2008)

Do you think doing a cricothyrotomy with seldinger's technique may work?
If you can feed the wire, you may be able to push the trocar, maybe a little more scapel work to facilitate ....


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## Ridryder911 (Feb 29, 2008)

bonedog said:


> Do you think doing a cricothyrotomy with seldinger's technique may work?
> If you can feed the wire, you may be able to push the trocar, maybe a little more scapel work to facilitate ....



Possibly, but performing such is similar to retrograde intubation and again the position of performing the cricoid is the fracture site. Pushing the seldinger wire guide to an opening in the trachea, I would believe could increase more trauma and if you have attempted to retrieve such device with blood, etc. I can attest is difficult and time consuming. 

Personally, I would believe that just performing the tracheotomy right the first time, would still be the easiest and fastest alternative and truly recognized treatment.

If you are going to have to perform an incision why not just do one time and be done with it?  

R/r 911


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## traumaangel26 (Feb 29, 2008)

On your chest pain pt.  Why is he so RED?  The red sounds like carbon dioxide poising.  What was he doing before he called you?


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## skyemt (Feb 29, 2008)

traumaangel26 said:


> On your chest pain pt.  Why is he so RED?  The red sounds like carbon dioxide poising.  What was he doing before he called you?



ok... before you get hammered, you might want to correct your post... lol.


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## traumaangel26 (Feb 29, 2008)

traumaangel26 said:


> On your chest pain pt.  Why is he so RED?  The red sounds like carbon monoxide poisoning.  What was he doing before he called you?




Sorry, long night!!


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## bonedog (Mar 2, 2008)

Good point Rid.  Surgical technique for myself is very limited, therefore was thinking about augmenting what I have been trained to do.


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