# During a code, she blew up like a balloon. Questions..



## tazman7 (Dec 14, 2008)

We got a call today for 85 yo lady who fell just needed help getting up. On our way out the door dispatch said lady was now unconscious but had a pulse. UOA we found pt lying on kitchen floor in cardiac arrest. cpr was started...intubated, monitor showed asystole, pushed epi and atropine, yada yada yada.....Intubation was confirmed by visualisation, condensation in tube, lung sounds, et co2

enroute to hospital approx 10 minutes after arriving on scene pt face starts swelling like a balloon!! I cut her shirt off and you could literally see her expand. So now we are thinking allergic reaction. So we push benedryl...pt still keeps getting bigger. By the time I got her shirt and bra cut her stomach and chest were so hard we could barely do compressions. I then went to cut her pants off and they were so tight to her skin that I could barely get my fingers in her pants to pull them away from her body to cut them, when I finally started cutting they ripped on their own.  This little old lady who weighed prob 100 lbs now looked like she was 300. Her skin was so stretched out that I thought when we were doing compressions her stomach was going to blow! if you squeezed her arm you could feel the sub q air underneath the skin.
UOA to hospital doctor was like wtf?!?! he then basically did the same thing but her wanted to decompress...well he did and got nothing.

What the hell could have happened to this lady.
Bystanders stated that she wasnt allergic to anything that she knew of,  pt has been acting normal


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## VentMedic (Dec 14, 2008)

I've seen this with a tracheal or bronchial wall tear. It can be caused by intubation with the tube or stylet or a fractured bone in the chest from compressions.


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## FF894 (Dec 14, 2008)

I would definitly get her to Princeton-Planesboro asap...  Well, air is coming from somewhere right?  Talk more about the airway..  recheck the tube?  Good lung sounds?  Good wave form?  Hard to bag?  Any follow-up from hospital?


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## tazman7 (Dec 14, 2008)

When we got to the hospital the dr rechecked the tube, said it was good...then he pulled it out! and put in a new one, twice. Dont ask me why...it he wasnt able to get the tube back in from her massive swelling there would have been no way to do a surgical cricothyrotomy because her neck was gone. (Dont ask me why he did it) lung sounds were good, bagging was difficult. Dr called it a pneumothorax.

Im wondering if it was a fractured bone in the chest...the first compression I gave her i thought i felt one pop but then I had another guy take over so i could do other things...so im not sure..


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## tazman7 (Dec 14, 2008)

im not familiar with what you mean by good wave form?

im not even sure what you would call this kind of swelling..I was trying to google it to show it to my girlfriend who is in nursing school.


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## FF894 (Dec 14, 2008)

End-tital wave form.  Vent is right, however I would suspect tension-pnuemo s/p lung rupture (pop) from hyperventilation and hyper tidal volume.  Studies show (and I'm sure Rid or Vent or someone can back this up with the actual data?) that we (health care as a whole) are huge offenders of hyperinflation.  The reason why I say this is because it sounds like you were on the road for a while before you started to notice it and it happened markedly and rapidly? A trachial tear would be a "slower" leak depending on size, location, cuff placement, etc.  Bronchial tear would be fairly rapid but less likely?


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## VentMedic (Dec 14, 2008)

tazman7 said:


> im not even sure what you would call this kind of swelling..I was trying to google it to show it to my girlfriend who is in nursing school.


 
I thought you said 





> sub q air underneath the skin


 
Here's one link. You can google for more.

http://emedicine.medscape.com/article/362315-overview

If one is bagging a patient with positive pressure, the body will blow up quick. Air may still move in and out of the lungs depending on where the tear is.

I've seen bronchial tears from feeding tube placement, or misplacement.

It actually doesn't take much pressure to put a stylet or ETT through either branch.


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## daedalus (Dec 15, 2008)

I have STAT paged Greg House. Call CCT and arrange emergent transport to princeton plainsboro.


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## mycrofft (Dec 15, 2008)

*Must be paraneoplastic syundrome, but then, pt's lie...*

Subcutaneous emphysema. My quarter's on the square that says tube went into mediastnum and air went there. Pt live?

Hey, imagine being the corpsman who went to place a nasogastric tube in a multiple GSW battle case, the pt seized and died...the tube had gone through a internal riccochet frag tract from the nasopharynx into the brain.


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## MOflightmedic (Dec 15, 2008)

Disected bronchus or perforation is my thoughts as well.  Probably more common with a signifcant traumatic MOI but wierder things have happened.  Nonetheless, every PPV filled her dermis like it was a big pleura.  CXR reveal anything?  

Have you ever intubated a trauma Pt and not been able to get lung sounds on one side or the other?  You start thinking you've R main stemed your tube or your so bad that you're the first person you know that's actually tubed the left bronchus!   Then.......you start discover sub q air and a scrotum that looks like it belongs on an elephant. :unsure:


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## Ridryder911 (Dec 15, 2008)

There are many reasons for a pneumo. Bleb's, P.E., over zealous of bagging the patient, pulmonary tree rupture as Vent described. 

This is not an uncommon event. Paramedics or anyone that can intubate, should be well educated on this as well on how to treat. 

Geez... Are they not teaching anything anymore?

R/r 911


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## remote_medic (Dec 15, 2008)

Ridryder911 said:


> Geez... Are they not teaching anything anymore?
> 
> R/r 911



Awesome support of another EMS provider asking a question...


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## VentMedic (Dec 15, 2008)

remote_medic said:


> Awesome support of another EMS provider asking a question...


 
But his statement is a good one for thought.  We have had numerous threads about who should intubate and how to intubate which can lead one to believe they have dumbed down a very important skill that requires some education to accompany it.


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## remote_medic (Dec 15, 2008)

VentMedic said:


> But his statement is a good one for thought.  We have had numerous threads about who should intubate and how to intubate which can lead one to believe they have dumbed down a very important skill that requires some education to accompany it.



I will agree with you on that one 100%. I know I am a "new kid" around here on the site. I am pretty new to EMS after a 10 year nursing carreer. Every day that I work in EMS I learn something new, and that is after 10 years as a critical care nurse. I can only imagine how I would feel after coming out of a paramedic program and not having the knowledge and background that I have.

All Rid's comment has done is discourage this  provider (and probably others) from asking further questions. I know in my paramedic program, tracheal rupture / bleb / pneumomediastinum was never covered. Yes we talked about pneumothorax and treatment. But I think this provider was taken back by how quickly this patient developed the swelling he described.

I have been a troll on the site for awhile, reading for a while before even registering an account. I value the knowledge and advice recieved from both you and Rid. I might think twice though before asking for advice or a question though

Chris


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## FF894 (Dec 15, 2008)

Don't be discouraged.  Thats sort of what you have to deal with in any forum whether its online or in person.  You have to skip over the part where they tool on you a little for not knowing the answer and realize that they still provided the answer you were looking for and you learned something...


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## VentMedic (Dec 15, 2008)

What does one have to lose by posting?  If one takes comments made at or around them personally from an anonymous forum, then life may be a challenge.


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## exodus (Dec 15, 2008)

remote_medic said:


> I have been a troll on the site for awhile, reading for a while before even registering an account. I value the knowledge and advice recieved from both you and Rid. I might think twice though before asking for advice or a question though
> 
> Chris



That's not a troll! That's a lurker (A good thing). A troll is some one who comes in and posts stupid crap just to get reactions out of people.

Don't be discouraged 99% of the people here WILL answer your questions, just look at the first page of this thread, followed by the negative post of one person.

RR, I have noticed with you though, that you are constantly critiquing the schooling of new EMT's, if you think it's so horrible, why don't you become an instructor and change that?


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## marineman (Dec 15, 2008)

exodus said:


> That's not a troll! That's a lurker (A good thing). A troll is some one who comes in and posts stupid crap just to get reactions out of people.
> 
> Don't be discouraged 99% of the people here WILL answer your questions, just look at the first page of this thread, followed by the negative post of one person.
> 
> RR, I have noticed with you though, that you are constantly critiquing the schooling of new EMT's, if you think it's so horrible, why don't you become an instructor and change that?



I'll get this one for him... he is an instructor and I for one would love to attend his class as I'm sure they are very well educated.

As for worrying about R/R's style you need to get some thick skin. Dr. Cox is a very appropriate avatar for him as he will give you the answer provided you have attempted to find it yourself however he is not one to sugar coat anything. If you get bent out of shape about one person not being overly friendly on an internet forum god help you on the rig.


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## exodus (Dec 15, 2008)

marineman said:


> I'll get this one for him... he is an instructor and I for one would love to attend his class as I'm sure they are very well educated.
> 
> As for worrying about R/R's style you need to get some thick skin. Dr. Cox is a very appropriate avatar for him as he will give you the answer provided you have attempted to find it yourself however he is not one to sugar coat anything. If you get bent out of shape about one person not being overly friendly on an internet forum god help you on the rig.



I'm not getting bent out of shape! I was mentioning this because of r_m responded, if he is an instructor and is trying to change this, then awesome! I'd also like to be in one of his classes.

He has a strong opinion on things and tells it like it is. That is a good thing!


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## FF894 (Dec 15, 2008)

Yeah dude, what he said.  Read some of his posts.  You think someone who spends that much time on here is here solely here to bust balls?  Get over it and read to learn and your skin shall get thicker


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## remote_medic (Dec 15, 2008)

Points taken...but not necessarily agreed with


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## Melbourne MICA (Dec 15, 2008)

*IPPV induced pneumothorax*

Hi troops

The most likely and logical explanation for this event is a ventilation induced pneumothorax under the positive pressure of a closed circuit. This is not uncommon but the usual outcome is an unrecognised tension and confused operators who can't understand why the patient is crashing so fast. 

The sequence is typically after suceesful reversion with defib, the ETT is passed , ROSC achieved then a deteriorating perfusion state occurs. Its propped up with epi boluses and infusions but goes nowhere until someone decides to do a decompression or two. 

Alternately you overventilate and the raised interthoracic pressures significantly reduce venous return. Thus resp rates and TV's with the bag need to be done very delicately and with great attention to all the details - resp state and perfusion state as well.

Many a potentially viable arrest patient has died not from the precipitating event but from unrecognised tensions. As a rule of thumb any patient who gets ROSC but loses perfusion should get needled. Use your ETCO2/SPO2 tools as a guide also.

In this case some visceral pleura has sprung a leak and instead of the lung space filling with air it has gone subcutaneous. Its a bit like the way water will find any path to flow. So the air just keeps travelling particularly when your'e providing plenty of positive pressure. There is also the risk of penetrating or blunt trauma from overzealous ECC doing the same thing.

There are plenty of "interesting" photos - I use the term delicately - of scrotums the size of basketballs filled with just air from blunt trauma induced pneumos. 

Whilst I don't dispute that a tracheal rupture could occur I believe this highly doubtful as the ETT is passing largely parallel to the wall. The trachea is very tough. As for one of the main branches - I wouldn't think you could pass a tube that far unless the patients neck was 3 inches long and you inserted your whole hand down the gullet.

Still the effect must have been startling to say the least. Did you consider needle testing both sides?

MM


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## VentMedic (Dec 15, 2008)

Melbourne MICA said:


> Whilst I don't dispute that a tracheal rupture could occur I believe this highly doubtful as the ETT is passing largely parallel to the wall. The trachea is very tough. As for one of the main branches - I wouldn't think you could pass a tube that far unless the patients neck was 3 inches long and you inserted your whole hand down the gullet.
> 
> 
> MM


 
The trachea is just as delicate as any other organ or structure in the body when foreign objects such as an ETT, Stylet or gastric tube is pushed into it. One also has to take into consideration anomalies that may already be present such as malformations or tissue damage from radiation, age and disease processes.

Please do not give the impression that intubation can do no harm if one has little education about the technique, does not do a quick assessment of the airway structures for degree of difficulty or fails to exercise some caution when intubating.

Being associated with a large trauma and research facility, and an RRT also, I get to see these injuries from various causes arrive from many different surrounding hospitals for repair. Some tears are small and some tears are destined to be fatal. 

If one recognizes "swelling" or subcutaneous emphysema early enough, they may be able to correct their technique or even reposition the tube. We keep a flex bronchoscope handy in the ED to do a quick look and/or insert a double lumen tube to ventilate each lung independently if we suspect a serious lung rupture. We also do alot of trachs due to damage to the soft tissue or the larynx.

The ETCO2 and SpO2 many reflect a change after the subcutaneous emphysema is present and the patient is already compromised. It is always a good idea to watch your patient also.


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## tazman7 (Dec 15, 2008)

I can take the heat, i have big shoulders...I was just the emt on the call so I didnt do the intubation..I dont take my medic test until wednesday. 

As far as reading the spo2 it was reading at 99%. ETCO2 was golden yellow. 

Interesting case...like others said its very easy to over-ventilate pts.


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## tazman7 (Dec 15, 2008)

talked to my two medic teachers, they called in subqutaneous emphysema.


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## VentMedic (Dec 15, 2008)

tazman7 said:


> talked to my two medic teachers, they called in subqutaneous emphysema.


 
You already described that in your OP.

Subcutaneous Emphysema is the result of a disruption in the pleural membranes where air escapes. In some cases it can come from the GI tract but usually not as severe. 

The cause would probably be determined by a CT Scan if the patient lived and an autopsy if she died.


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## fma08 (Dec 15, 2008)

Seen this. However it was primarily in the face and due to a false tract created after someone botched up a trach. The tube went into the false tract and then all the air was being pushed into tissue instead of the lungs. Very creepy thing to see.


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## Melbourne MICA (Dec 16, 2008)

VentMedic said:


> *Please do not give the impression that intubation can do no harm if one has little education about the technique, does not do a quick assessment of the airway structures for degree of difficulty or fails to exercise some caution when intubating*.



Hi Venty

I did nothing of the sort. 

There is no book called "intubation for dummies".

I thought it better to point out more realistic and common problems with equally dangerous consequnces an EMT will come across when ventilating patients under any circumstances especially in the setting of ETT.

Like I said - I don't dispute tracheal peforation can occur. Personally however, in twenty years, Iv'e not once seen one occur from intubations I have watched or particpaited in but have seen multiple occasions when over-ventilation has created all kinds of perfusion and respiratory complications.

The original poster asked about the clinical situation he observed. I gave him the most likely causes and threw in some information on technique as well.

I'm sure you have read some of my other posts where ETT has been talked about eg the RSI thread. I agree - It's no game for beginners and certainly not without serious consequnces when due attention to precision and care is neglected.

But like I said to the original poster - his situation must have been startling to see in the flesh.:blush:

MM


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## rhan101277 (Dec 16, 2008)

This thread was a good read, I have heard of sub-q emphysema from stuff like trauma and air getting inside the wound.  I have never head about it occurring from bagging a patient with a pnuemo or from improper inserting a endo tube.  When you bag a patient with pnuemo isn't it going to make the collapsed lung more collapsed?  You are also going to have to do 1/2 less of tidal volume than usual or risk a tension pneumo in the other lung right?


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## FF894 (Dec 16, 2008)

rhan101277 said:


> You are also going to have to do 1/2 less of tidal volume than usual or risk a tension pneumo in the other lung right?



Do what with who? :unsure::unsure:


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## 41 Duck (Dec 16, 2008)

Interesting thread.  Far as Rid's comments... I took them to be more aimed at the education the provider received than directed toward the provider himself, but hey... 

Having just got signed off on intubations this past Saturday, I can say that this potential complication wasn't covered in any of the didactic, but during lab, one of the instructors mentioned it and made sure it was something of which we were all aware.




Later!

--Coop


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## Ridryder911 (Dec 16, 2008)

Melbourne MICA said:


> Hi Venty
> 
> There is no book called "intubation for dummies".



No, but we have.....


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## remote_medic (Dec 16, 2008)

Ridryder911 said:


> No, but we have.....





Please for the love of god tell me that is a photoshopped picture


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## Melbourne MICA (Dec 16, 2008)

rhan101277 said:


> This thread was a good read, I have heard of sub-q emphysema from stuff like trauma and air getting inside the wound.  I have never head about it occurring from bagging a patient with a pnuemo or from improper inserting a endo tube.  *When you bag a patient with pnuemo isn't it going to make the collapsed lung more collapsed? * You are also going to have to do 1/2 less of tidal volume than usual or risk a tension pneumo in the other lung right?



Absolutely it is. What will be needed is first recognition that a tension pneumo is developing  - this will be observable through changes in capnography/spo2 readings and a rapid and marked deterioration in perfusion state - indeed the pt will probably go into PEA, a scenario you will often see in trauma cases with chest injuries.

The Subcut emhysema will occur from tearing or dissection of the parietal pleura not from tearing or rupture of the viceral pleura - that is the pleura attached directly to the lungs - remember there is a pleural layer attached to the lung, a gap (the pleural space), then the pleural layer that adjoins the inside of the chest wall. The lungs adhere to the chest wall layer through surface adhesion - they can't be rigidly attached otherwise how would they move as you breathe?  

See the difference? The sub cut air won't enter the pleural cavity but instead wind its merry way between the outer layers and into other body cavities - hence you can get swelling just about anywhere the air can travel if it can find a pathway.

So the solution for each will be different in some ways - for the tension you will need to decompress the chest otherwise its perfusion collapse, PEA and rapid death. For the subcut emphysema you will need to reduce both TV and RR when bagging and attempt to maintain SPO2's until the Docs can deal with it in the A&E. As Venty pointed out they may use a dual lumen ETT so each lung can be separately ventilated.

With a pnuemo you won't produce a second one in the other lung simply because the first has one. The air will just keep accumulating in one side till the venous structures start getting compressed, then venous return will slow and stop - no input, no output - the pt will arrest again or go into arrest. With enough air entrapped you can even encroach on the heart itself. Not a good thing if the patient wants to see Obama institute universal health care.

Suffice it to say, when you bag a patient it's not just matter of attaching the equipment and bagging away. You must watch and assess, treating each patient with a view to ventilating based on that patients anatomy, pathologies etc. You won't bag grandma the same way you would a robust twenty year old male.

You must bag to achieve a result, that being adequate oxygenation that will be revealed through your various assessment procedures and tools, like perfusion state and SPo2 readings.

It is so important to recognise the physiology at work and not just look upon your ventilation as a simplistic mechanical task.

Delivering oxygen and removing CO2 is to provide a drug and remove another no different from other drugs. And as you would be well aware, all drugs come with effects and side effects. In this case there is also potential problems associated with delivery as well. This goes for IV meds as well. See what happens to someones arm if you give 50% dextrose into the tissues instead of the veins.

MM


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## Melbourne MICA (Dec 16, 2008)

*Addendum and correction*



rhan101277 said:


> This thread was a good read, I have heard of sub-q emphysema from stuff like trauma and air getting inside the wound.  I have never head about it occurring from bagging a patient with a pnuemo or from improper inserting a endo tube.  *When you bag a patient with pnuemo isn't it going to make the collapsed lung more collapsed? * You are also going to have to do 1/2 less of tidal volume than usual or risk a tension pneumo in the other lung right?



The Subcut emhysema will normally occur from tearing or dissection of the parietal pleura not from tearing or rupture of the viceral pleura - that is the pleura attached directly to the lungs - remember there is a pleural layer attached to the lung, a gap (the pleural space), then the pleural layer that adjoins the inside of the chest wall. The lungs adhere to the chest wall layer through surface adhesion - they can't be rigidly attached otherwise how would they move as you breathe?  This what you may see in trauma with the air winding its merry way between the outer layers and into other body cavities - hence you can get swelling just about anywhere the air can travel if it can find a pathway.

But the air may also enter the pleural cavity and so produce a tension pnuemo - this is why it is recognised as a sign that tension pneumo may be occuring.


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## Melbourne MICA (Dec 16, 2008)

*Oops*



Melbourne MICA said:


> The Subcut emhysema will normally occur from tearing or dissection of the parietal pleura not from tearing or rupture of the viceral pleura - that is the pleura attached directly to the lungs - remember there is a pleural layer attached to the lung, a gap (the pleural space), then the pleural layer that adjoins the inside of the chest wall. The lungs adhere to the chest wall layer through surface adhesion - they can't be rigidly attached otherwise how would they move as you breathe?  This what you may see in trauma with the air winding its merry way between the outer layers and into other body cavities - hence you can get swelling just about anywhere the air can travel if it can find a pathway.
> 
> But the air may also enter the pleural cavity and so produce a tension pnuemo - this is why it is recognised as a sign that tension pneumo may be occuring.



Sorry Rhan - managed to make a meal of the explanation. Hope it makes  abit more sense.

MM


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## VentMedic (Dec 17, 2008)

Here are some links to get a better visual:

Chest trauma
http://www.trauma.org/archive/thoracic/index.html


Subcutaneous Emphysema
http://www.learningradiology.com/archives05/COW 180-Subcu Emphysema/subcuemphysemacorrect.htm

Tracheal Bronchial Rupture
http://ejm.yyu.edu.tr/old/99-1/39.pdf


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## bonedog (Dec 17, 2008)

Excellent sites as usual Vent.

Here's a story related to me.

Octagenarian COPD, thin emaciated female, respiratory distress, medic takes time to relate to the family how he has to put a tube down her throat to help her breathing.

Out of the bed room comes the crew in a rush, the patient now has been added to the cast of Ghost Busters, the marshmallow gramma.....


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## Melbourne MICA (Dec 17, 2008)

*Of interest*



VentMedic said:


> Here are some links to get a better visual:
> 
> Chest trauma
> http://www.trauma.org/archive/thoracic/index.html
> ...



Thanks for the links as always Venty.

Of interest from the radiology site was their description and diagnosis of tension pneumothorax on the basis of chest radiography.

My understanding is that tension pneumo is diagnosed clinically as their is no demonstarted relationship between any particular percentage or degree of pneumothorax seen on chest film and the onset of tension pneumothorax with corresponding respiratory and cardiovascular compromise. 

One of our ED directors recently recounted a great story that amplifies this fact when he was called by the radiologist who had just done a chest film on a patient declaring excitedly that the patient was tensioning and in dire straits and should be immediately needle thoracostomised (is there such a word? - sounds allright!!!!).

The ED director checked on his patient who he instantly noted was sitting up in bed eatiing a sandwich.

Apparently what appeared to be a sizeable pnuemothorax on film had no immediate clinical repercussions for this particular patient.

It's a great area of interest for ambos and such an important one don't you think?

PS Iv'e thrown in a link to a Wiki article about the trauma centre where my MICA branch is located. It's just out of picture to the right of the main entrance seen in the photo.

http://en.wikipedia.org/wiki/The_Alfred_Hospital

Cheers

MM


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## VentMedic (Dec 17, 2008)

Melbourne MICA said:


> Apparently what appeared to be a sizeable pnuemothorax on film had no immediate *clinical* repercussions for *this particular patient.*


 
Key words. That is why radiologists almost always include "clinical correlation" in their reports.
They are required to notify the ordering physician of their findings and some may have to use certain words to get the attention of a physician in a busy ED.  It is their butt if that ED doctor says he didn't hear it was that bad if the patient crumps. 


thoracostomised: He was just playing off the word thoracostomy.

http://www.emedmag.com/html/pre/cov/covers/101505.asp

Decent photos although I do recommend the use of sterile gloves.

http://www.brooksidepress.org/Produ...perationalmed/Procedures/InsertaChestTube.htm

YouTube is full of medical procedures for those that are interested.


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## Airwaygoddess (Dec 17, 2008)

*Intubation question*

I have a question, is this one of the reasons why some anesthesiologist do not use a styet while intubating a patient?  I have spoken with many paramedic students while on their OR rotation and many have told me this.  Is it personal preference or part of a safety factor?


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## 41 Duck (Dec 17, 2008)

I'm guessing for them, it's personal preference... they're working under optimal conditions, too...


Later!

--Coop


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## tazman7 (Dec 17, 2008)

Few more things I forgot to add in my first post, which will make things even more interesting.

Once we arrived at the hospital the Dr figured that the tube was in the stomach because at this time she was so "puffed" up that you couldnt hear lung sounds or anything. So he pulled the tube!!! Reintubated and pulled it again and reintubated..!! Dont ask me why he did it twice.Very dangerous thing to do i would say being that her airway was basically swelled up to nothing. So after the dr trashed the airway she was bleeding like a stuck pig. He then decided to do a chest decompression.. He had 6 needles in this ladys chest probing around like she was a pin cushion....no air came out of any of them....

Her swelling was in her entire body except from her knees down she was perfectly normal..
Her swelling was so bad it was pulling the iv's out of her arms.

I have tried finding a pic on the internet of something similar but nothing compares to this lady, not even close


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## VentMedic (Dec 17, 2008)

Airwaygoddess said:


> I have a question, is this one of the reasons why some anesthesiologist do not use a styet while intubating a patient? I have spoken with many paramedic students while on their OR rotation and many have told me this. Is it personal preference or part of a safety factor?


 
Since the tubes are stored in the OR where it is cooler, the tubes may not "flop" around as they are likely to at room or outside temperature. 

It depends a lot on the make and model of the tube. Some are stiffer than others and some may even have a built in stylet for maximum control during different percedures. The anesthesiologist assisting some of our ENT surgeons may use those to bend the tube in different ways once inserted. Those with the subglottic suction ports are also a little stiffer. 

There are many different ETTs availabe for different purposes. That is also why they may see us (RRTs, MDs) switching tubes out when they come in with a prehospital tube. 

All of our specialty (NICU, PICU, Flight) team members have had to give intubating without a stylet a try.


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## Melbourne MICA (Dec 17, 2008)

*alternative causes*



tazman7 said:


> Few more things I forgot to add in my first post, which will make things even more interesting.
> 
> Once we arrived at the hospital the Dr figured that the tube was in the stomach because at this time she was so "puffed" up that you couldnt hear lung sounds or anything. So he pulled the tube!!! Reintubated and pulled it again and reintubated..!! Dont ask me why he did it twice.Very dangerous thing to do i would say being that her airway was basically swelled up to nothing. So after the dr trashed the airway she was bleeding like a stuck pig. He then decided to do a chest decompression.. He had 6 needles in this ladys chest probing around like she was a pin cushion....no air came out of any of them....
> 
> ...



Is there any chance we are looking at another cause for this "swelling" such as anaphylaxis? Can you give any info on IV meds that were given or the background to the case?

MM

MM


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## Melbourne MICA (Dec 17, 2008)

VentMedic said:


> Since the tubes are stored in the OR where it is cooler, the tubes may not "flop" around as they are likely to at room or outside temperature.
> 
> It depends a lot on the make and model of the tube. Some are stiffer than others and some may even have a built in stylet for maximum control during different percedures. The anesthesiologist assisting some of our ENT surgeons may use those to bend the tube in different ways once inserted. Those with the subglottic suction ports are also a little stiffer.
> 
> ...




Venty, you mentioned gastric leaks as a cause of subcut emphysema - if this intubation was an unrecognised oesophogeal tube is there any chance that overventialtion could have produced a stomach tear or the like?

Also, did the EMT-P use capno and other testing to confirm his tube placement ? No offense intended but unrecognised oesophogeal tubes are a bad miss for a competent Para with good experience and support though I appreciate that mistakes can happen and nearly always do no matter how vigilant we are. Or perhaps the Doc was wrong. I assume he did a chest film to confirm amongst other things that the tube was in the right hole and also of course, to check for a pneumo.

The plot thickens.

MM


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## tazman7 (Dec 17, 2008)

The meds we gave were Epi, Atropine Epi, Atropine...lady started swelling at this point so we pushed Benedryl, that didnt help. So back to Epi and Atropine.   Im not exactly sure what they gave at the hospital...I dont think that they gave much different.. 

No chest film was taken....

We confirmed tube placement by visualization, etco2, lung sounds, condensation in tube, and it also bagged good (cant think of the word right now)

No idea if this was caused from anaphylaxis. Pt niece who was with her stated that she had just ate lunch, nothing out of the norm. No change in meds, been taking her meds, kind of an unknown history, we only got no allergies. Pt had just stood up from the kitchen table and was walking to the sink, then fell over. She laid there for approx 1 minute they called 911 approx a minute later pt went unconscious, we arrived another minute later to a full arrest with pt being asystolic.


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## VentMedic (Dec 17, 2008)

Melbourne MICA said:


> Venty, you mentioned gastric leaks as a cause of subcut emphysema - if this intubation was an unrecognised oesophogeal tube is there any chance that overventialtion could have produced a stomach tear or the like?
> 
> Also, did the EMT-P use capno and other testing to confirm his tube placement ?
> MM


 
Tube appears to have checked out initially. But if I remember correctly without looking at all of the posts a *colormetric* CO2 detector was used. The pt could have had a couple of Cuba Libres and/or a few beers. Without a continuous waveform, the tube could have moved.




tazman7 said:


> We confirmed tube placement by *visualization, etco2, lung sounds, condensation in tube, and it also bagged good* (cant think of the word right now)


 
tazman,

Please do not take offense to any comments made. The Australian and I, as well as anyone else, may just toss a few things around from experience and brainstorming. Whatever we come up with may not even pertain to your patient but I'm sure there'll be good points made that might assist someone else's assessment in another situation.


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## Melbourne MICA (Dec 18, 2008)

tazman7 said:


> The meds we gave were Epi, Atropine Epi, Atropine...lady started swelling at this point so we pushed Benedryl, that didnt help. So back to Epi and Atropine.   Im not exactly sure what they gave at the hospital...I dont think that they gave much different..
> 
> No chest film was taken....
> 
> ...



So the mystery remains. Good ETT checks but surprising the doc didn't order a film especially if he thought the tube was in the wrong hole. I wonder what checks he did. Did you ask for the tube placement to be checked when you arrived? 

As an aside, we do them as matter of course now regrettably because an ED intern once mucked around with the ETT in an arrested pt who had been salvaged and came in with good obs. The pt then re-arrested when the intern replaced the tube in the wrong hole despite fantastic obs an all the numbers in the right ranges. She insisted the ETT was wrong.

There was a coroners investigation after the pt died and the intern blamed the MICA guys. Very bad vibe created with that one. All is well now - great ED staff at my local and fantastic relationship with them.

Sorry I forgot you said you gave benadryl - good covering of your bases.

All in all, sounds like it was a bit of a puzzle in the ED as well. Wonders never cease in medicine.

I don't think we can talk enough about artificial ventilation in EMS - its a fantastic area of our practice but strangely one where we have such a mixed bag of skill standards.

Thanks for the interesting case.

MM


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## VentMedic (Dec 18, 2008)

tazman7 said:


> enroute to hospital approx 10 minutes after arriving on scene pt face starts swelling like a balloon!!


 
The other thing about ETI and ventilation is securing the ETT.  Check your mark at the teeth or gum line not the lips.  If swelling does start, as described here, too much play in the securing device will pop that tube up and out of place.

If we do an active fluid resuscitation such as in the Burn ICU, I may have to change my tube holding device secure mark several times.  What I use does not have much give to it but it can damage the skin if too tight.   The marking at the gum or teeth line should remain the same but the lip tape mark may move as much as 4 - 6 cm.


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## 41 Duck (Dec 18, 2008)

VentMedic said:


> The other thing about ETI and ventilation is securing the ETT.  Check your mark at the teeth or gum line not the lips.  If swelling does start, as described here, too much play in the securing device will pop that tube up and out of place.
> 
> If we do an active fluid resuscitation such as in the Burn ICU, I may have to change my tube holding device secure mark several times.  What I use does not have much give to it but it can damage the skin if too tight.   The marking at the gum or teeth line should remain the same but the lip tape mark may move as much as 4 - 6 cm.



Good point!


Later!

--Coop


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## maxwell (Jan 30, 2009)

Sounds like a vascular catastrophe (dissection, AAA, etc)


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