the 100% directionless thread

[SandpitMedic]

Congratulations Houston Astros!
#HoustonStrong

 

[CALEMT]

Yu mad @VentMonkey? Sorry had to, better luck next year. Cool to see Houston pull it off considering a hurricane demolished the city.

 

[VentMonkey]

Congratulations Houston Astros!
#HoustonStrong

Great Series, good for them, that said...

Tried and true, I still bleed blue.

#DemBumsin2018

 

[StCEMT]

So certain paramedics aren't meeting the standard

Fixed that for you.

 

[PotatoMedic]

Any chance we can get the rsi topic broken off into a thread called "The Great RSI Debate"? It's too linear for the 100% directionless thread.

 

[Carlos Danger]

I was attempting to be a smart ***.

Sorry, I missed that.

 

[VentMonkey]

Any chance we can get the rsi topic broken off into a thread called "The Great RSI Debate"? It's too linear for the 100% directionless thread.

Stick it in here:
http://emtlife.com/threads/the-great-airway-debate.44436/

 

[EpiEMS]

Stick it in here:
http://emtlife.com/threads/the-great-airway-debate.44436/

(That's a good thread idea...I will try and come up with something to write )

 

[VFlutter]

So I guess someone order the 10g NAR decompression needles instead of the 14g. Looked like I was ramming a railroad spike in some poor old lady’s chest. Worked like a champ tho. Tracheobronchial rupture ain’t no joke.

Here is a fun scenario. Patient has a Trachenobroncial injury to the right bronchus. Can’t see anything distal to the right mainstem bronchus on CT. Right Tension Pnuemothroax with massive tracheal deviation to the left. You need to intubate, what to do you with the tube? Try to blindly left mainstem it? Bury it to the hub and hope you are distal to the injury? Will that make the issue worse?

 

[Carlos Danger]

So I guess someone order the 10g NAR decompression needles instead of the 14g. Looked like I was ramming a railroad spike in some poor old lady’s chest. Worked like a champ tho. Tracheobronchial rupture ain’t no joke.

Here is a fun scenario. Patient has a Trachenobroncial injury to the right bronchus. Can’t see anything distal to the right mainstem bronchus on CT. Right Tension Pnuemothroax with massive tracheal deviation to the left. You need to intubate, what to do you with the tube? Try to blindly left mainstem it? Bury it to the hub and hope you are distal to the injury? Will that make the issue worse?

Man that is a tough one. Decompress and then try to intubate the left side, I guess. You can do it with a regular ETT, though it is probably much easier with a DLT. I'm sure @E tank has much more experience with that than I do.

 

[EpiEMS]

DLT

https://en.wikipedia.org/wiki/Double-lumen_endobronchial_tube?

Looks like sorcery to me...

 

[GMCmedic]

So I guess someone order the 10g NAR decompression needles instead of the 14g. Looked like I was ramming a railroad spike in some poor old lady’s chest. Worked like a champ tho. Tracheobronchial rupture ain’t no joke.

Here is a fun scenario. Patient has a Trachenobroncial injury to the right bronchus. Can’t see anything distal to the right mainstem bronchus on CT. Right Tension Pnuemothroax with massive tracheal deviation to the left. You need to intubate, what to do you with the tube? Try to blindly left mainstem it? Bury it to the hub and hope you are distal to the injury? Will that make the issue worse?

I want nothing to do with that.

Couldn't the left subsequently collapse also with a right mainstem intubation?

 

[Chris07]

Question to all you medics:

Has any of you ever seen Electrical Alternans in a patient?

The amount of pericardial effusion required to literally allow the heart to swing back and forth within the pericardial sac seems like it would make it a relatively uncommon.


Edit: I’d imagine that an ultrasound finding like below would not be common and is probably an extreme example. That’s a lot of fluid!

 

[StCEMT]

Question to all you medics:

Has any of you ever seen Electrical Alternans in a patient?

The amount of pericardial effusion required to literally allow the heart to swing back and forth within the pericardial sac seems like it would make it a relatively uncommon.

I think I might have as a student, but I honestly don't remember with 100% certainty.

 

[Chris07]

I updated my post. Get the needle out. Time to do a little pericardiocentesis.

 

[VFlutter]

Question to all you medics:

Has any of you ever seen Electrical Alternans in a patient?

The amount of pericardial effusion required to literally allow the heart to swing back and forth within the pericardial sac seems like it would make it a relatively uncommon.

I’ve seen it a few times in the ICU. Pulsus paradoxus is more commonly noticed. Usually it is seen in patients with a large slowly forming pericardial effusion most commonly with malignancy. Those who acutely develop a large enough effusion to cause Electrical Alterans die shortly there after.

 

[Chris07]

I’ve seen it a few times in the ICU. Pulsus paradoxus is more commonly noticed. Usually it is seen in patients with a large slowly forming pericardial effusion most commonly with malignancy. Those who acutely develop a large enough effusion to cause Electrical Alterans die shortly there after.

Yea. In a clinical simulation we had a patient who was a cancer patient with gradually worsening SOB x2 weeks with wheezing. So malignant pericardial effusion is the likely cause.

While the pericardium is pretty stiff, I’d imagine that if fluid leakage into the pericardium was gradual enough, the pericardium would have some degree of compliance and stretch a bit. Going from zero to full bore quickly is just going to crush the heart immediately.

 

[VFlutter]

While the pericardium is pretty stiff, I’d imagine that if fluid leakage into the pericardium was gradual enough, the pericardium would have some degree of compliance and stretch a bit. Going from zero to full bore quickly is just going to crush the heart immediately.

It’s all about volume vs time. A relatively small increase in pericardial volume abruptly, something like 100ml, can cause Tamponade and a slowly accumulating effusion can be something crazy like 1000ml before causing hemodynamic compromise. Also depends on the compliance of the pericardium. Stiff, I.e pericarditis, with effusion is bad.

 

[E tank]

Man that is a tough one. Decompress and then try to intubate the left side, I guess. You can do it with a regular ETT, though it is probably much easier with a DLT. I'm sure @E tank has much more experience with that than I do.

Yeah...no...any pathology like that makes even a DLT really hard, and thats with a fiber optic bronchoscope. Without a FOB, chest tube, normal intubation just past cords, place patient on left side and get to the OR.

 

[VFlutter]

Yeah...no...any pathology like that makes even a DLT really hard, and thats with a fiber optic bronchoscope. Without a FOB, chest tube, normal intubation just past cords, place patient on left side and get to the OR.

Pretty much what we did. Attempted to blindly intubate the left which wasn’t going to happen given the amount of deviation and then just left it at the normal depth and rapid transport to the trauma center for a fiberoptic bronch and chest tube. Had to decompress a couple times. If she coded I would have maybe just buried it to the hub to try to pass the injury.