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

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tazman7

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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
 
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.
 
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?
 
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..
 
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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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?
 
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.
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I thought you said
sub q air underneath the skin
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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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I have STAT paged Greg House. Call CCT and arrange emergent transport to princeton plainsboro.
 
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.
 
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! :rolleyes: Then.......you start discover sub q air and a scrotum that looks like it belongs on an elephant. :unsure:
 
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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
 
remote_medic said:
Awesome support of another EMS provider asking a question...
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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.
 
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.
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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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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...
 
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.
 
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
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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?
 
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?
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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.
 
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.
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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!
 
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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