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

Points taken...but not necessarily agreed with
 
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
 
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
Click to expand...

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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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.
 
talked to my two medic teachers, they called in subqutaneous emphysema.
 
tazman7 said:
talked to my two medic teachers, they called in subqutaneous emphysema.
Click to expand...

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.
 
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.
 
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.
Click to expand...

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
 
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?
 
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
 
Melbourne MICA said:
Hi Venty

There is no book called "intubation for dummies".
Click to expand...

No, but we have.....


dummies.jpg
 
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?
Click to expand...

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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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?
Click to expand...

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.
 
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.
Click to expand...

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

MM
 
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.....
 
Of interest

VentMedic said:
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
Click to expand...

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
 
Melbourne MICA said:
Apparently what appeared to be a sizeable pnuemothorax on film had no immediate clinical repercussions for this particular patient.
Click to expand...

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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