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

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


Later!

--Coop
 
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
 
Last edited by a moderator:
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?
Click to expand...

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.
 
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....

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
Click to expand...

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
 
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.

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.
Click to expand...


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
 
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.
 
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
Click to expand...

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)
Click to expand...

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.
 
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....

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.
Click to expand...

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
 
tazman7 said:
enroute to hospital approx 10 minutes after arriving on scene pt face starts swelling like a balloon!!
Click to expand...

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.
 
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.
Click to expand...

Good point!


Later!

--Coop
 
You must log in or register to reply here.
Back
Top