Respiratory Calls

[Uclabruin103]

Post away with your most difficult/dynamic respiratory call. What went right, what went wrong, how they presented, how they responded to treatment, what do you felt you could have used that you don't have in your scope.

 

[ThadeusJ]

I experienced this when I was working as a RT (actually I was at the hospital one evening for an educational lecture and was "drawn into" this case). As a former trainer for the advanced paramedic program, I am curious to your thoughts:

17 y/o athletic male, one day post-op from having thyroid surgery, living in a urban but relatively remote city. Surgery was performed by a specialist 100 km (60 miles) from his home (i.e. he chose to have the surgery in the "Big City" and in the 100 km corridor in between were several smaller community hospitals as well as a smattering of highly skilled teaching hospitals).
He was a home watching TV and playing with his sutures when he felt something go "pop" and his neck started to swell. He went to ER in his local hospital where the ER MD didn't want to touch the fresh surgical site. So they notified the original surgeon and sent him via ambulance for the 100 km trip. Along the way, his respiratory function worsened and he "turned blue" about 20 minutes into the transport. The ambulance saw the community hospital I was at (right in the middle of the journey and beside the highway exit) and pulled into the ER (not knowing where to go but they made it to ER).
The doc giving the lecture was called down to ER and then asked the porter to grab me for additional help. I entered the trauma room to a very interesting picture at the same time as the original surgeon who decided to meet the ambulance half way (no hospital privileges which created an almost comical scenario with some pencil neck who wanted to prevent them from working on the patient).

Co-incidentally I also worked part time at the "Big City" hospital and was able to hear their side of the story shortly afterwards.

Any thoughts on what you would do considering the paramedics where there primary for transport and were initially told to take the patient for a 100 km trip (I don't believe they patient was accompanied by a RN or MD from the local hospital)?

 

[MonkeyArrow]

I know that in-hospital, there used to be a policy where any pt. post-neck surgery would have a trach tray accompanying them everywhere they went until discharge (although that changed when trach trays were put onto every crash cart). I wonder why he was discharged so quickly post-operatively? To manage this airway, I would preferably like a video laryngoscope, although I would probably try to hold off intubating if at all possible until at the hospital. There, I would mark landmarks for a surgical airway while trying to either tube him with a VL or more likely try a flexible bronchoscope to land the tube.

 

[E tank]

I've seen expanding hematomas immediately post op carotid endarterectomies both on the ward and in the recovery room.

This is a very weird scenario with the "pop" and all, but the approach would be the same. If there were a large hematoma causing airway compression and distress, you'd splash on some betadine, glove up with sterile scissors, zip the sutures and evacuate the hematoma with your finger. That will fix the problem. Direct pressure to the site for bleeding control.

Whatever damage you do to the surgical site, which probably wouldn't be a whole lot, is worth the payoff of avoiding the hypoxic arrest.

If there were no distress, it would be a hurry up to the OR with a controlled induction or an awake FOB (not required that often anymore with VL)

 

[ThadeusJ]

Sorry about the ambiguity...the "pop" was the internal suture breaking as he was playing with the wound. And he may have been discharged a day or so longer than the one day I stated. I believe he had thyroid surgery and was discharged according to practice, but not fully healed. It was quite a while ago, so field intubation was practiced by a select few and maybe not even possible with this local service (in the infinite wisdom of the decision makers, they placed the most highly skilled paramedics in the "Big City" where you couldn't swing a cat without hitting a teaching hospital).

 

[VFlutter]

In Hospital: I have seen a couple post-carotid dissections/hematoma. Worst airway was a patient with Ludwigs Angina whom arrived from an outside hospital with a horribly butchered surgical airway with a massive hemtoma and subcutaneous emphysema.. Had a 5.0 ETT which appeared to be just below the Hyoid, nowhere near the cricothyroid membrane. ET tube had a piece of cartilage stuck in it acting as a one way valve and she hypercapnic arrested on the helipad. Ended up with an ENT, Anesthesia, and Pulmonary doing damage control surgery attempting to ligate all the bleeding vessels and place a tracheostomy while we coded her. Actually had a great recovery after all that.

Pre Hospital: Self inflicted gunshot, put a revolver in their mouth. Bullet must have bounced around before exiting the skull and probably transected their external carotid or vertebral artery. Never seen such a fountain of bright red blood.

 

[MSDeltaFlt]

Thadeus,

Sounds like the sending ER MD got extremely lucky that kid didn't die. Sending a swelling neck/airway down the highway without securing said airway is a disaster waiting to happen, in my honest opinion.

 

[zzyzx]

Yeah, can't believe the ER doc would send a patient like that out by ambulance.