WWYD: Butane inhalation & ignition

ErikWeeWoo

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Got dispatched to a residential address for 16yo with burns. On arrival, we find obese 16yo male patient in obvious distress - in the tripod position with a tachypnec respiratory rate. Not coughing, mildly tachycardic, oxygen saturation 100% - but complaint of 6-7 out of 10 chest pain, shortness of breath. Mallampati grade 4 airway, tachypnea seemed to be worsening. Friends showed us a video of the mechanism - kid took several giant hits of his lighter while depressing the button as if it was a vape, then lit it on fire. Proceeded to run around with obvious flames on video hitting himself in the face. Lung sounds were clear, BP hypertensive, pansystolic murmur noted on cardiac auscultation. WWYD??

Medic student riding along ended up getting an 18g IV in the hand. I had my EMT put him on 6lpm nasal cannula and 15lpm nasal cannula for preoxygenation. Loaded into the ambulance just to control the enviorment better, and I made the decision to attempt DSI. This was probably not the best method that could have been chosen as we are RSI capable, but I was concerned about the anticipated difficulty of the airway. Got medic student riding along to position him in head-tilt & jaw thrust, 2 person technique, I gave some ketamine and the EMT bagged @ 15lpm with nasal cannula still going at 6lpm. Our plan was 3 attempts to pass ETT via VL, if all failed we'd place iGel then. I failed first attempt, and the patient suddenly got very brady. Second attempt success, BP was quite hypotensive (86/palp per EMT) but went up with a fluid bolus. Patient was transported relatively uneventfully from there to our lvl 1 center / childrens hospital.
 

akflightmedic

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Questioning why you felt it necessary to check heart tones and then even was able to calm and quiet the scene/obese patient long enough for a proper test to be conducted to conclude there is a heart murmur; especially with the symptoms going on, and other ongoing/needed more important interventions and assessments.

1, What was initial BP as you only stated "hypertensive"?
2. What was the HR as you said "mildly tachy"?
3. What was the resp rate as you only said "tachypneic".
4. What did 12 lead show or even just ECG strip?

Other feedback:

1. Why 18g in the hand? I get the patient is 16, but why the hand?
2. Why only one IV if your plan is to RSI? (And again, why the hand, if RSI is the plan?)
3. I am going to assume you did not have a double nasal cannula in place and this was a typo.
4. Being he was obese, did you consider or perform better body positioning prior to intubating?
5. Was ketamine the only medication given?
6. How much fluid bolus?
7. How obese is obese? What was the patient's weight?
8. The kid has a Grade IV airway and your plan was to NOT do RSI? Obese, pediatric, airway compromised, one IV in hand...
 

Carlos Danger

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My concern in this patient would obviously be airway edema, which can evolve rapidly. You said he's MP4 and obese, so you are already behind the curve in terms of potential difficulty even BEFORE his upper airway begins to swell. For me given what I do, this is very clearly a PROP-->SUX-->TUBE situation with humidified oxygen and bronchodilators as indicated. Since intubating is everyone's favorite procedure and we all know that every burn patient's airway decompensates quickly, my guess is that this would be the option that most of us would choose.

I think you can also make a really good argument for conservative management during transport, as long as his lungs are clear and he isn't stridorous. While these CAN progress quickly to really lousy airways, they usually don't do so precipitously and you can catch them before they do as long as you monitor closely. There are real risks involved in attempting intubation because he's quite possibly not going to be an easy tube and you can make the situation worse with anything but a smooth, rapid intubation. This option would probably be the best choice if you aren't someone who intubates every day, especially if your transport time is short.

The one option that I can't think of any supporting argument for the one you chose. DSI is a pre-oxygenation strategy only. This guy's sats were 100% even before supplemental oxygen and was presumably moving air well. Why not just place a face mask with humidified oxygen? Or a NRB? What was the thought process that led you to believe that unnecessarily giving positive pressure to an obese, full-stomach patient with a difficult airway was the best choice?
 

DrParasite

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Other than giving the kid a darwin award honorable mention....

this kid is inhaling a flammable gas, and then lighting it on fire... Assuming the gas is in both his upper airway and lower airway prior to ignition, I can't see how this kid isn't getting out of an RSI and a trip to the burn center.

I'll differ to @Carlos Danger expertise on this question (he is much more experienced than me): if his airway does get stridorous, doesn't that mean it will be a more difficult intubation, because you get more edema? wouldn't an aggressive intubation be more proactive, and ensure the airway remains patent during the trip, and it if doesn't progress, the patient can be extubated more easily in the hospital?
 
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ErikWeeWoo

ErikWeeWoo

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Questioning why you felt it necessary to check heart tones and then even was able to calm and quiet the scene/obese patient long enough for a proper test to be conducted to conclude there is a heart murmur; especially with the symptoms going on, and other ongoing/needed more important interventions and assessments.

1, What was initial BP as you only stated "hypertensive"?
2. What was the HR as you said "mildly tachy"?
3. What was the resp rate as you only said "tachypneic".
4. What did 12 lead show or even just ECG strip?

Other feedback:

1. Why 18g in the hand? I get the patient is 16, but why the hand?
2. Why only one IV if your plan is to RSI? (And again, why the hand, if RSI is the plan?)
3. I am going to assume you did not have a double nasal cannula in place and this was a typo.
4. Being he was obese, did you consider or perform better body positioning prior to intubating?
5. Was ketamine the only medication given?
6. How much fluid bolus?
7. How obese is obese? What was the patient's weight?
8. The kid has a Grade IV airway and your plan was to NOT do RSI? Obese, pediatric, airway compromised, one IV in hand...
Very rarely do I intentionally auscultate heart tones on a call with this much chaos. It was so loud that I could hear it on pulmonary auscultation, which is what prompted me to listen to the heart too.

1. 150s systolic, don't have it exactly

2. ~120

3. Initially didn't count, estimated 24. Came back to it later when it seemed to be worsening, counted 28.

4. 12 lead after tube was sinus brady 52bpm, 5 lead monitoring showed that come up to high 90s in transit & with frequent PVCs

I really do appreciate all feedback

1. Both myself and the medic student tried an AC line but couldn't get one, dorsal hand was the next best place & the medic student was able to get it

2. I don't really have an excuse here aside from not thinking

3. Yep, only 1 nasal cannula

4. We tried ramping him up quite a bit, couldn't quite achieve earlobe level with sternum, but it didn't seem to provide much of a better view & I forgot to write it here

5/6. Ketamine & LR only at first, about 300ml into the 1L bag things started to look better. Fentanyl (100mcg) after the tube

7. Quite, like ~280-300lb at 5'5

8. I'm not proud of that decision or my overall performance on this call. I originally went into it with the plan to RSI, in fact we discussed it en route o the call based on call notes, but I think I siked myself out when I saw the airway. Wasn't confident in getting that tube, but also was deeply uncomfortable with a relatively long transport time without a secured airway in an airway burn with +SOB & inspiratory chest pain
 
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ErikWeeWoo

ErikWeeWoo

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My concern in this patient would obviously be airway edema, which can evolve rapidly. You said he's MP4 and obese, so you are already behind the curve in terms of potential difficulty even BEFORE his upper airway begins to swell. For me given what I do, this is very clearly a PROP-->SUX-->TUBE situation with humidified oxygen and bronchodilators as indicated. Since intubating is everyone's favorite procedure and we all know that every burn patient's airway decompensates quickly, my guess is that this would be the option that most of us would choose.

I think you can also make a really good argument for conservative management during transport, as long as his lungs are clear and he isn't stridorous. While these CAN progress quickly to really lousy airways, they usually don't do so precipitously and you can catch them before they do as long as you monitor closely. There are real risks involved in attempting intubation because he's quite possibly not going to be an easy tube and you can make the situation worse with anything but a smooth, rapid intubation. This option would probably be the best choice if you aren't someone who intubates every day, especially if your transport time is short.

The one option that I can't think of any supporting argument for the one you chose. DSI is a pre-oxygenation strategy only. This guy's sats were 100% even before supplemental oxygen and was presumably moving air well. Why not just place a face mask with humidified oxygen? Or a NRB? What was the thought process that led you to believe that unnecessarily giving positive pressure to an obese, full-stomach patient with a difficult airway was the best choice?
Yeah, I think I siked myself out. We went into the call just based on the call notes with a plan to likely RSI. When I saw the patient & his airway though, it made me pretty anxious. I'm intubating pretty darn frequently compared to many, just was not confident in my ability to get that tube even in RSI. In the moment I felt like I couldn't justify not doing it though, especially with a fairly lengthy transport time through some areas where pulling over quickly wouldn't be easy. In retrospect though, one of the first questions I asked myself was "was that actually a necessary tube?"..

As far as why I went nuts with the preoxygenation, answer was basically panic. Pretty much expected I wouldn't be able to get it on first pass, and I have a personal first pass success of like 92%. And I was right, didn't get it until attempt 2.
 

akflightmedic

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What paralytic do you carry in your box?

Do you have sux?

I think you stated you were worried about not being able to get the tube, which is why you chose DSI over RSI. But if you have sux, then you have a short acting paralytic, you miss the tube, you bag them until it wears off. Ketamine, how long before that wears off? What if he was exceptionally responsive to the Ketamine? Are you creating a worse problem for yourself?

What was the hospital's feedback when you got there? Any feedback later on?
 

Carlos Danger

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Yeah, I think I siked myself out. We went into the call just based on the call notes with a plan to likely RSI. When I saw the patient & his airway though, it made me pretty anxious. I'm intubating pretty darn frequently compared to many, just was not confident in my ability to get that tube even in RSI. In the moment I felt like I couldn't justify not doing it though, especially with a fairly lengthy transport time through some areas where pulling over quickly wouldn't be easy. In retrospect though, one of the first questions I asked myself was "was that actually a necessary tube?"..

As far as why I went nuts with the preoxygenation, answer was basically panic. Pretty much expected I wouldn't be able to get it on first pass, and I have a personal first pass success of like 92%. And I was right, didn't get it until attempt 2.
You'll never know for sure what would have happened if you'd made a different choice. Maybe it would've worked out even better, and maybe it would've been a train wreck. But either way, this kind of honest self-reflection and seeking of feedback will serve you well. It's probably the only way to get better at this job.

Were you able to do any follow-up with the hospital?
 

Carlos Danger

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Keep in mind that DSI is a technique for pre-oxygenation of an uncooperative patient. If someone tolerates a NRB and is ventilating well - especially if they are able to take a few vital capacity breaths - there is no need to sedate them until immediately before you push the sux.
 

Carlos Danger

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Questioning why you felt it necessary to check heart tones and then even was able to calm and quiet the scene/obese patient long enough for a proper test to be conducted to conclude there is a heart murmur; especially with the symptoms going on, and other ongoing/needed more important interventions and assessments.

1, What was initial BP as you only stated "hypertensive"?
2. What was the HR as you said "mildly tachy"?
3. What was the resp rate as you only said "tachypneic".
4. What did 12 lead show or even just ECG strip?

Other feedback:

1. Why 18g in the hand? I get the patient is 16, but why the hand?
2. Why only one IV if your plan is to RSI? (And again, why the hand, if RSI is the plan?)
3. I am going to assume you did not have a double nasal cannula in place and this was a typo.
4. Being he was obese, did you consider or perform better body positioning prior to intubating?
5. Was ketamine the only medication given?
6. How much fluid bolus?
7. How obese is obese? What was the patient's weight?
8. The kid has a Grade IV airway and your plan was to NOT do RSI? Obese, pediatric, airway compromised, one IV in hand...
What is wrong with only having one IV, and what is wrong with it being in the hand?
 

E tank

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Not a lot to add except that 86/p is not really hypotensive in a 16 yo after a whack of ketamine and 52 isn't terribly bradycardic. When you said hypotensive and bradycardic I imagined an SBP of 50 and a HR of 25. Given the lack of muscle relaxant with this kid, I'd say 2 tries to get the tube in is pretty good. A tube needed to go in one way or the other and without a lot of screwing around. Sounds like you did that. One good IV in the hand is reasonable as far as I'm concerned.

I think the only big risk you took was the very real possibility of him aspirating his bacon whopper with cheese and fries, That would have been way more likely than a lousy VL view preventing intubation. The lack of muscle relaxant just made it harder for you. Being obese/morbidly obese on it's own, contrary to conventional wisdom, is no reason to suspect a difficult intubation. They can be, but that's only because there are other worrisome findings on the airway exam.

Over all I'd give it a C+/B- mostly for lack of style points and a good outcome.
 

Carlos Danger

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Being obese/morbidly obese on it's own, contrary to conventional wisdom, is no reason to suspect a difficult intubation. They can be, but that's only because there are other worrisome findings on the airway exam.
No mechanically more difficult necessarily, but positioning can be more difficult and they are more prone to desaturation and regurgitation.
 

E tank

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No mechanically more difficult necessarily, but positioning can be more difficult and they are more prone to desaturation and regurgitation.
All true...but neither of those two things would merit VL/DL and intubation attempt without muscle relaxant because they're viewed as 'more difficult'. Doing that would increase the chance of aspiration and that's what I was getting at.
 

Carlos Danger

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All true...but neither of those two things would merit VL/DL and intubation attempt without muscle relaxant because they're viewed as 'more difficult'. Doing that would increase the chance of aspiration and that's what I was getting at.
Oh I agree 1000%. I have always said that nothing is gained and much can be lost by trying to avoid NMB because they "look difficult".

Give NMB = apnea + great intubating conditions.
Give enough sedative to facilitate intubation = apnea + potentially still horrible intubating conditions.

Of course, that's notwithstanding a planned awake intubation which is irrelevant here.
 

akflightmedic

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What is wrong with only having one IV, and what is wrong with it being in the hand?

I did not say it is wrong, however I gave food for thought. You do not know what they are thinking, if you do not ask the question. If I have a high acuity patient, I am planning on two IVs before they decompensate further, that is common sense. Yes, I could just say if needed, I will do an EJ or IO, but if I have time to listen to heart tones then I have time to place a second IV as a backup.

The hand, I am just tired of the school of thought that dropping an 18 in the hand is "normal". Especially when they are 80 year old grandmas, which is why I mentioned the age in my comment. I see so many medic preceptors stating the "go big or go home" mantra along with the encouragement of it in the hand, one of the more sensitive and "valvey" locations without giving any regard to how or what the patient is experiencing. If it is all you can get or all you can do in a situation, totally understand. Why he went in the hand was information that came later in the post so it makes some sense. As the poster is a newish medic along with a student, I was trying to give more food for thought earlier in the career.

Additionally, there are plenty of studies regarding value/benefit of catheter size. Fairly certain we have discussed this in the past.
 

Carlos Danger

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I did not say it is wrong, however I gave food for thought. You do not know what they are thinking, if you do not ask the question. If I have a high acuity patient, I am planning on two IVs before they decompensate further, that is common sense. Yes, I could just say if needed, I will do an EJ or IO, but if I have time to listen to heart tones then I have time to place a second IV as a backup.

The hand, I am just tired of the school of thought that dropping an 18 in the hand is "normal". Especially when they are 80 year old grandmas, which is why I mentioned the age in my comment. I see so many medic preceptors stating the "go big or go home" mantra along with the encouragement of it in the hand, one of the more sensitive and "valvey" locations without giving any regard to how or what the patient is experiencing. If it is all you can get or all you can do in a situation, totally understand. Why he went in the hand was information that came later in the post so it makes some sense. As the poster is a newish medic along with a student, I was trying to give more food for thought earlier in the career.

Additionally, there are plenty of studies regarding value/benefit of catheter size. Fairly certain we have discussed this in the past.
Yeah, I guess. I would have never thought to question the motivation of any of that aspect of this scenario, because on it's face it appears so routine and reasonable. Sure two IV's are nice to have, but I'm not going to delay giving meds - especially in a compromised airway situation - to get a second one. In a scenario like the one described, I'll look for the easiest vein I can find and that's often in the hand, and then I'll place a 20g or 18g and run with it.
 

HardKnocks

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Question;

I understand the mechanics of the possibility of upper//lower airway burn and compromise;

If a BLS Crew, was on first scene, (and ALS was extended ETA), would an IGEL (for an unconscious Pt) be an interim Vent option, until ALS or ER can tube em? (Note: I-Gels are in the Scope of Practice for EMT-B here in AZ).

I've read that a large bore I-gel can be used as a conduit for later intubation, in some circumstances.

Btw, what was the Kids Tidal Volume and 02 Sat?
 
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