BoCat9 Posted November 4, 2010 Posted November 4, 2010 Ok, two quick questions about stabilization. Can a flail segment safely and effectively be stabilized using a KED? My partner said it could, but just wanted to get other input. Also, I was told in class not to use sandbags, IV bags or anything heavy due to the fact it will cause respiratory difficulty or make it worse. Are sandbags still an accepted practice, or is it best to use bulky dressings? Thanks for looking. Bo
tniuqs Posted November 6, 2010 Posted November 6, 2010 It is going to be whatever gets my Co2 near 40. I assume that your talking arterial PaCO2 @ 40 ... with no "suspected" metabolic acidosis that would be ventilating to a normal expected PH of 7.40. Question is do you need to attempt to get PH that high ? hmmm Ok ... but is permissive hypercapnic ventilation NOT acceptable ? AND we need to blow down "buddy's" CO2 down that much ? With normal VQ matching your looking about 36 to 38 ~ with ETCO2 (all things being equal) but this patient safely assumed is NON normal V/Q matching. Probably 600ml TV. RR 22 to start.... once excess C02 is blown off, rate can come down. Are rapid changes good, like for patients ? in passing you just but RSI this guy WAY reduced his work of breathing because you just took the wheel (so to speak) SOO you saying start high and then go down OR start lower and move up, (hint pick the thing is if your ETCO2 is 48 and personally not terrifying to myself (from the numbers you have provided ETCO2 and not ABG values .... heck a 48 for PaCO2 isnt that exciting without a metabilic acidosis that's around an expected PH of 7.30 .... BUT Good point ... just where the heck do you start Volume Control / Assist Control CMV ... when ventilating on a stone age machine ... So lets do the math 600 x 22 = (what just is that for MV minute volume ???) "hint" with this high a rate could you "auto PEEP" the patient in of itself, remember that Flow rate with "that ventilator" is very limited. So What would the I;E ratio be ... with that machine ... ??? A big concern is with that high MV and low flows ... could you not allow enough time for exhalation. Next query if your MV being that high, Limited ability with flow rate, could you cause a BP issue ? Back to VT (Tidal Volume) based on ideal body wt ... ps I will follow up on this wtf are they teaching these days paramedic in school anyway ? I want to keep my volumes at the lower end to keep chest movement minimal. Volumes or Peak Pressures ? .... careful I still have a baseball bat at my door ! PEEP will be set at 5cm to replace physiological PEEP made at the vocal cords, and taken away by the tube, + 5cm extra (10cm total) for "internal splint". Good conservative start even in a head injury .. 4/5 points on the Dust Devil Scale, but what would be use as your GUIDE ? And in passing with ventilating just like a school science protect only affect one variable at a time to see the response. This PEEP aint no game, I need to be really careful of hypotension, and REALLY aware of the pneumo possibility (more like inevitebility). BING ! but what bubbling would you see in the underwater seal after ventilating, second query what would you do if suddenly the ventilator is ringing off and no bubbling in the CT undewater seal. ? Ok, two quick questions about stabilization. Can a flail segment safely and effectively be stabilized using a KED? My partner said it could, but just wanted to get other input. Also, I was told in class not to use sandbags, IV bags or anything heavy due to the fact it will cause respiratory difficulty or make it worse. Are sandbags still an accepted practice, or is it best to use bulky dressings? HEY BOCAT ... nice to see you again. MOI big time poly trauma ... yup KED why not ? ... heck in the vid, not even a collar on WTF OVER ?and I doubt patient in this condition, even without leads on has had C Spine radilogically cleared. Will the KED affect breathing ability ... yes and no ... if your ventilating him most likely NOT but without intubation I would think so but again depends how tight the chest straps ... that said your restricting the pump handle effect (but not diaphragmatic breathing) well too much. IMHO a Ked far superior neck rstriction than a old ass wooden board. Back to sand bags OK ... So do this simple test Go "Find a 10 lb sand bag" put it on your chest (no pain, no injury) and breath on your back for 15 minute's, then go watch TV ... just what will this do to WOB work of breathing (if spontaneously) then YOU tell me what YOU think ... ps if any MD asks why you did NOT use a Sandbag on a FLAIL ... ask him to do the same "test" cheers
penguin_pong Posted November 6, 2010 Posted November 6, 2010 What is flail chest? What caused it? What are your primary short term concerns? Longer term concerns? Load and go/stay and play? Why? Treatment? Please folks, if you know all of the above answers, please don't ruin it for those that can learn by asking and exploring. We already know you're smart. To the rest that are familiar with this, please feel free to jump into this thread in a mentor-ish way and help it move along if you would. I have no info on this patient so we're going to deal with him in gross terms only, OK? Dwayne Thanks Dwayne we just learned about this in class. 1
chbare Posted November 6, 2010 Posted November 6, 2010 Thought I would throw a few considerations into the mix. The video is quite dramatic and all this ventilator talk is getting me wet. However, the decision to intubate and place these patients on a ventilator should be based on the clinical presentation as a whole. In other words, not every patient will need intubation. Regarding the best mode; I am not aware of any specific mode that leads to improved outcomes. If you are talking about a patient you just did an RSI on who will be paralysed for the next 30 minutes or so, the choice of mode is irrelevant as all modes act like CMV with an unresponsive and apneic patient. Clearly, if we have compliance issues, pressure controlled ventilation may be indicated, but PCV is not a mode of ventilation. There exists some limited evidence that does support the use of non invasive ventilation, so it is a consideration. Honestly, intubating these patients because of failure will typically mean that there is a significant, underlying pulmonary deficit such as a large pulmonary contusion. However, the decision to wean and liberate said patients is not actually based on the stability of the chest wall. (ie: how dramatic of a video you have.) The mainstay initial therapy IMHO will revolve around good pain control. In conclusion, isolated fail chest alone is not an indication for intubation. If we need to intubate, the patient has additional injuries and or problems that should be addressed. If anything, this could easily become a case of tunnel vision. Regarding the quantum comment: I am actually involved in discussions about the interpretation of the time independent Schrodinger equation on other forums. More accurately, interpreting aspects of the solutions and incorporating them into a "physical" description/framework. I would be more than happy to present my question, but I am not sure how many people here would enjoy the discussion? Take care, chbare.
mobey Posted November 6, 2010 Posted November 6, 2010 I assume that your talking arterial PaCO2 @ 40 ... with no "suspected" metabolic acidosis that would be ventilating to a normal expected PH of 7.40. Question is do you need to attempt to get PH that high ? Sorry i meant ETC02 Are rapid changes good, like for patients ? in passing you just but RSI this guy WAY reduced his work of breathing because you just took the wheel (so to speak) SOO you saying start high and then go down OR start lower and move up, (hint pick the thing is if your ETCO2 is 48 and personally not terrifying to myself.... Hmm.... Well I WAS confident when I wrote it..... There is this EMT in me that wants to "Normalize" things as rapidly as possible Perhaps I need to silence the voices. BUT Good point ... just where the heck do you start Volume Control / Assist Control CMV ... when ventilating on a stone age machine ... So lets do the math 600 x 22 = (what just is that for MV minute volume ???) "hint" with this high a rate could you "auto PEEP" the patient in of itself, remember that Flow rate with "that ventilator" is very limited. OKOK, I had the VT way too high. My minute volume was over 13, ya... mistake for sure. Again, I was trying to bring down the ETC02 as quick as possible. This MV in in someone with a chest injury needled or not, is a bad idea. YES, the rate/volume would indeed auto PEEP, adding more PEEP with a valve could spell disaster for this patient. So What would the I;E ratio be ... with that machine ... ??? A big concern is with that high MV and low flows ... could you not allow enough time for exhalation. Next query if your MV being that high, Limited ability with flow rate, could you cause a BP issue ? I;E?? (Inhale/Exhale?) OKOK... I digress Quote Back to VT (Tidal Volume) based on ideal body wt ... ps I will follow up on this wtf are they teaching these days paramedic in school anyway ? 7-10ml/kg. See above for excuses I want to keep my volumes at the lower end to keep chest movement minimal. Volumes or Peak Pressures ? .... careful I still have a baseball bat at my door ! I'm just a Saskatchewan boy who mixes up words, and dumbs it down for us common folk!! PEEP will be set at 5cm to replace physiological PEEP made at the vocal cords, and taken away by the tube, + 5cm extra (10cm total) for "internal splint". Quote Good conservative start even in a head injury .. 4/5 points on the Dust Devil Scale, but what would be use as your GUIDE ? I would use chest expansion (or lack therof) and flail segment movement. And in passing with ventilating just like a school science protect only affect one variable at a time to see the response. Solid advice... Thank you This PEEP aint no game, I need to be really careful of hypotension, and REALLY aware of the pneumo possibility (more like inevitebility). BING ! YES... Got one right Just let me enjoy that for a second but what bubbling would you see in the underwater seal after ventilating, second query what would you do if suddenly the ventilator is ringing off and no bubbling in the CT undewater seal. ? EEK! Umm.... Pass (can I do that?) Biggest problem is I don't know what the alarm is? High pressure? Better pull it off and bag by hand for a minute to feel compliance. Check out the A/E sounds. Check for tracheal deviation LOL... OK that last one was a joke No bubbling I will ASSume CT problem. Might require another needle..... Little outta my comfort zone here. Maybe, just maybe I need to drink some rum and get schooled on CT's?
Richard B the EMT Posted November 6, 2010 Posted November 6, 2010 Also, I was told in class not to use sandbags, IV bags or anything heavy due to the fact it will cause respiratory difficulty or make it worse. Are sandbags still an accepted practice, or is it best to use bulky dressings? Current NYS DoH policies hold as NO weight, such as sandbags or IV bags, but use bulky dressings. My unsubstantiated belief re bulky dressings is not so much for stabilization, but as cushioning and/or protection. AS belief, don't hold to it until and unless your medical control and state/provence DoH agrees, as I could be wrong.
DwayneEMTP Posted November 6, 2010 Author Posted November 6, 2010 (edited) <br>Thought I would throw a few considerations into the mix. That's always a good thing... ...Honestly, intubating these patients because of failure will typically mean that there is a significant, underlying pulmonary deficit such as a large pulmonary contusion. However, the decision to wean and liberate said patients is not actually based on the stability of the chest wall. (ie: how dramatic of a video you have.) Have you seen these without a significant cardiac/pulmonary issue? Intuitively it seems that the force necessary to create this type of injury would be pretty severe, to the point that soft tissues would not likely escape unscathed. Though we know how well intuition and medicine go together sometimes... And it seems that your pain management and weaned tidal volume (making up terms now) would be dependent on the stabilization of the chest segment, wouldn't it? Again, intuitively it seems that this would be a terribly painful injury with significant co-morbidities so stabilization would be necessary to facilitate pain management. It also seems intuitive that a person injured this severely would need all of the tidal volume with the least effort possible, again mandating immediate/early stabilization. But I don't know... The mainstay initial therapy IMHO will revolve around good pain control. As above In conclusion, isolated fail chest alone is not an indication for intubation. If we need to intubate, the patient has additional injuries and or problems that should be addressed. If anything, this could easily become a case of tunnel vision. Great points! But I don't think we got terribly tunnel visioned here, I think in most cases it was an over estimation of ventilatory/respiratory compromise as well as possibly an over estimation of likely co-morbidities that sent most to intubation. Regarding the quantum comment: I am actually involved in discussions about the interpretation of the time independent Schrodinger equation on other forums. More accurately, interpreting aspects of the solutions and incorporating them into a "physical" description/framework. I would be more than happy to present my question, but I am not sure how many people here would enjoy the discussion? I would have been happy to answer your silly little question but I just saw a study on the internet that says that physics is a myth...Just thought you should know before you waste any more time dinking around with it... :-) Dwayne Sometimes I hate this fucking editor...Edited to reformat. Edited November 6, 2010 by DwayneEMTP
chbare Posted November 6, 2010 Posted November 6, 2010 That's always a good thing... Have you seen these without a significant cardiac/pulmonary issue? Intuitively it seems that the force necessary to create this type of injury would be pretty severe, to the point that soft tissues would not likely escape unscathed. Though we know how well intuition and medicine go together sometimes... And it seems that your pain management and weaned tidal volume (making up terms now) would be dependent on the stabilization of the chest segment, wouldn't it? Again, intuitively it seems that this would be a terribly painful injury with significant co-morbidities so stabilization would be necessary to facilitate pain management. It also seems intuitive that a person injured this severely would need all of the tidal volume with the least effort possible, again mandating immediate/early stabilization. But I don't know... As above Great points! But I don't think we got terribly tunnel visioned here, I think in most cases it was an over estimation of ventilatory/respiratory compromise as well as possibly an over estimation of likely co-morbidities that sent most to intubation. I would have been happy to answer your silly little question but I just saw a study on the internet that says that physics is a myth...Just thought you should know before you waste any more time dinking around with it... :-) Dwayne Sometimes I hate this fucking editor...Edited to reformat. As nonintuitive as it may seem, the chest wall stability is not the primary concern in many of these patients. Take a look at the literature and treatment recommendations. There is some evidence in support of surgical stabilisation in select cases, but most patients who go on to develop failure do so as a result of the underlying injuries and not the flail chest alone. Pain control is a challenge and I've seen modalities such as nerve blocks and epidural infusions used. I wish physics was a myth, life would be easier on me right now. However, as absolutely insane as it may seem, I found my self stunned a couple of weeks ago. I was doing a set of exercises where we use solutions of the Schrodinger equation to calculate electron binding and ionisation energies. I converted my answers in joules to electron volts so I could compare my results to what we actually find experimentally. I was simply stunned that this absurd concept of quantum mechanics predicted binding and ionisation energies perfectly. As crazy as it seems, I have to say it's the real deal until somebody can develop a framework that describes nature better. Take care, chbare.
tniuqs Posted November 8, 2010 Posted November 8, 2010 (edited) Thought I would throw a few considerations into the mix. The video is quite dramatic and all this ventilator talk is getting me wet. However, the decision to intubate and place these patients on a ventilator should be based on the clinical presentation as a whole. In other words, not every patient will need intubation. Regarding the best mode; I am not aware of any specific mode that leads to improved outcomes. If you are talking about a patient you just did an RSI on who will be paralysed for the next 30 minutes or so, the choice of mode is irrelevant as all modes act like CMV with an unresponsive and apneic patient. Clearly, if we have compliance issues, pressure controlled ventilation may be indicated, but PCV is not a mode of ventilation. There exists some limited evidence that does support the use of non invasive ventilation, so it is a consideration. Honestly, intubating these patients because of failure will typically mean that there is a significant, underlying pulmonary deficit such as a large pulmonary contusion. However, the decision to wean and liberate said patients is not actually based on the stability of the chest wall. (ie: how dramatic of a video you have.) Any large pulmonary contusion = ARDS = Death, very few survive btw and in passing H1N1 rapidly progressed to ARDS in the severe rapid onset atypical demographic cases ... I digress. http://en.wikipedia.org/wiki/Acute_respiratory_distress_syndrome The mainstay initial therapy IMHO will revolve around good pain control. In conclusion, isolated fail chest alone is not an indication for intubation. If we need to intubate, the patient has additional injuries and or problems that should be addressed. If anything, this could easily become a case of tunnel vision. Again loss of chest wall integrity in this magnitude alone is grounds to RSI and take all WOB away especially (and highly likely) there are other injuries. Regarding the quantum comment: I am actually involved in discussions about the interpretation of the time independent Schrodinger equation on other forums. More accurately, interpreting aspects of the solutions and incorporating them into a "physical" description/framework. I would be more than happy to present my question, but I am not sure how many people here would enjoy the discussion? Take care, chbare. Edited November 8, 2010 by tniuqs
chbare Posted November 8, 2010 Posted November 8, 2010 I stand by my statements. Not all flail chest patients need intubation. In fact, we open a new can of worms when we intubate. The complications can be as bad or worse than the condition that led to the intubation. However, I never said do not intubate if it is needed, I said tunnel vision is possible and not every patient will need intubation. Just a physics point, most everything we deal with in science and medicine is theory. However, if said theory explains the physical world accurately, I believe it until something more accurate comes along. Quantum mechanics, explains much of the physical world. We have used it to predict the bonding and thus creation of new medications, we used it to create wondrous diagnostic technology such as MRI, we used it to push foreword into the technology revolution and even the most nonintuitive aspects of it explain how flash drives and solid state hard drives work. I agree, that how we use the predictions of the theory is very important. In fact, I know very little of how to work through quantum mechanical calculations, but understand the basic implications of the solutions. Take care, chbare.
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