Rezq304 Posted July 2, 2007 Posted July 2, 2007 I might check a CBG, but I really do not see the point of performing a 12-lead. There are more effective diagnostic tools at the hospital and they might actually be able to DO something about a tamponade. So, you'd rather not know about it if it's happening?
chbare Posted July 2, 2007 Author Posted July 2, 2007 Allow me to clarify the helmet issue: There is no indication that the patient was wearing a helmet. Post auricular ecchymosis is noted. The patient has an intact gag reflex, so you opt to perform BLS airway management techniques while direct pressure is applied over the flap and manual spinal precautions are maintained. A jaw thrust is performed and a two person BVM technique is utilized to provide PPV. You note facial crepitus and you also experience allot of difficulty in maintaining a face seal. In addition, the patient has a full beard. You suction the airway and not copious amounts of blood. You also note that the patient is quite obese with a very short neck. You understand that this will be a difficult intubation and if you need to transition to a surgical airway, you will have difficulty in locating landmarks. You are able to maintain a seal with much difficulty while an EMT first responder provides BVM ventilations. Your partner controls the scalp hemorrhage and obtains a set of baseline vital signs. P-130, B/P- 80/42, SPO2- 88% R/A-->94-96% with BVM ventilations. He also starts an IV lifeline and obtains a BGL of 112mg/dl. The nearest trauma center is 25 minutes by ground and 15 minutes by air. If you are looking at this scenario as a ground medic/EMT, then you have no air resources available and only you and your partner have ALS capabilities. However, your partner is a newly minted medic and appears very anxious and overwhelmed about the whole situation. If you are looking at this as a flight medic, then all people on scene are BLS and your partner is a newly minted flight nurse with rudimentary airway management experience. All advanced interventions will most likely be performed by you. (It's all you!!!) So, it appears that we are at the crux of this scenario. What path do we take to secure this patients airway? We know that this will be difficult at best. Do we take the path of RSI? Take care, chbare.
pyroknight Posted July 2, 2007 Posted July 2, 2007 So, you'd rather not know about it if it's happening? What good will this knowledge do me? If the twelve-lead could differentiate between ovarian cysts and endometriosis would that knowledge assist me in delivering patient care? Even that would be more useful than knowledge of tamponade in a patient with a GCS of 6. I could at least explain to my conscious pelvic pain patient the difference. This organ donor could care less what his diagnosis is. As far as the scenario: I am sure each provider's definition of "copious" varies considerably, but let's assume that copious indicates airway compromise. RSI. If unsuccessful, PERTRACH. Keep the patient warm and get him to a trauma center for harvest.
chbare Posted July 2, 2007 Author Posted July 2, 2007 Cardiac tamponade is very much a clinical diagnosis. 12 lead findings may indicated electrical altrans, low voltage QRS, or possible ST changes. These are not always found in tamponade and should not be used to diagnose tamponade without clinical evidence. I do not think it is unreasonable to obtain a 12 lead if thoracic trauma or tamponade is suspected, providing, interventions to secure ABC's are completed. This is however not the case with this patient. There are no external indications of thoracic trauma with this patient. This is not to say we can rule out thoracic trauma; however, I think we will have our hands full with other priorities and interventions as this time. Allow me to further quantify the use of copious. Initial suctioning brings up about 30 ML of blood and several 1 cm diameter blood clots along with several teeth. We decide to go the route of RSI. After giving whatever cocktail of medications are in our giudelines ( I will not start a discussion about defasciculation and lidocaine for head trauma. Perhaps another thread.), a flaccid and unresponsive patient is the outcome. The first attempt is unsuccessful. You suction about 20 ml of blood out of the airway, but are unable to visualize any landmarks. After about 30 seconds a SPO2 of 92% is noted, and you abandon the attempt. You are still able to maintain a seal and BVM ventilations with BLS techniques; however, it takes allot of work to do so. After about a minute of BLS maneuvers, the SPO2 is 96%. A HR is 130 is still noted and the B/P is 82/40. Go for another attempt? Take care, chbare.
pyroknight Posted July 2, 2007 Posted July 2, 2007 IMHO, that would depend on your medical director and your protocols plus what you observed in attempt #1. If your protocols require two attempts before calling a failed airway, then a second attempt is in order. If you believe you will be successful, then a second attempt is in order. If you know there is no way in hell you are getting a tube in this guy and you know that your medical director has your back, then skip the second attempt, do not pass go, proceed directly to PERTRACH.
p3medic Posted July 2, 2007 Posted July 2, 2007 I would not have RSI'd this patient. With that being said, and the senario now at the point of a sedated and paralyzed pt with a single failed intubation attempt and reasonable sp02, I'd say give it another shot while prepping a rescue airway device of your choice while prepping his neck as well......
pyroknight Posted July 2, 2007 Posted July 2, 2007 I would not have RSI'd this patient. . . . . . . . I'd say give it another shot while prepping a rescue airway device of your choice while prepping his neck as well...... Why not? If you are suctioning copious amounts of blood from the airway you do NOT have a secure airway, not to mention the problems that you are having with BVM seal even with two-rescuer technique. I do not believe most of the BIAD rescue devices would be acceptable in this case because the hemorrhage could very well be pharyngeal and one could end up bagging blood into the lungs even after airway placement. The LMA is the only device I can think of that might be worth a shot. Whaddaya think?
chbare Posted July 2, 2007 Author Posted July 2, 2007 P3medic, how would you have managed this airway? This is not a challenge; however, discussing other strategies is very important with this scenario. Pyroknight, does your system allow for the use of rescue airway devices? We know that attempting a cric on this guy will be difficult. Is it reasonable to consider a rescue device with this patient? I will not disagree with your stance; however, we could take a number of paths with this patient. I think a few good points have been identified: 1) This is a difficult airway. 2) Are we confident we can successfully intubate this patient? 3) We are able to maintain effective ventilation and oxygenation with BLS maneuvers, so we are not in a "cannot intubate, cannot ventilate situation." 4) What are our options? In this case, the provider takes a second attempt. You change your blade and directs one of the EMT's to provide ELM during the attempt. You are still unable to visualize anything and must abandon the attempt after the SPO2 decreases to 92%. However, with some difficulty you are able effectively ventilate with BLS techniques and the SPO2 again rises into the mid 90's. What options are available at this point in time? What path do you choose and why? Take care, chbare.
ERDoc Posted July 2, 2007 Posted July 2, 2007 Just to clarify the tamponade point, you may or may not see anything on EKG. Even if there is a contusion, there is nothing to do about it, unless it casues an arrythmia and then you will see it on your rhythm strip. It is not a clinical diagnosis anymore (at least in the ER). We will put a quick ultrasound on the chest to look for tamponade.
p3medic Posted July 2, 2007 Posted July 2, 2007 The patient has an intact gag reflex, A jaw thrust is performed and a two person BVM technique is utilized to provide PPV. You note facial crepitus and you also experience allot of difficulty in maintaining a face seal. In addition, the patient has a full beard. You suction the airway and not copious amounts of blood. You also note that the patient is quite obese with a very short neck. You understand that this will be a difficult intubation and if you need to transition to a surgical airway, you will have difficulty in locating landmarks. You are able to maintain a seal with much difficulty while an EMT first responder provides BVM ventilations. Your partner controls the scalp hemorrhage and obtains a set of baseline vital signs. P-130, B/P- 80/42, SPO2- 88% R/A-->94-96% with BVM ventilations. The nearest trauma center is 25 minutes by ground and 15 minutes by air. If you are looking at this scenario as a ground medic/EMT, then you have no air resources available and only you and your partner have ALS capabilities. However, your partner is a newly minted medic and appears very anxious and overwhelmed about the whole situation. If you are looking at this as a flight medic, then all people on scene are BLS and your partner is a newly minted flight nurse with rudimentary airway management experience. All advanced interventions will most likely be performed by you. (It's all you!!!) So, it appears that we are at the crux of this scenario. What path do we take to secure this patients airway? We know that this will be difficult at best. Do we take the path of RSI? Take care, chbare. Well, you have improved his spo2 from the 80's to mid 90's with BLS airway maneuvers, and with all the highlights above, going down the path of RSI may be the wrong path. You have difficulty masking the patient due to trauma to the anatomy, facial hair and body habitus. Whatever muscle tone this patient has may be contributing to the patency of his airway, and removing that tone with the use of a NMB may result in its complete loss. Failed RSI may very well put us in a "can't intubate, can't ventilate" situation, in a patient with anatomy that not only makes oral intubation difficult, but surgical access as well. As it is now, we have a patent, albiet unstable airway, time to put pt on his side, and continue doing what your doing. If the airway becomes unmanageable enroute, I believe the needle/surgical option may be the best. If its going in the helicopter, BLS airway may not be a valid option, in which case the neck should be prepped prior to induction....IMHO.
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