spenac Posted December 31, 2007 Share Posted December 31, 2007 "it is recognized that decompensation is a late stage in the disease and it may be appropriate to decompress earlier" Exactly what I said get ahead of it. In any situation stay ahead never fall behind. Be aggressive and give your patients the greatest chance of survival. Link to comment Share on other sites More sharing options...
ERDoc Posted January 1, 2008 Share Posted January 1, 2008 I'm sorry I am coming into this so late. Any discussion with FF523 is interesting. It always makes me search the literature to make sure I am not the crazy one. As for the original scenario, I find it hard to believe that this was a true call. Bilat, nontraumatic tensions pneumos just don't happen. What stars and planets aligned to cause the exact same pathology to occur on two seperate organs at the same exact moment? I'm not saying that it doesn't happen, because there are cases in the literature, but these are usually sick people or pneumos that have been induced via some form of trauma. A quick pubmed search will turn up a few case reports. It also appears that needle decompression is not overly successful. It usually requires chest tube insertion. As for your run of the mill unilateral tension pneumo, the teaching is that if you xray it you might as well give the pt their malpractice check before they leave the ER. TENSION pneumo is a clinical diagnosis (especially by the time they get to the ER). If you are not able to distinguish a tension pneumo from a pulmonary contusion you need to go back to whatever school you graduated from for some remediation. Spontaneous pneumos, however, are diagnosed with xrays. There is no emergent rush to fix them, which is why we don't needle them. Get your chest xray, set up your chest tube under nice, sterile condtions, appropriately anesthestize your patient and make them feel better. As for the discussion of cyanosis and pulse ox, you need to have 5 mg of deoxygenated hemoblobin in order to become cyanotic. This means that the pulse ox at which you see cyanosis depends on their hemoglobin level. Anemic patients will require a much lower pusle ox before they become cyanotic. Let's us 15 as our normal hemoglobin level. This means that your pulse ox would need to be about 67% before you see cyanosis. Take an anemic person with a hemoglobin of 7. They would need to get there deoxygenated hemoglobin down to 2, which means they would need a pulse ox of about 30% before you would see cyanosis. Let's look at some one who is a heavy smoker or lives at a high altitude and has a higher hemoglobin level of say 25. They would be cyanotic with a pulse ox of about 75%. It is possible to be cyanotic with a pulse ox over 90% depending on your hemoglobin level as well as the cause of the cyanosis. Back to the OP, I guess when all else has failed, drop two needles in the chest. They will just end up with two chest tubes. Hope I have made the situation as clear as mud. Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted January 1, 2008 Share Posted January 1, 2008 Actually ER Doc I had a case in the ER with a 87 year old lady with pneumonia bilaterally. She had an extended coughing episode for over 20 minutes and she decomp'd at home. We got called and went and got her. Bilat decreased breath sounds. Sats in 70's We got to the ER, I was working hospital based ems at the time. chest x-rays confirmed bilat pneumos with a tension developing to the left. The doc was busy with another very sick patient. I brought him the x-rays and he said to dart the left and prep for bilat chest tubes. WE did that and after we chest tubed her she got better but after a little bit she worsened and ended up on a vent. After 3 days in the icu she ended up dying. Not sure if this classifies as non-traumatic what with the coughing fit but she had bilat pneumos. She was a really sick lady anyway and this didn't help her. Link to comment Share on other sites More sharing options...
hammerpcp Posted January 8, 2008 Share Posted January 8, 2008 Okay so I stopped reading responses on page three, so if I am repeating anything someone else has already said I will still take full credit. I am not sure if it has ever happened in the history of humanity that a person has experienced spontaneous bilateral pneumothoraces without some kind of previous history of lung disease. This means that this patient must have a tension pneumothorax if he is having no air entry bilaterally. This automatically will cause decreased cardiac output. You would be able to recognize this because strong radial pulses would not be present even if you did not have time to obtain a BP. BTW, we dont treat a pt with a pulse prior to at least trying to obtain a BP. Who does that? a needle thorocostomy on a pt with an unknwon history who is supposedly hemodynamically stable? Is your preceptor retarded? typos edited. some left in for interest. Link to comment Share on other sites More sharing options...
Dustdevil Posted January 10, 2008 Share Posted January 10, 2008 lolz@"very short scenario" We're just a couple of posts short of breaking the record for the longest scenario ever posted at EMT City. Link to comment Share on other sites More sharing options...
spenac Posted January 10, 2008 Share Posted January 10, 2008 lolz@"very short scenario" We're just a couple of posts short of breaking the record for the longest scenario ever posted at EMT City. Funny how that works. Sometimes when I post a topic and expect no or few replys it runs forever. Then items I feel will get lots of interest go unanswered. Just never no what will get people talking. Now 1 reply closer to the record. Link to comment Share on other sites More sharing options...
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