DartmouthDave Posted June 27, 2012 Author Share Posted June 27, 2012 (edited) Hello Mobey, Island, ed1040 and et al...., Sorry, ATL in my world means ''...at the lip..." =) A CXR was done and it shows the cuff is just.....barley.....below the cords. The pilot ballon is soft to the touch. You advance the tube and add air to the cuff but the leak soon returns. They did not do an ABG because of his burns and not enough time. He is on a transport vent (AC 12x550 FiO2 100% PEEP +5). He is riding the ventilator. He has been given 2000cc NS so far. No LR. Parkland works out too 11,520cc in 24 hours. With a goal of 5760 in the first 8 hours...around 725cc/hr. He is cold (Temp 35) so you cover him with dry burn sheets. When they inserted the central line they drew labs. They are back now: Lytes: K 4.2 Na 145 Mg .6 Phos .9 Profile: Hgb 64 CBC 22 His current VS: HR 140 (well sedated) BP 75/50 O2 100% Temp 35.1 Urine 10 cc in 2 hours His abd seems a little bigger. The ED is anxious for you to leave ASAP. =) Cheers Edited June 27, 2012 by DartmouthDave Link to comment Share on other sites More sharing options...
eb1040 Posted June 27, 2012 Share Posted June 27, 2012 Is there an OG (or NG in some parts of the world) in place? Was it seen on the CXR as good placement or at least below the diaphragm? When doing a placement check do you get the gurgling noise at the same time? Does decompressing the belly alleviate the gurgling? Link to comment Share on other sites More sharing options...
DartmouthDave Posted June 27, 2012 Author Share Posted June 27, 2012 Hello, An OG is insert and it dose not stop the gurgling. The abd is more distended as well. Cheers Link to comment Share on other sites More sharing options...
island emt Posted June 27, 2012 Share Posted June 27, 2012 (edited) I know that this might seem strange: But does he have a hole in his airway thats leaking into his gut??? increased distention and continued gurgling?? JVD or tracheal deviation? what do his lungs sound like? Equal flow to all fields? did the chest x ray show lung damage? Hemo or spontaneous pneumothorax caused by the seizure activity. Back to lifelong seizure hx. What meds does he regularly take to control this? Don't like the elevate pulse rate or low BP at this point. He should have higher urinary output with the fluids he's gotten. renal failure early on with this case. Have to think on this a little more. Edited June 27, 2012 by island emt Link to comment Share on other sites More sharing options...
DartmouthDave Posted June 28, 2012 Author Share Posted June 28, 2012 (edited) I know that this might seem strange: But does he have a hole in his airway thats leaking into his gut??? increased distention and continued gurgling?? JVD or tracheal deviation? what do his lungs sound like? Equal flow to all fields? did the chest x ray show lung damage? Hemo or spontaneous pneumothorax caused by the seizure activity. Back to lifelong seizure hx. What meds does he regularly take to control this? Don't like the elevate pulse rate or low BP at this point. He should have higher urinary output with the fluids he's gotten. renal failure early on with this case. Have to think on this a little more. Hello, His CXR showed an ET tube that was too high (...which has been corrected...) and well aerated lungs with no pathological findings. His lungs are clear and his is easy to ventilated. He had a CNS infection in his late 20's and developed a seizure disorder after that. I was (until now) well managed with Dilantin T.I.D. Some questions: So, why do we have a burn patient with a low Hgb that is looking like a hypovolemic shock? Why is he more distended and firm? (Despite decompression with an OG) (The second leak in this scenario) What is the plan for the leaking cuff? Cheers Edited June 28, 2012 by DartmouthDave Link to comment Share on other sites More sharing options...
eb1040 Posted June 29, 2012 Share Posted June 29, 2012 Hgb 6.4? Any chance they shot a KUB plate? Since there is some fluid going in urine output should be better unless the increasing abdominal compartment pressure is high which the bladder pressure can not overcome and/or bleeding. A rare complication of a femoral CVC is an abdominal hematoma. The scenario did not indicate a trauma to the abdominal area. For the ETT cuff, you could try a stopcock to the pilot balloon to see if it stop the leak. If that does not work and it is suspected the cuff is blown, changing the tube with a tube changer would be the best option but maybe not for this ER. In that situation I would ensure adequate ventiation by physical and monitoring data and leave it alone. Link to comment Share on other sites More sharing options...
island emt Posted June 29, 2012 Share Posted June 29, 2012 Okay after going back and reading the original post::: Did he suffer from an electrical injury to the soft organs by chance? Lets get him back into X-ray and do an abdominal series . Did they check him for electrical exit wound? front& back? As far as the leaking tube, Put in a gum bougie and install new tube over that with plenty of lube. reverify with CXR. ETCO2 & waveform? Do they have the capability to type & crossmatch? If so lets get that done and hang some whole blood for transport. My spidey sense tells me there is some other injury going on we just haven't deduced yet. Burn pt's are like that, never as simple as it seems. Link to comment Share on other sites More sharing options...
DartmouthDave Posted June 29, 2012 Author Share Posted June 29, 2012 (edited) Hello, Hgb 64 g/L (110-160) ed1040 says, "A rare complication of a femoral CVC is an abdominal hematoma" You are correct on this. I have never seen this until recently. A patinet had a large retroperitoneal bleed from multiple femoral line attempts. So, I figure it would be a nice concept for a scenario. Island syas, "As far as the leaking tube, Put in a gum bougie and install new tube over that with plenty of lube. reverify with CXR." Yes, the cuff keeps deflating. You exchange the tube with a bougie without complications and the portable CXR is on the way. Do they have the capability to type & crossmatch? Yes they do but it will take some time. They have 4 units of O -ve that can be transfused now. Cheers Edited June 29, 2012 by DartmouthDave 1 Link to comment Share on other sites More sharing options...
island emt Posted June 29, 2012 Share Posted June 29, 2012 (edited) Nice one Dave! Nothing like physician induced trauma to add to his other problems. No wonder they wanted him out of their ER quickly. Hoping he would die in your truck instead of there in the ER. Edited June 29, 2012 by island emt Link to comment Share on other sites More sharing options...
eb1040 Posted June 29, 2012 Share Posted June 29, 2012 (edited) Hello, Hgb 64 g/L (110-160) Apologies. I didn't see the g/L. We use g/dL which would be 11 - 16. If this patient had died at the other hospital, this complication would have been noted and the sending physician held accountable. If he attempted to correct some of his mistake or notify the rec'g they could have evacuated the hematoma upon arrival. If he survives the clotting factors will also have to be considered in a burn patient. Bad situation either way. At that point I would be contacting my own medical director for advice about this transport since this is an IFT and there are now more complications to consider other than just the burns. Additional staff from the hospital may need to accompany especially with blood products (in some states). The need for pressors etc. Edited June 29, 2012 by eb1040 Link to comment Share on other sites More sharing options...
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