ERDoc Posted July 30, 2013 Share Posted July 30, 2013 If we are worried about a perforated trachea, do you think PPV is the best idea? He's already pushing air out of the respiratory tree. I'm a big fan of RSI but I would agree, not in this case. I also think blind nasotracheal intubation would be a bad idea. You have no idea what the airway looks like and may just push the tube through the defect in the trachea. I know you can't do it in the field but in the ER this is someone I would want to use a bronchoscope to intubate. I also agree with 2 large bore IVs, central line once in the ER. I'd be hesitant to cric this person also. Again, we don't know what the airway looks like so we may do more damage than good, although of all options in the field it might be the best idea. Link to comment Share on other sites More sharing options...
Kaisu Posted July 30, 2013 Share Posted July 30, 2013 This guys got a perforated trachea. How much air is getting out of the thoracic cavity? I would try to tube him without RSI. The other thing to consider is a needle decompression - just in case there is even a hint of pneumo going on. I would use lung sounds, if I can discern them over the sirens, to try and weigh the percentages that needle decompression would help. Link to comment Share on other sites More sharing options...
scubanurse Posted July 30, 2013 Share Posted July 30, 2013 /> If we are worried about a perforated trachea, do you think PPV is the best idea? He's already pushing air out of the respiratory tree. I'm a big fan of RSI but I would agree, not in this case. I also think blind nasotracheal intubation would be a bad idea. You have no idea what the airway looks like and may just push the tube through the defect in the trachea. I know you can't do it in the field but in the ER this is someone I would want to use a bronchoscope to intubate. I also agree with 2 large bore IVs, central line once in the ER. I'd be hesitant to cric this person also. Again, we don't know what the airway looks like so we may do more damage than good, although of all options in the field it might be the best idea. Would NPA or OPA be a feasible option to help control the airway? Link to comment Share on other sites More sharing options...
paramedicmike Posted July 30, 2013 Share Posted July 30, 2013 I agree PPV may not be the best thing for a perforated trachea. However, supplemental oxygen hasn't done much for his sats or apparent work of breathing. I think it is at least worth a brief trial to see how he responds. If it's a slow or positional leak he may hold until we get him to the hospital where I'd want anesthesia waiting. If it is immediately obvious that it's not working then of course we'd stop. In a sense it's a matter of the lesser of two evils. Yes, SQ air is bad. But so is a hypoxia complicated septic death. Aside from his raging sepsis I'm concerned more about preventing the latter. Yes? No? Maybe? This is a good case and discussion. Link to comment Share on other sites More sharing options...
ERDoc Posted July 30, 2013 Share Posted July 30, 2013 I can agree on those points. This is a case where you won't find any studies or textbooks to support or refute your treatment. If whatever you do works, you will look like a hero. If whatever you do makes the pt worse, people will criticize you. Another thing to consider is that this stent may have involved the junction of the mainstem bronchi and placing a tube will do nothing. Maybe we need to think about putting it in the right mainstem, beyond where the stent might have been. Granted we are shutting off one lung but again, it is an option. Link to comment Share on other sites More sharing options...
MariB Posted July 30, 2013 Share Posted July 30, 2013 I'm applying diesel and hoping he makes it to the er. I would have my medic intercept, and call in ahead telling them we have a perforated trachea. This is a patient I don't want to see. It is definitely a reason I want to go back to school. Bls is not going to save this guy of he loses his air way. I can give him an opa, NPA and a king airway, but he needs more than that. Link to comment Share on other sites More sharing options...
paramedicmike Posted July 30, 2013 Share Posted July 30, 2013 Thanks. And good points. This is one of those case discussions where I'm glad we have a couple of docs on the forums. Link to comment Share on other sites More sharing options...
Happiness Posted July 30, 2013 Share Posted July 30, 2013 Well this is an interesting scenario. It's always great to call in ALS but alas I do not have that luxury. Since I'm so efficient I have all my equipment with me As I am doing my initial assessment ABC's, I will ask my partner to get the O2 on, I am choosing a non-rebreather at 15 lts. and to get the cot ready. As soon as this is done my patient is getting onto my cot ASAP in a sitting position unless he goes unconscious then supine it is. In all reality getting this patient to the ER and getting notification to them ASAP is my priority. I can help with the secretions with suction but I need to be careful not to get to suction happy or I can wipe with a gauze to help. With the hx that has been given I am also suspecting a stint has dislodged from the infection, so that is going to tell me that there is a chance the air is not necessarily going into the lungs but the chest cavity. I think that using a BVM may be detrimental in this case as the pressure may cause more damage, but if I had to it would be very gentle. I can only use a King if the patient codes, so if he goes unconscious I am more apt to try a nasal airway first. I will continue to monitor and reassure this patient all the way to the hospital and stay, help in the ER and truly hope for the best. What is air to Chair? Link to comment Share on other sites More sharing options...
MariB Posted July 30, 2013 Share Posted July 30, 2013 O2 and cot Link to comment Share on other sites More sharing options...
scubanurse Posted July 30, 2013 Share Posted July 30, 2013 O2 and cot Or self ambulate him to the captain's chair...wouldn't put it past him. 1 Link to comment Share on other sites More sharing options...
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