Just Plain Ruff Posted April 6, 2006 Share Posted April 6, 2006 I worked for a small rural ems system and had this call one day. On arrival found a 65 year old male face down on a concrete cinder block from approximately 40 feet from a tree. The patient was trying to trim some branches on his trees after an Ice storm and had three ladders jury rigged together to get to the top branch of the tree. (ironically his son was a tree trimmer for the local power and light and the patient was told not to do anything until his son got there that afternnon) Basically the patient made a perfect landing on this cinder block with one of the short edges of the cinder block at the top of his sternum and the other end below his xiphoid process. I don't think he could have landed any better or more perfect. We ascertained that this was a trauma code and did inline c-spine support and turned him over and off the cinder block. Rapidly intubated this patient, CPR and the whole works and full spinal precautions Transported to the ED, code 3. About 3 minutes into the transport we noticed that we were getting both chest rise and abdominal rise with pretty significant abd distension. I checked the Tube and it was thru the cords. We heard excellent breath sounds Bilaterally and original pulse ox was 99% with intubation, 30 and below pre-intubation. Abdominal sounds with ventillations were heard also. We decided to leave the tube in and drop a NG tube to evacuate some air which we did. Got him to the ED and they re-intubated him and got the same results as we did in the ambulance. What is happening to this guy???????? By the way, he was pronounced about 30 minutes into the treatment at the ED after a thorough eval and trauma workup by the Level II trauma center. Link to comment Share on other sites More sharing options...
Ridryder 911 Posted April 6, 2006 Share Posted April 6, 2006 Either the tube was to small and allowed leakage around the cuff or someone blew out his distal end of the trachea. I have had cases where I could hear both lung and belly sounds.. that it is why EtCo2 is so important. It will detect if you are in or not, again you can't have false positives... please see all posts regarding potential problems in intubations. In some patient the trachea is much larger distally and more air in the cuff is required to make a seal. Check the cuff pressure . if is still low you may have to re-intubate wit a larger tube. How did CXR look like in the ER ? Again, these scenarios is complexing at the time, but there is only so much that can be wrong. Be safe, R/R 911 Link to comment Share on other sites More sharing options...
brock8024 Posted April 12, 2006 Share Posted April 12, 2006 The first thing that comes to my mind is diaphragmatic rupture, esp where he hit. It is more common on the left side of the abd. You can hear bowel sounds in the lung fields. That would account for the good raise in o2 sats, but getting the bowel sounds and the possible distention. brock Link to comment Share on other sites More sharing options...
Ace844 Posted April 12, 2006 Share Posted April 12, 2006 as mentioned above both Diaphragmatic herniation and tracheal rupture come to mind...Was there sub-Q air present either in the neck or thorax???? Link to comment Share on other sites More sharing options...
paramedicmike Posted April 12, 2006 Share Posted April 12, 2006 I was thinking tracheal rupture, too. Link to comment Share on other sites More sharing options...
medik8 Posted April 12, 2006 Share Posted April 12, 2006 Ditto.... :shock: Are we right? huh? Huh?.....huh? Link to comment Share on other sites More sharing options...
brock8024 Posted April 12, 2006 Share Posted April 12, 2006 with the trachea rutpure would you have that good of pulse ox and breath sounds? I would think that there would not be good chest rise or breath sounds and had a good pulse ox? Link to comment Share on other sites More sharing options...
Ace844 Posted April 12, 2006 Share Posted April 12, 2006 with the trachea rutpure would you have that good of pulse ox and breath sounds? I would think that there would not be good chest rise or breath sounds and had a good pulse ox? You would have both of those initially, then over time both would decrease, this is also size dependent on the ruputure Link to comment Share on other sites More sharing options...
Ridryder 911 Posted April 12, 2006 Share Posted April 12, 2006 Usually with trachea rupture, after a few minutes of ventiallations, sub-glottic emphysema would start to occur. Diaphragmatic herniation, I would find to be rare in thsi situation .. could be, but rare. R/R 911 Link to comment Share on other sites More sharing options...
Ace844 Posted April 12, 2006 Share Posted April 12, 2006 Usually with trachea rupture, after a few minutes of ventiallations, sub-glottic emphysema would start to occur. Diaphragmatic herniation, I would find to be rare in thsi situation .. could be, but rare. R/R 911 agreed, but you would have soem of these PE findings with 'rupture', admittedly though I've most often seen it with imporperly worn seatbelts...but I digress... ACE844 Link to comment Share on other sites More sharing options...
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