chbare Posted July 2, 2007 Author Share Posted July 2, 2007 ERDoc, I agree with your post; however, from the perspective of a field provider, identification of tamponade will be based on history/MOI and the clinical presentation. P3medic, I understand your stance. The patient continued to have a resp rate of 6 even after his airway was suctioned and cleared with BLS techniques. He was unable to maintain adequate ventilation and oxygenation and required PPV. This would have been near impossible with the patient on his side. The provider did not go the path of an awake technique (nasal), because of the difficulty encountered in clearing the airway and the very slow resp rate. RSI was chosen because he wanted to rapidly establish airway control. Right or wrong? After the second attempt, you do not feel confident that you will be able to establish an airway via oral intubation. This in essence or reality constitutes a failed airway situation. Two options are considered: 1) Rescue device 2) Surgical option You prep for a surgical airway then insert a Combitube. The tube is inserted without difficulty and you are able to ventilate through port number 1. No epigastric sounds are noted and bilat lung sounds are appreciated. You note that the sounds are diminished bilat however. You attach a wave form capnography device and note the plateau shaped wave form with an ETCO2 of 55. SPO2 remains in the 94-96% range with BVM ventilation through the Combitube. Why the Combitube versus a surgical option? You were able to perform adequate BVM and BLS airway maneuvers and wanted to try a rescue device prior to the transition to a surgical option? Would the LMA have been better as somebody mentioned? Right or Wrong? What will we do during transport? Will we resuscitate with fluids? How about ventilatory management? (Vent settings, ongoing sedation or analgesia?) Take care, chbare. Link to comment Share on other sites More sharing options...
ERDoc Posted July 2, 2007 Share Posted July 2, 2007 I was thinking we should go Doug Ross on this guy. I'd like to break out my ball point pen and pocket knife and proceed with a cric. How about retrograde intubation? Link to comment Share on other sites More sharing options...
p3medic Posted July 2, 2007 Share Posted July 2, 2007 Playing monday morning quarterback, if I were to have come to the determination that the BLS airway is not going to be logistically feasible I may have chosen straight etomidate, with or without lido as your current protocols dictate. I can render patient unconsious, not alter much hemodynamically and not render patient apneic; direct laryngoscopy and either intubate, confirm landmarks and feel overwhelmingly confident of success with addition of a paralytic, or place an LMA, or supraglottic airway of choice. But thats just me, and its Monday. Link to comment Share on other sites More sharing options...
chbare Posted July 2, 2007 Author Share Posted July 2, 2007 ERDoc, you bring up a good point regarding retrograde intubation. This may have been a great choice for the patient. Unfortunately, this procedure was not approved or in the guidelines for the providers practice, so it was not even considered. P3medic, Monday it is. :wink: During transport, you are only able to keep the patients SPO2 around 49-95% and his ETCO2 stays in the upper 40's regardless of you ventilation strategy. I have my own theories as to why this occurred, but I will let other people chime in with their opinions. The patient was given a 1000ML challenge of warm saline in order to bring his MAP up due to the high possibility of a head injury. His pressure stabilizes at around 88-90/50-54 with a heart rate of 110. Pupil exam reveals a 3mm sluggish right pupil and a 5mm unreactive left pupil. Would you have done anything else? Take care, chbare. Link to comment Share on other sites More sharing options...
Dustdevil Posted July 3, 2007 Share Posted July 3, 2007 I was thinking we should go Doug Ross on this guy. I'd like to break out my ball point pen and pocket knife and proceed with a cric. I've done crics for less. Who is Doug Ross? Isn't he that freaky dude with the red afro that used to teach painting on PBS before he died? Link to comment Share on other sites More sharing options...
ERDoc Posted July 3, 2007 Share Posted July 3, 2007 I've done crics for less. Who is Doug Ross? Isn't he that freaky dude with the red afro that used to teach painting on PBS before he died? LOL, no the "Happy Little Trees," guy was Bob Ross. Doug Ross was George Clooney's character on ER. About the time the show was jumping the shark they did an episode where he was driving around depressed in a huge rainstorm. Somehow he came across a kid that was in cardiac arrest from drowning. He did a cric with a ball point pen and pocket knife. He then flagged down a passing TV station helicopter (in said monsoon). He had the crew broadcast that he was coming in and what he needed to the ER, who just happened to be watching the right channel at the right time. I may have some of the details wrong, but you get the idea. Link to comment Share on other sites More sharing options...
brentoli Posted July 3, 2007 Share Posted July 3, 2007 Who is Doug Ross? Isn't he that freaky dude with the red afro that used to teach painting on PBS before he died? I am not trying to hijack.... but I have not laughed so hard in weeks. Back to the senario. BLS is doing ALS assist so I can't help anymore. Link to comment Share on other sites More sharing options...
Dustdevil Posted July 3, 2007 Share Posted July 3, 2007 About the time the show was jumping the shark they did an episode where he was driving around depressed in a huge rainstorm. Somehow he came across a kid that was in cardiac arrest from drowning. He did a cric with a ball point pen and pocket knife. He then flagged down a passing TV station helicopter (in said monsoon). He had the crew broadcast that he was coming in and what he needed to the ER, who just happened to be watching the right channel at the right time. About the time? That sounds like the actual shark-jumping moment right there! I'm SO glad I never got into that show. :roll: Link to comment Share on other sites More sharing options...
spenac Posted July 3, 2007 Share Posted July 3, 2007 Mcgyver did it first, doug copied him. Link to comment Share on other sites More sharing options...
chbare Posted July 3, 2007 Author Share Posted July 3, 2007 Incorrect, anybody is free to participate in my scenarios and case studies. The purpose of these studies is to encourage critical thinking and produce viable discussion regarding the topic at hand. While many of my scenarios require ALS interentions, do not let this stop you from researching and joining the discussion. In addition, BLS interventions will always play a key role in any patient encounter. For example, could the provider in this scenario place an OPA if tolerated, have somebody hold cric pressure while another person holds a two hand mask seal, and continue ventilation with frequent suctioning for the entire trip to the trauma center? Perhaps a layer of surgilube over the beard would have helped ease the work of maintaining a mask seal? Do not sell your self short. The purpose of my scenarios is to help with learning and to encourage intelligent discussion. This scenario is not related to some of the other discussions on this site. Take care, chbare. Link to comment Share on other sites More sharing options...
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