Bongy's Quiz No.2- Tachypnea???

Bongy

Bongy

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Hello,my dear colleagues!
Time for another field based medical question,in order to keep you Little bit in shape!(Last time it was not much activity,so this time I'll give something easier)
Call received at 02:30 am...(in a middle of sweet dream;-))
Female,40 y/o,difficulty to breath
On arrival:Mid age obese women,orthopnea,RR40,BP150/90,HR110(Sinus tachy),Sat with O2 - 96,Lungs sounds - normal.
Sudden onset of difficulty to breath,woke up from sleep... No pain or other complains.
Background:Mild hypertension,hyperlipidemia,cast on the left leg(fracture 4 days ago).
Medicines:Statines,ACE inhibitors.
Hospitalization advised... On a beginning of transportation - Sat drops to 88 and than to 82... RR35,becomes "slow-speaking"...
Sedation with Ketamine (300mg) and intubation performed.
BP drops to 90 systolic... Lost of sounds in left lung(tube in a place)
In ED-asystole,CPR for 40 min... Time of death 03:45....
What do you think?
P.S.Ryder!! Give a chance to others...:)
 
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Airwaygoddess

Airwaygoddess

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based on the given information and how the patient presented My assessment would be a possible pulmonary embolism, or some type of thrombosis that came from the patient's broken leg.
 
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Bongy

Bongy

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Ok... Good... But try to explain further development of symptoms... And what kind of emboly it can be?
 
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Bongy

Bongy

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Good point... Fat emboli is a 35 % of embolies in patients with underlying flactures.. Pulmonary edema wasn't in this case-lung sounds was clear all the time - even when one lung "lost"
 
Airwaygoddess

Airwaygoddess

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The only way to find the cause of death is though an autopsy. I would treat the patient based on with the signs and symptoms, and work with the protocols that has been established by the EMS agency. Any further orders would be given by the emergency department physician. Since the patient did not survive, I would be curious on the of the cause of death, but as far as I am concerned there can be 50 other underlying medical problems that could have been going on with that patient. It is our job to assess the patient, provide treatment for the signs and symptoms, and maintain the ABC's. Anything else would be considered a gain towards personal knowledge.
 
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Bongy

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And what YOUR personal knowledge tells you? What can cause "lung lost" during mechanical ventilation?
 
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andrey

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I can say only two points, tube has gone in other bronh, high level of pressure at the end of a breathing- pneumothorax.
 
D

DOCMEDIC

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Bongy said:
Hello,my dear colleagues!
Time for another field based medical question,in order to keep you Little bit in shape!(Last time it was not much activity,so this time I'll give something easier)
Call received at 02:30 am...(in a middle of sweet dream;-))
Female,40 y/o,difficulty to breath
On arrival:Mid age obese women,orthopnea,RR40,BP150/90,HR110(Sinus tachy),Sat with O2 - 96,Lungs sounds - normal.
Sudden onset of difficulty to breath,woke up from sleep... No pain or other complains.
Background:Mild hypertension,hyperlipidemia,cast on the left leg(fracture 4 days ago).
Medicines:Statines,ACE inhibitors.
Hospitalization advised... On a beginning of transportation - Sat drops to 88 and than to 82... RR35,becomes "slow-speaking"...
Sedation with Ketamine (300mg) and intubation performed.
BP drops to 90 systolic... Lost of sounds in left lung(tube in a place)
In ED-asystole,CPR for 40 min... Time of death 03:45....
What do you think?
P.S.Ryder!! Give a chance to others...:)
Click to expand...

Just from the Bolded text I hit...
she is obese, tachypnic, headed towards respiratory failure due to an overworked system.

Given the leg fracture she "could" have overdosed on pain medication and affected her respiratory status as she was sleeping.

She became anoxic from the hyperventilation on her part thus the slow speech. (pain meds could be a factor here as well)

The intubation, as stated leaves me to believe the tube was main stem and not ventilating both bronchi, thus the loss of sound and loss of saturation. Tube placement should have be re-positioned and lung sounds re-assesed.

Hyperlipidemia could be an indication leading more towards a fatti emboli but cannot be concluded from info given.

my thoughts.
 
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andrey

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It is only clinical quiz.So fractura leg,s bone can cause an ambolia of trunci pulmonale.
 
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Bongy

Bongy

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Well... Let's think together...
At first.. Tube No 7.5 as on 2o cm dept,so tube was in place... But still "lost of lung"...
Second... Hyperlipidemia is much more risk factor for coronary thrombosisand acute MI as following but not for massive pulmonary embolism as it appears from a case. So..
As RidRyder says:"Wear your thinking caps"...
I can tell you that D-Dimer values was low,that means it wasn't a thrombus(blood source) but something else.. Like Andrey mentioned already "Fat emboly" - can be from damaged adipose tissue in a fractured leg.
Think about a mechanism o pulmonary blockade - which pressure rise and what can cause lung closure...
Common!! You can do it!!
 
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andrey

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Pneumotorax caused by rising pressure in a lungs.I think pleura can be damaged by drugs or by something else.
 
KEVD18

KEVD18

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whatever it was, i think it was bush's fault
 
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Bongy

Bongy

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Well...It wasn't a pneumothorax... No more ideas?
 
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Bongy

Bongy

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Ok..folks... I'm getting bored from you...
It was an intrapulmonary hemmorage due to overpressure on large pulmonary vessels...
I'm sorry...But I hoped for alittle bit more activity...
I think that I will go back to my cave...
 
MMiz

MMiz

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Bongy said:
Ok..folks... I'm getting bored from you...
It was an intrapulmonary hemmorage due to overpressure on large pulmonary vessels...
I'm sorry...But I hoped for alittle bit more activity...
I think that I will go back to my cave...
Click to expand...
How often do you truly see this stuff in EMS? I'm all for the quizzery and games, I think it's great, but pulling random conditions out of left field is only fun to watch on those TV shows. Again, I love puzzles, but you may have to tone in down a bit :)
 
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Bongy

Bongy

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Obvious thing are OBVIOUS... Aren't you prefer to think a little? Something that not seen every day??
 
MEDIC213

MEDIC213

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Bongy said:
Ok..folks... I'm getting bored from you...
It was an intrapulmonary hemmorage due to overpressure on large pulmonary vessels...
I'm sorry...But I hoped for alittle bit more activity...
I think that I will go back to my cave...
Click to expand...

I knew that!!:p
 
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