Trainwreck #4

[NomadicMedic]

I agree with darting her chest and electricity.

Waiting to see what's next.

 

[fast65]

I'm late to the party, like usual

I'm definitely thinking sepsis/septic shock. I don't think it is hypovolemic in nature due to her receiving ~3L at the sending facility then us putting more onboard and the pt having no urine output. The ulcers and perforated bowel don't help her case either.

I agree with everyone's treatment on the current problem, check the tube, decompress the right side of her chest, cardiovert/defib as appropriate.

Kinda glad we don't do too many IFTs around here, cause this one is making me feel on the slow side.

I would agree, now that I've had a few cups of coffee, I can actually put it all together I don't know why I said hypovolemic, the 3L of fluid is a big red flag.

 

[abckidsmom]

I'm late to the party, like usual

I'm definitely thinking sepsis/septic shock. I don't think it is hypovolemic in nature due to her receiving ~3L at the sending facility then us putting more onboard and the pt having no urine output. The ulcers and perforated bowel don't help her case either.

I agree with everyone's treatment on the current problem, check the tube, decompress the right side of her chest, cardiovert/defib as appropriate.

Kinda glad we don't do too many IFTs around here, cause this one is making me feel on the slow side.

But at her baseline, did she have any urine output? Plenty of people who have ongoing hemodialysis do not.

I am thinking that she was on the edge of sepsis, they did the standard HD plan, pulling off a couple of liters over a couple of hours, and that was too much for her. Then they over reacted with the fluid, and she's back overtanked.

I bet once we fix that pneumo, we'll listen again and she'll be having fluid in those lungs. Then what? Let's flex these critical care muscles, huh?

 

[fast65]

But at her baseline, did she have any urine output? Plenty of people who have ongoing hemodialysis do not.

I am thinking that she was on the edge of sepsis, they did the standard HD plan, pulling off a couple of liters over a couple of hours, and that was too much for her. Then they over reacted with the fluid, and she's back overtanked.

I bet once we fix that pneumo, we'll listen again and she'll be having fluid in those lungs. Then what? Let's flex these critical care muscles, huh?

I suppose if that was the case we might be able to increase the PEEP?

 

[abckidsmom]

I suppose if that was the case we might be able to increase the PEEP?

Only if you wanted another pneumo. Blowing a lung like that so soon after transitioning to a transport vent screams vent malfunction or user error in setting the settings.

People who are stable on their settings don't typically all of the sudden develop a tension pneumo without some outside changes, even in a train wreck. Well, maybe in a train wreck...

 

[fast65]

Only if you wanted another pneumo. Blowing a lung like that so soon after transitioning to a transport vent screams vent malfunction or user error in setting the settings.

People who are stable on their settings don't typically all of the sudden develop a tension pneumo without some outside changes, even in a train wreck. Well, maybe in a train wreck...

Dammit, you're right, I'm not sure what I was thinking :/ So let's say that after we decompress the pneumo we find a good amount of fluid in the lungs, what can we do? I mean going with diuretics isn't going to do much good, her kidneys aren't functioning well enough for them too; and PEEP is out because as you said, it would probably just cause another pneumo.

 

[usalsfyre]

We dart the chest, the SpO2 improves to >90%, the B/P improves slightly to 70/30...but we're still in V-Tach. We do have a carotid and very weak peripheral pulses.

So synchronized cardioversion? Or medication?

Oh yeah, we're now stuck in traffic, and your 20 min ETE just turned into an hour, and you used a standard angiocath for the decompression...(ok, being slightly mean here )

 

[fast65]

Well, let's go with synchronized cardioversion and see where that gets us. How are our LS?

 

[Handsome Robb]

But at her baseline, did she have any urine output? Plenty of people who have ongoing hemodialysis do not.

I am thinking that she was on the edge of sepsis, they did the standard HD plan, pulling off a couple of liters over a couple of hours, and that was too much for her. Then they over reacted with the fluid, and she's back overtanked.

I bet once we fix that pneumo, we'll listen again and she'll be having fluid in those lungs. Then what? Let's flex these critical care muscles, huh?

My critical care muscles are still itty bitty.

Why would she have a foley cath in place with a baseline of no urine output though? Standard procedure by the care home possibly? Seems like an unnecessary risk to the patient when you consider the chance of UTI -> urosepsis.

I'm kind of lost with this one, probably fluid in the longs but can't use peep otherwise risk another pnuemo. I have a thought but it might be a dumb one. We are on a CCT truck correct? Do we have hypertonic solutions available to us? Increase the osmotic pressure in the vascular space to draw fluid out of the alveoli and back into the vasculature thus reducing the fluid problem in the lungs, increasing oxygenation and volume/bp?

Be gentle please!!!

 

[Handsome Robb]

Well, let's go with synchronized cardioversion and see where that gets us. How are our LS?

agreed.

 

[usalsfyre]

Cardioversion a 100j, post cardioversion EKG resembles, however think more tachycardia:

(sorry couldn't find what I wanted).

The B/P improves to 110/74.

Lung sounds are...crappy. Especially on the right.

We ARE on a CCT truck. What can we do that would allow us to use PEEP and go a long way towards helping the pneumo?

 

[usalsfyre]

You sure know how to bring a train wreck. IFT scenarios should be "Usals's EMTALA violations."

Nahhh, that's an upcoming L&D case that the truck I'm precepting on ran a couple of weeks ago. I've just got to figure out how to sufficiently change the details :unsure:.

 

[usalsfyre]

I'm kind of lost with this one, probably fluid in the longs but can't use peep otherwise risk another pnuemo. I have a thought but it might be a dumb one. We are on a CCT truck correct? Do we have hypertonic solutions available to us? Increase the osmotic pressure in the vascular space to draw fluid out of the alveoli and back into the vasculature thus reducing the fluid problem in the lungs, increasing oxygenation and volume/bp?

Be gentle please!!!

Hypertonic saline is not a bad thought, but there's something else we can do while sitting in traffic.

 

[usalsfyre]

More on hypertonic saline. So if the patient is volume overloaded, would pulling fluid into the vasculature be good? What's are some of the membranes most likely to allow fluid to deposit?

Like I said, I understand the thought but there's better options. Hypertonic saline won't fix the fluid maldistribution problem. Your on the right road with PEEP, now how can we prevent the pneumo?

 

[Handsome Robb]

More on hypertonic saline. So if the patient is volume overloaded, would pulling fluid into the vasculature be good? What's are some of the membranes most likely to allow fluid to deposit?

Like I said, I understand the thought but there's better options. Hypertonic saline won't fix the fluid maldistribution problem. Your on the right road with PEEP, now how can we prevent the pneumo?

That was my worry. It wouldn't be good but it would be better than having fluid build up in the lungs? Seems like I would have fixed one problem while building upon one that was already present :unsure:

In regards to what I bolded, can you go into a little more detail? I'm not sure I understand what your asking.

I'm pretty stuck on how to further prevent another pnuemo. I'm not keen on bagging this guy the entire time we are in traffic, can the vent be set to have no PEEP? I would think the lack of PEEP would help prevent another one from developing but then your not helping the wet lungs...

 

[fast65]

Cardioversion a 100j, post cardioversion EKG resembles, however think more tachycardia:

(sorry couldn't find what I wanted).

The B/P improves to 110/74.

Lung sounds are...crappy. Especially on the right.

We ARE on a CCT truck. What can we do that would allow us to use PEEP and go a long way towards helping the pneumo?

Hmmmm, now that is a tough one, to be quite honest, I'm not sure how to handle that one. My initial thought was to increase PEEP, but decrease tidal volume, in my mind that might somehow work, but in reality I'm not so sure

 

[Handsome Robb]

I have a thought and as usual I'm probably barking up the wrong tree but here it goes.

Could the pnuemo be caused by the patient having a spontaneous respiration against the vent causing a spike in intrathoracic pressure? Super long shot but it's about all I can come up with but if this is the case could paralyzing and sedating the patient reduce the risk of another pnuemo by removing the patients ability to breath spontaneously? In turn could the PEEP then be maintained or increased a bit to help with the displacement of fluid?

Ok back to my neurology paper.

 

[usalsfyre]

One last hint. Since we're on a CCT truck, can we do something to definitively treat the pneumo allowing us to use PEEP?

 

[fast65]

One last hint. Since we're on a CCT truck, can we do something to definitively treat the pneumo allowing us to use PEEP?

Wait, we can't place a chest tube, right?

EDIT: the more I think about it, the more I'm second guessing it. A chest tube would only be for hemothrorax, correct?

 

[Handsome Robb]

I know CCRNs can place chest tubes in many flight programs. Can a medic do that? Our flight medics can only monitor chest tubes last time I checked. Caveat being that I don't pay a ton of attention to their protocols. Thats about the only thing I can think of.

Chest tube is truly the only definitive treatment of a pnuemo unless you have some sort of trauma to the lung(s) that requires surgical intervention from what I have read.