Clinical case for Jet (and others)

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Another thing would be pericardial tamponade, which won't be fun.
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nap$ter said:
you're alone on a boat :laugh:
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No I am not. A few people here have shown understanding of the issue at hand. and Im not chasing academic dogma. I am chasing "I dont wanna kill anyone" dogma. Sure anyone can get lucky. But for the residents reading. You mess with the wrong patient... and your judgement is a little off one day and choose an anesthetic that is not appropriate. You WILL have some splainin to do. And it wont be to the patient.
 
criticalelement said:
No I am not. A few people here have shown understanding of the issue at hand. and Im not chasing academic dogma. I am chasing "I dont wanna kill anyone" dogma. Sure anyone can get lucky. But for the residents reading. You mess with the wrong patient... and your judgement is a little off one day and choose an anesthetic that is not appropriate. You WILL have some splainin to do. And it wont be to the patient.
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Again, this study is done in left lateral position. You place the patient in the position awake, and then slowly give propofol (preferably by pump, after a few appropriately small boluses) while maintaining spontaneous ventilation. If there is trouble, this is where it starts showing. And if it does, you stop.

As long as one is not a cowboy, one is always less than a minute away from recovering spontaneous ventilation. There is a reason many people consider this MAC: it's basically deep sedation, except the few cases where one needs to manage the airway to maintain deep enough (for the procedure) sedation. It's scary until you do a few hundred of these solo.
 
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sevoflurane said:
Well I'll share an old case that I'll never forget. This will be quick. There is only one thing to learn.

It involved an unknown ant. mediastinal mass pedi patient that presented to the ED after a MVC. 7 y/o patient arrives to the trauma bay accompanied only be EMS with very little history. The only thing that is known is that child has been seeing an oncologist and was in a bad MVC. GCS is 5 with obvious cranial hematoma and likely IC injury. There is no protected AW. Team decides to go with rapid sequence induction and then proceed to CT. Shortly after induction, HR drops to 20 bpm and BP drops to 40/20. Pressors aren't working nor is volume expansion. Things are going down a dark tunnel really fast.

What do you do?
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Place him prone?
 
criticalelement said:
No I am not. A few people here have shown understanding of the issue at hand. and Im not chasing academic dogma. I am chasing "I dont wanna kill anyone" dogma. Sure anyone can get lucky. But for the residents reading. You mess with the wrong patient... and your judgement is a little off one day and choose an anesthetic that is not appropriate. You WILL have some splainin to do. And it wont be to the patient.
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you're right - the trick is to know when you can do the same ol same ol and when you need to do something special to prevent death (residents are residents to learn this and the first few years out of residency can be pretty tricky - asking older partners if unsure is never a bad idea - whether you end up taking their advice or not).

however - this is a same ol same ol case. recumbent cough doesn't get my hackles up at all. postnasal drip will give ya a recumbent cough - so will run o' the mill gerd. ask a few other questions to be sure - examine the pt.

anterior mediastinal mass is one of those things we all fear and it gets drilled into your head cuz it should cuz you can kill someone with anesthesia quickly. but don't start seeing it everywhere. i've had a few patients with big nasty life threatening masses - and all of em had scary symptoms. ie noisy breathing or positional syncope or something pretty gloomy.

you can think all you want (and i think everyone on here understands the issue at hand - there were just varying degrees of concern about it) so long as you don't delay this case or do something weird for the anesthetic. if you do that you will be in a lonesome boat with a select few who are overly cautious and unpopular with their partners and surgeons.

don't be a cowboy - but on the flip side don't be a mental spider monkey.
 
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So yeah... I figured you guys would pick up great vessel obstruction with induction. It is a zebra, but one that residents and private/academic docs should keep stored somewhere in the back of their minds. It is very impressive when you see it and it happens fast. If you don't recognize it and the patient keeps on getting pressors/volume/PALS, you've already thrown in the towel.

Prone positioning and discontinuation of anesthesia/resumption of spontaneous ventilation brought him back.
Nice to actually see it and not just read about it.
 
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