Case

[AlmostJesus]

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Hey, thought I would share a case I had this weekend. I am a paramedic working in a rural area and I do ED work when I am not on calls.
I got called for SOB on a 68 year old male with long history of medical problems including COPD and on home oxygen, also with a history of frequent ED visits for minor things. Pt vomits just prior to arrival I get there. The family states he was in the clinic for a sore throat had difficulty swallowing, but now appears to be managing okay. It was suggested by the doctor to crush pills and take them after using some chloraseptic for pain. He vomited when attempting to do this. Pt also has expiratory wheezing throughout despite a neb one hour previously. Sat is 89% on 4L pre-neb. Enroute, I gave him an albuterol neb which improved the wheezing. I didn't give any other medications before arrival.
He feels better upon presentation to the ED. The main complaint he now has is a sore throat. No apparent difficulty handling secretions, etc. Patient was recently hospitalized approximately one week ago for back pain.
CXR is doesn't look bad, white count and CRP are slightly elevated, no other odd labs.
Given his past history and fairly benign workup, do you admit him or send him home for follow up with his PCP?
What else do you want to know?


I am doing this just as a learning opportunity. I am always curious to see the variety of answers, and I love when people post cases.

 

[Apollyon]

Hey, thought I would share a case I had this weekend. I am a paramedic working in a rural area and I do ED work when I am not on calls.
I got called for SOB on a 68 year old male with long history of medical problems including COPD and on home oxygen, also with a history of frequent ED visits for minor things. Pt vomits just prior to arrival I get there. The family states he was in the clinic for a sore throat had difficulty swallowing, but now appears to be managing okay. It was suggested by the doctor to crush pills and take them after using some chloraseptic for pain. He vomited when attempting to do this. Pt also has expiratory wheezing throughout despite a neb one hour previously. Sat is 89% on 4L pre-neb. Enroute, I gave him an albuterol neb which improved the wheezing. I didn't give any other medications before arrival.
He feels better upon presentation to the ED. The main complaint he now has is a sore throat. No apparent difficulty handling secretions, etc. Patient was recently hospitalized approximately one week ago for back pain.
CXR is doesn't look bad, white count and CRP are slightly elevated, no other odd labs.
Given her past history and fairly benign workup, do you admit her or send her home for follow up with his PCP?
What else do you want to know?


I am doing this just as a learning opportunity. I am always curious to see the variety of answers, and I love when people post cases.

Were there 2 patients you mixed up here?

 

[AlmostJesus]

Were there 2 patients you mixed up here?

fixed...

 

[link2swim06]

Hey, thought I would share a case I had this weekend. I am a paramedic working in a rural area and I do ED work when I am not on calls.
I got called for SOB on a 68 year old male with long history of medical problems including COPD and on home oxygen, also with a history of frequent ED visits for minor things. Pt vomits just prior to arrival I get there. The family states he was in the clinic for a sore throat had difficulty swallowing, but now appears to be managing okay. It was suggested by the doctor to crush pills and take them after using some chloraseptic for pain. He vomited when attempting to do this. Pt also has expiratory wheezing throughout despite a neb one hour previously. Sat is 89% on 4L pre-neb. Enroute, I gave him an albuterol neb which improved the wheezing. I didn't give any other medications before arrival.
He feels better upon presentation to the ED. The main complaint he now has is a sore throat. No apparent difficulty handling secretions, etc. Patient was recently hospitalized approximately one week ago for back pain.
CXR is doesn't look bad, white count and CRP are slightly elevated, no other odd labs.
Given his past history and fairly benign workup, do you admit him or send him home for follow up with his PCP?
What else do you want to know?


I am doing this just as a learning opportunity. I am always curious to see the variety of answers, and I love when people post cases.

How much home oxygen?

What was his oxygen sat while in the ED? Was it on room air or 4L still?

What are the rest of his vitals?

How long was he hospitalized during the prior week?


A straight forward COPD exacerbation seems high on the differential...am I missing something obvious?

 

[RustedFox]

Here at my shop this would be "rule-out aspiration", and is a slam-dunk admit.

If I were planning on sending him home... EKG, 2-sets of zymes, and a healthy obs period where he needs to return to baseline.

Of course, I live in seniorcitizenland.



Also, I agree that we need more "cases" as posts.

 

[bad virus]

Here at my shop this would be "rule-out aspiration", and is a slam-dunk admit.

If I were planning on sending him home... EKG, 2-sets of zymes, and a healthy obs period where he needs to return to baseline.

Of course, I live in seniorcitizenland.



Also, I agree that we need more "cases" as posts.

Does your shop happen to be predominantly located between the trade winds of a few hospice centers?

Oh and to the rest of you guys buggering the OP with bunches of questions and little fixes, I think he's more interested in some teaching about COPD exacerbations. The differential, evaluation and treatment in a formulaic easy to understand way may be a nice start if you guys were kind enough, instead of acting like a bunch of tossers.

 

[Apollyon]

Oh and to the rest of you guys buggering the OP with bunches of questions and little fixes, I think he's more interested in some teaching about COPD exacerbations. The differential, evaluation and treatment in a formulaic easy to understand way may be a nice start if you guys were kind enough, instead of acting like a bunch of tossers.

Step back, and don't refer to people as "a bunch of tossers". And you are certainly over-reacting if you find this thread to not be "kind enough". You're finding fault where there isn't any.

(For those of you that don't know what that means, to "have a toss" is to masturbate in the UK. And, ironically, this poster uses "buggering" instead of "bugging". If you are not sure of that, look up "buggery".)

 

[Ibuprofen]

The sore throat and difficulty swallowing, and slightly elevated WBC makes me think epiglottitis. However, I only know the EMS care for this, not what the hospital would do. I assume they would admit or at least observe for a few hours?

 

[8654Marine]

....

 

[AlmostJesus]

How much home oxygen?

What was his oxygen sat while in the ED? Was it on room air or 4L still?

What are the rest of his vitals?

How long was he hospitalized during the prior week?


A straight forward COPD exacerbation seems high on the differential...am I missing something obvious?

He is on 2L at home normally

Oxygen sat improved to 90% on 4L after the neb treatment and hung right around there.

Hospitalized for three days last week. Patient has a history of frequent hospitalization, a typical train wreck type patient
Vital signs 130/88, p. 90, RR - 20, Temp 98.8 tympanic, Sat 90% on room air

Here at my shop this would be "rule-out aspiration", and is a slam-dunk admit.

If I were planning on sending him home... EKG, 2-sets of zymes, and a healthy obs period where he needs to return to baseline.

Of course, I live in seniorcitizenland.



Also, I agree that we need more "cases" as posts.

EKG is fine, 1st set of cardiacs are fine. Sorry I dont have the exact numbers
Since you plan to observe
You are covering the ED for this small 25 bed hospital and write tuck in orders for at least 6 hours of observation. His PCP is out of town.

After you hit the on call room for awhile, you get a call from the patient's nurse that patient is having increased difficulty breathing. You are the only physician in house at this time. An albuterol neb was given to no avail. Sat is 86% on 4L. He has become febrile. When you walk in, he develops some stridor.

What's next?

 

[bad virus]

Step back, and don't refer to people as "a bunch of tossers". And you are certainly over-reacting if you find this thread to not be "kind enough". You're finding fault where there isn't any.

(For those of you that don't know what that means, to "have a toss" is to masturbate in the UK. And, ironically, this poster uses "buggering" instead of "bugging". If you are not sure of that, look up "buggery".)

Lol obviously my attempt at UK humor fell on deaf ears so let me translate: Stop being picky and give the gentleman some advice in regards to his case.

 

[Apollyon]

Lol obviously my attempt at UK humor fell on deaf ears so let me translate: Stop being picky and give the gentleman some advice in regards to his case.

Well, truth be told, to most people not from Britain, "British humor" is an oxymoron.

One thing you'll learn is that the medicine is in the details. What you now call "picky" is the difference, or can be.

 

[tkim]

Well, truth be told, to most people not from Britain, "British humor" is an oxymoron.

One thing you'll learn is that the medicine is in the details. What you now call "picky" is the difference, or can be.

 

[ptarmigan]

AlmostJ - the ddx on this patient is very wide. A 68 year old with shortness of breath is an extremely high risk situation. Just to give you an idea how I approach this in the ED . . . even if it sounds like a straightforward COPD exacerbation, I cast a wide net initiallly. EKG, CXR, +/- cardiac enzymes, etc. If I feel like it is a COPD exacerbation, then I load with prednisone and treat with albuterol/ipratroprium. If the sx completely resolve, O2 requirement is back to baseline, vitals are normal, EKG is unchanged or normal, patient looks great and has good follow up, I check another set of cardiac enzymes if they were part of the initial package after x hours and DC. Sx not completely resolved or O2 not back to baseline = admit.

Now, in the background, there's a lot more thinking going on . . . ddx includes STEMI, NSTEMI, unstable angina, CHF exacerbation, PE, PNA - depending on what your suspicion for each is and what the studies show, its kind of a choose your own adventure from there. Virtually anything can cause shortness of breath in a 68 year old. I have seen abdominal catastrophes present with shortness breath as the main symptoms a number of times. The wheezing could be a red herring - some COPDers and smokers wheeze most of the time, even when they are their baseline.

One thing I try to focus on with our paramedics is not narrowing down on a diagnosis too quickly. I tell them that If you think it is a COPD exacerbation, then thats great - go ahead and treat. But keep entertaining the other diagnoses in the differntial - especially do a 12 lead, do a complete exam, multiple sets of vital signs, put on the moitor, etc.

 

[Arcan57]

He is on 2L at home normally

Oxygen sat improved to 90% on 4L after the neb treatment and hung right around there.

Hospitalized for three days last week. Patient has a history of frequent hospitalization, a typical train wreck type patient
Vital signs 130/88, p. 90, RR - 20, Temp 98.8 tympanic, Sat 90% on room air


EKG is fine, 1st set of cardiacs are fine. Sorry I dont have the exact numbers
Since you plan to observe
You are covering the ED for this small 25 bed hospital and write tuck in orders for at least 6 hours of observation. His PCP is out of town.

After you hit the on call room for awhile, you get a call from the patient's nurse that patient is having increased difficulty breathing. You are the only physician in house at this time. An albuterol neb was given to no avail. Sat is 86% on 4L. He has become febrile. When you walk in, he develops some stridor.

What's next?

90% on RA after nebs or is he still on the 4L prior to decompensation? Also, how do his lungs sound (are they relatively clear and the hypoxia is out of proportion to lung findings?)

When I walk in the room, what are the rest of the patient's vital signs (am I dealing just with a respiratory issue or has the patient slid into septic shock)?

Being hospitalized 3 days for back pain is really unusual in my neck of the woods, and I'd want to see at least the discharge summary and find out if the patient had any procedures during their stay. With immobility, pulmonary embolism is going to be on the differential although that doesn't explain the odynophagia and stridor. When was the last time the patient was on steroids? Septic thrombophlebitis, retropharyngeal abscess, and epiglottis would all need to be given a consideration. What does the HEENT exam and lung exam look like currently?

Based on your description of the patient, they need a definitive airway although I don't have enough information to determine if it's someone I'd RSI, try an awake inbubation on, or temporize until ENT and anesthesia arrive. After the airway was secured, pt gets broad-spectrum abx, decadron, and CT scans (soft-tissue neck and CTPE). Depending on hospital capability, I'd consider transfer (does the hospital have an ICU or ENT available?).

 

[RustedFox]

Does your shop happen to be predominantly located between the trade winds of a few hospice centers?

Oh and to the rest of you guys buggering the OP with bunches of questions and little fixes, I think he's more interested in some teaching about COPD exacerbations. The differential, evaluation and treatment in a formulaic easy to understand way may be a nice start if you guys were kind enough, instead of acting like a bunch of tossers.

1. Yes, my shop is between about eleventeen nursing home, hospices, etc. 🙂

2. The diff is broad. The devil is in the details.

3. Now, let me be picky. I like a lot of your contributions - but since you're applying for residency this cycle... change your status.

4. +1 to Arcan's management, though I'd be more likely to just tube the guy straight off (getting ENT/Anes in my shop takes awhiiiile).

 

[EMquest3]

He is on 2L at home normally

Oxygen sat improved to 90% on 4L after the neb treatment and hung right around there.

Hospitalized for three days last week. Patient has a history of frequent hospitalization, a typical train wreck type patient
Vital signs 130/88, p. 90, RR - 20, Temp 98.8 tympanic, Sat 90% on room air


EKG is fine, 1st set of cardiacs are fine. Sorry I dont have the exact numbers
Since you plan to observe
You are covering the ED for this small 25 bed hospital and write tuck in orders for at least 6 hours of observation. His PCP is out of town.

After you hit the on call room for awhile, you get a call from the patient's nurse that patient is having increased difficulty breathing. You are the only physician in house at this time. An albuterol neb was given to no avail. Sat is 86% on 4L. He has become febrile. When you walk in, he develops some stridor.

What's next?

Just off the top of my head, non-rebreather ---> bipap ---> intubate if sats don't go back up.
Did he already have a CXR? If it seems clinically like this could be an epiglotitis on top of COPD then get lateral neck films.

 

[Arcan57]

4. +1 to Arcan's management, though I'd be more likely to just tube the guy straight off (getting ENT/Anes in my shop takes awhiiiile).

If he looked at all reasonable for being able to intubate then that'd be my preferred strategy (preferably with video laryngoscopy, although my shop's Glidescope is currently broken). If I looked at him and thought there is no way I'm getting plastic in trachea (I'd try a pedi bronchoscope or intubating NP scope if he looked unfavorable for orotracheal) then I'd do BiPap with a racemic neb and go ahead and open the trach tray and prep the neck while waiting to see whether ENT gets there before I have to cut.

 

[Arcan57]

Just off the top of my head, non-rebreather ---> bipap ---> intubate if sats don't go back up.
Did he already have a CXR? If it seems clinically like this could be an epiglotitis on top of COPD then get lateral neck films.

CXR was stated to be clear. At this point we have a hypoxic COPD pt developing upper airway obstruction. The patient satting 90% on supplemental O2 isn't an immediate problem, but it's going to complicate things. As painted (still need to know rest of vitals), this is a patient that is having problems with oxygenation and ventilation. The non-rebreather probably isn't a great choice for a COPDer since it only addresses oxygenation (and may worsen ventilation with the hypoxic drive to breathe gone). BiPap is a fantastic way to assist oxygenation and ventilation, and would be my first choice for treatment in this patient except... the patient's developing airway obstruction. What this means is that the BiPap will keep the patient's numbers looking good while the underlying obstruction worsens. This will lead to the patient crashing with an airway that's impossible to access from above.

If the patient is starting off with healthy lungs and has some mild stridor then you can get plain films (although I much prefer CT), give steroids, and monitor. This is a patient with little to no pulmonary reserve on the floor of a hospital where you are the only doctor. It would be nice to get a definitive diagnosis prior to managing the airway, but if you don't secure it while you are on the floor the first time the next time you get called is probably going to be because the patient is coding. The only way I'd even think about leaving the patient without a tube is if it looked like an obvious allergic reaction and they started improving after a dose of IM epi.

 

[AlmostJesus]

AlmostJ - the ddx on this patient is very wide. A 68 year old with shortness of breath is an extremely high risk situation. Just to give you an idea how I approach this in the ED . . . even if it sounds like a straightforward COPD exacerbation, I cast a wide net initiallly. EKG, CXR, +/- cardiac enzymes, etc. If I feel like it is a COPD exacerbation, then I load with prednisone and treat with albuterol/ipratroprium. If the sx completely resolve, O2 requirement is back to baseline, vitals are normal, EKG is unchanged or normal, patient looks great and has good follow up, I check another set of cardiac enzymes if they were part of the initial package after x hours and DC. Sx not completely resolved or O2 not back to baseline = admit.

Now, in the background, there's a lot more thinking going on . . . ddx includes STEMI, NSTEMI, unstable angina, CHF exacerbation, PE, PNA - depending on what your suspicion for each is and what the studies show, its kind of a choose your own adventure from there. Virtually anything can cause shortness of breath in a 68 year old. I have seen abdominal catastrophes present with shortness breath as the main symptoms a number of times. The wheezing could be a red herring - some COPDers and smokers wheeze most of the time, even when they are their baseline.

One thing I try to focus on with our paramedics is not narrowing down on a diagnosis too quickly. I tell them that If you think it is a COPD exacerbation, then thats great - go ahead and treat. But keep entertaining the other diagnoses in the differntial - especially do a 12 lead, do a complete exam, multiple sets of vital signs, put on the moitor, etc.

The only thing I did for him enroute was provide an albuterol neb, put him on the monitor (which did show questionable periods of a-fib), and continue with his oxygen. He had expiratory wheezing throughout pretreatment which improved significantly afterwards. I agree on not closing too far in on a differential, I figured it was a likely COPD exacerbation. It was the zebra that it ended up being that had me writing this.

90% on RA after nebs or is he still on the 4L prior to decompensation? Also, how do his lungs sound (are they relatively clear and the hypoxia is out of proportion to lung findings?)

When I walk in the room, what are the rest of the patient's vital signs (am I dealing just with a respiratory issue or has the patient slid into septic shock)?

Being hospitalized 3 days for back pain is really unusual in my neck of the woods, and I'd want to see at least the discharge summary and find out if the patient had any procedures during their stay. With immobility, pulmonary embolism is going to be on the differential although that doesn't explain the odynophagia and stridor. When was the last time the patient was on steroids? Septic thrombophlebitis, retropharyngeal abscess, and epiglottis would all need to be given a consideration. What does the HEENT exam and lung exam look like currently?

Based on your description of the patient, they need a definitive airway although I don't have enough information to determine if it's someone I'd RSI, try an awake inbubation on, or temporize until ENT and anesthesia arrive. After the airway was secured, pt gets broad-spectrum abx, decadron, and CT scans (soft-tissue neck and CTPE). Depending on hospital capability, I'd consider transfer (does the hospital have an ICU or ENT available?).

89% on 4L when I walked in the door of the residence. 90-94% post neb.
Lungs had expiratory wheezing throughout pre neb and improvement post neb. No stridor was noted while he was in my care.

When you walk in some time later, his work of breathing is increased sat is 84% on 4L, his BP is running in the 90/60 range, and the temp is 101.0. Lung sounds are fine aside from the stridor. You do not have the ability to do a lactate.
You do a soft tissue neck CT which reveals epiglottitis. As earlier, you gave steroids and started the broad spectrum abx.

In your small hospital, you do have a single ENT that may be available along with an experienced CRNA and GS on call. CRNA is standing in the ED right now. It is a 30 minute flight from tertiary care. So it would be an hour until the patient would land at tertiary care.
Right now he is holding his own as far as work of breathing, but is starting to tire out. Your only bi-pap machine in the hospital is being used on another patient right now. You do have disposable CPAP that you can get from the ambulance. He does have a short, fat neck and a known difficult airway.
Do you rally your troops and try and get the airway there, or wait until the helicopter comes? How would you preferably go about securing the airway? You do have either a glidescope or McGrath video laryngoscope available. OR could be available in ~20 minutes, GS could be there in 10.

 

[ptarmigan]

Agree with Arcan - needs an airway. Missed your second post where the patient was deteriorating.

Bipap and CPAP are unlikely to help in this situation anyway and could make the situation worse. The patient with an upper airway obstruction will natuarally position himself in the best position possible.

Ideally what you want here is a double prep in the OR - with anesthesia or an EP intubating the patient while a surgeon (ENT, general) is ready to do a surgical airway with the neck prepped.

I would call in anesthesia, ENT, general surgery, whoever you have available. If you can have a surgeon there in 10 minutes, I would consider waiting until he was at the bedside to do the cric in case I could not intubate. If the surgeon gets there, the patient is holding is holding his own and you can get to the OR safely then all the better. In the menatime - non rebreather, treat the septic shock, IV steroids and racemic epi.

The patient may not be able to wait 10 minutes. If that's the case, just intubate and have all your adjuncts ready. I would have a cric kit open and a knife ready.

 

[Arcan57]

Agree with Arcan - needs an airway. Missed your second post where the patient was deteriorating.

Bipap and CPAP are unlikely to help in this situation anyway and could make the situation worse. The patient with an upper airway obstruction will natuarally position himself in the best position possible.

Ideally what you want here is a double prep in the OR - with anesthesia or an EP intubating the patient while a surgeon (ENT, general) is ready to do a surgical airway with the neck prepped.

I would call in anesthesia, ENT, general surgery, whoever you have available. If you can have a surgeon there in 10 minutes, I would consider waiting until he was at the bedside to do the cric in case I could not intubate. If the surgeon gets there, the patient is holding is holding his own and you can get to the OR safely then all the better. In the menatime - non rebreather, treat the septic shock, IV steroids and racemic epi.

The patient may not be able to wait 10 minutes. If that's the case, just intubate and have all your adjuncts ready. I would have a cric kit open and a knife ready.

This.

 

[TooMuchResearch]

I agree - more cases would be great. Thanks for the teaching today, ladies/gentlemen.

 

[AlmostJesus]

Agree with Arcan - needs an airway. Missed your second post where the patient was deteriorating.

Bipap and CPAP are unlikely to help in this situation anyway and could make the situation worse. The patient with an upper airway obstruction will natuarally position himself in the best position possible.

Ideally what you want here is a double prep in the OR - with anesthesia or an EP intubating the patient while a surgeon (ENT, general) is ready to do a surgical airway with the neck prepped.

I would call in anesthesia, ENT, general surgery, whoever you have available. If you can have a surgeon there in 10 minutes, I would consider waiting until he was at the bedside to do the cric in case I could not intubate. If the surgeon gets there, the patient is holding is holding his own and you can get to the OR safely then all the better. In the menatime - non rebreather, treat the septic shock, IV steroids and racemic epi.

The patient may not be able to wait 10 minutes. If that's the case, just intubate and have all your adjuncts ready. I would have a cric kit open and a knife ready.

I like that plan, a racemic epi was given early in the course. Before I go with how it was managed.

Now we can go with the more likely to encounter part of the scenario. You are the physician oversight for the helicopter transport team. They call report on the patient. The patient is moving air better, stridor has decreased. They put him on 12L by NRB and sats are up to 96%. IV solu-medrol, broad spectrum abx, and a racemic epi have been given. Patient clinically looks better, but still states he is tired. They have a 20-30 minute flight. Your transport team has an RN, EMT-P, and RT.
Given that the small hospital does have access to the OR, a GS, ENT, and CRNA along with the FP doc that covers ER, do you request that they take the airway there with the flight team transporting the patient afterwards, or do you just have the flight team transport the patient?
I suppose I could make this pertinent to residents that fly and include the question if you were a resident with the flight team, how would you choose to manage the airway?

 

[ptarmigan]

Intubate before flying. Do not fly a patient with impending airway collapse from epiglottitis, and a 12 liter oxygen requirement, who also happens to be in septic shock, without a definitive airway.

 

[Rendar5]

Intubate before flying. Do not fly a patient with impending airway collapse from epiglottitis, and a 12 liter oxygen requirement, who also happens to be in septic shock, without a definitive airway.

A helicopter is not the ideal setting to do a surgical airway. Too cramped, too many variables, fewer toys.

 

[8654Marine]

Agree, get anyone w/ surgical experience and secure an airway (oral, nasal, or cric) before that guy leaves the hospital. You only bought yourself minutes.

 

[AlmostJesus]

Thanks for the great posts
The flight team in consultation with their ED medical control decided to hold off and do it in a more controlled situation since he improved some. They had him on 12L by NRB when they left. They ended up initiating bipap either in route or after arriving at the tertiary care hospital. He had a sat of 90% on bipap when they got to the OR. It ended up being ENT and anesthesiology that did the tube successfully in the OR with a prep for a trach as needed. That is the last that I heard.

While not the ideal management, the outcome ended up turning out okay. Thought it would be good to present a zebra case and see how everyone would manage it, great learning experience.

 

[Apollyon]

Thought it would be good to present a zebra case and see how everyone would manage it, great learning experience.

A "zebra" case is one where the diagnosis is uncommon, and easily confused with something more common. The origin of the phrase is "when you hear hoofbeats outside the window, think of horses, not zebras".

Did I miss it, or was there some exotic diagnosis? It sounds more like a more straightforward COPD and reactive airway case that just didn't turn around as much as we hope.

Or was it the epiglottitis? In an older guy, in conjunction with COPD, sure, a tough case, but not exceedingly rare. In a stridulous patient, the lateral neck tells us a lot.

 

[ptarmigan]

I'm curious ... what did the medical director think you were going to do in the helicopter if this person lost his airway? Has your medical director ever tended to patients in a helicopter? You had a surgeon and (presumably) someone who could intubate the patient at your hospital . . . how would you and your medical director look back at this case if the patient died of airway obstruction in the air (which is certainly possible from what you described)? I know it wasn't your decision, but I would never put a flight paramedic or a flight nurse in that situation. The OR with someone to intubate and someone to cric is what you need and it seemed like you had that . . . did the surgeon not want to come in? Did the FP not feel comfortable going up to the OR to intubate?

 

[AlmostJesus]

A "zebra" case is one where the diagnosis is uncommon, and easily confused with something more common. The origin of the phrase is "when you hear hoofbeats outside the window, think of horses, not zebras".

Did I miss it, or was there some exotic diagnosis? It sounds more like a more straightforward COPD and reactive airway case that just didn't turn around as much as we hope.

Or was it the epiglottitis? In an older guy, in conjunction with COPD, sure, a tough case, but not exceedingly rare. In a stridulous patient, the lateral neck tells us a lot.

I was talking the epiglottitis
The presentation was interesting. True, once the stridor came about, it became a lot more clear.

 

[AlmostJesus]

I'm curious ... what did the medical director think you were going to do in the helicopter if this person lost his airway? Has your medical director ever tended to patients in a helicopter? You had a surgeon and (presumably) someone who could intubate the patient at your hospital . . . how would you and your medical director look back at this case if the patient died of airway obstruction in the air (which is certainly possible from what you described)? I know it wasn't your decision, but I would never put a flight paramedic or a flight nurse in that situation. The OR with someone to intubate and someone to cric is what you need and it seemed like you had that . . . did the surgeon not want to come in? Did the FP not feel comfortable going up to the OR to intubate?

For clarification, I wasn't on the flight team, I work in a hospital based EMS system.
I do agree on your point about the lost airway. About the only thing possible would have been to do a needle cric, I am unsure if they carry any type of video laryngoscope that they could have attempted an inflight intubation.
My guess why they didn't was because the med control doctor didn't realize GS was available along with the flight team not really considering/realizing/recommending that they do an airway in a controlled setting in the OR.
The CRNA on call was in favor of tubing beforehand, we had the equipment out and ready, the trigger just wasn't pulled. I do not know if GS was called.
I guess part of the reason why I posted this was that I was interested in hearing how everyone else would have managed this. I felt from the time the stridor came about, and especially after the confirmation of the diagnosis, we should have been doing the tube.

 

[Arcan57]

If the sending hospital had ENT and anesthesia, it inexcusable to make the patient wait >1hr to get a definitive airway. Pt gets airway secured then transferred, end of story.

 

[bad virus]

If the sending hospital had ENT and anesthesia, it inexcusable to make the patient wait >1hr to get a definitive airway. Pt gets airway secured then transferred, end of story.

1. I loved seeing the management proposed by all of you, thank you especially Arcan57.

2. Rusted Fox is definitely my favorite poster on this part of the forum, I don't know why (I will change my status soon, I have a reason for it, I promise).

3. Sorry for my British Humor fail.

4. More cases please, I love seeing the thought process you guys bring to the table.

 

[RustedFox]

1. You're alright, too.

2. You actually get a "pass" on the British Humour. Its the ppl that post lik dis that rlly get 2 most of us on here LOLZ. Apollyon really loses his rag when he sees that. I'm not far behind.

3. If we're going to post more cases, I suggest we title the thread like: "The Case of the Yadda Yadda Yadda" in an homage to the old Encyclopedia Brown books. If you don't know what those were, I feel bad for you. I'll start one later tonight, lemme think of a good'n.

4. My shop really is between several nursing homes and hospice centers. Its wobbly old folks all day long for me.

 

[jdh71]

The non-rebreather probably isn't a great choice for a COPDer since it only addresses oxygenation (and may worsen ventilation with the hypoxic drive to breathe gone)

My turn to be picky in this thread . . . oxygen does not worsen ventilation via a decrease in drive to breathe. This has been told to medical trainees including myself for decades, though was thoroughly rejected even as long ago as the late 70s. What's the saying about how long it takes to get a good idea into medicine and bad idea out? Anyway, any changes in ventilation that may occur with the application of oxygen in bad COPDers is a result of an increase in oxygen tension in and an increase blood flow (as a result of increased oxygen tension) to parts of the lung already poorly ventilated at baseline. More blood flow to bad parts of lungs = worse abg.

The idea that these guys (COPDers) need to be satting anything over 90 is often inviting a physician to create problems when there is none.

 

[Glitterbox]

My turn to be picky in this thread . . . oxygen does not worsen ventilation via a decrease in drive to breathe. This has been told to medical trainees including myself for decades, though was thoroughly rejected even as long ago as the late 70s. What's the saying about how long it takes to get a good idea into medicine and bad idea out? Anyway, any changes in ventilation that may occur with the application of oxygen in bad COPDers is a result of an increase in oxygen tension in and an increase blood flow (as a result of increased oxygen tension) to parts of the lung already poorly ventilated at baseline. More blood flow to bad parts of lungs = worse abg.

The idea that these guys (COPDers) need to be satting anything over 90 is often inviting a physician to create problems when there is none.

Yup, I've heard the same as well, except no one really had a good reason for why a change in ventilation was observed. I appreciate that explanation, thanks.