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What is going on here and how do you proceed?
would love to see the AP view
Need more background.
HMMMM, it looks like the abdominal contents may have herniated through the diaphragm into the mediastinum causing the heart to displace L and the R lung to become displaced posteriorly, along with a R pleural effusion. I suppose the space occupying stuff could be a malignancy or an infection/abscess- I see air fluid levels. Crazy stuff whatever it is.
Did you do this case?
Edit: I forgot to touch on how to proceed...
How are his vitals?
If stable, AFOI is a possibility, but seems like RSI with ET tube would be OK, then gastric suction. Hopefully you'd have 2 lg bore IVs by now. Seems like peak pressures would be a concern, not sure what to do about that, keep FiO2 high with smaller TVs I guess. With increased intrathoracic pressures, preload would be decreased. Counteract with fluids and afterload control. What else?
Is this a baby? Chest looks too round for an adult.
Why is all the action happening on the right? That's strange.
Awake arterial line prior to induction, send an ABG as well. Obtain 2 large bore IV's, start dripping in some fluids. I'm guessing her hypotension is from the herniated intestines, colon all up in her thorax, but the temperature is concerning. Any possible source for infection. I don't know her HR or WBC, but she looks close to SIRS. Possible hypotension from pending sepsis? Her hypotension is not going to be good for her heart, need to bump up her pressures. She gets an awake intubation, fiber or glide, whichever flavor you choose. Are you going to tell us she is allergic to lidocaine?
Who has tried to rail road a 35 fr DLT over a cook exchanger?
Is that Colon I see in the lateral? Who here is afraid of aspiration?
Who has tried to rail road a 35 fr DLT over a cook exchanger?
Is that Colon I see in the lateral?
I see a full stomach on the chest CT.
Who here is afraid of aspiration?
You ever put a DLT in a bad Aw? or how 'bout a DLT in a full stomach?
Hmmm....
On another ocasion, had a very difficult time placing BB in left main with FO scope. Old school attending walks in tells me to mainstem the left with my tube using FO, then blindly just pass BB, then withdraw only tube. Worked like a charm.
What is the time course of this ruq pain? Hours, days? More history on pain specifics, please. Would like to have an idea of what we're up against before stumbling ahead.
Do we have a sort of acute on chronic hernia, and is there a perfusion issue with some newly-prolapsed gut? That would be a true now now now emergency.
It occurs to me that the appendix could be hanging out in the ruq. Would be the best presentation of appendicitis ever.
I posted this earlier in the thread. What about an NG before anything, suck out all the goo in her stomach?
What is the foramen of morgagni?
Pretty sure that's the foramen in the diaphragm that the esophagus passes through. Or possibly the appendix in this case.
Who has tried to rail road a 35 fr DLT over a cook exchanger?
Anyone ever awake FOI passing the DLT straight in over the bronch?
I think it's the foramen between the sternal and costal attachments of the diaphragm. Superior epigastric a. and internal thoracic a. pass through there.
I've done it. Very important to use a 14 french catheter. I insist on the soft tipped (purple end) since I've seen bronchial injuries from the extra-stiff ones. Put it in the endobronchial lumen and go gentle.