toughlife

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60+ y/o patient in for resection of supraglottic mass with your typical comorbidities Dm, HTN, etc.

In OR patient is induced, unable to intubate/ventilate, emergency crycothyroidotomy is performed with 14g angiocath placed and jet ventilation initiated. ENT staff not in room at that time, but was called urgently and tracheostomy was performed.

You then receive patient in PACU from your attending and patient is noted to be hypotensive, tachycardic and tachypneic. You order stat ABG and CXR.

CXR looks like this:




Here's your patient:




What happened medical studs?
 
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Planktonmd

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60+ y/o patient in for resection of supraglottic mass with your typical comorbidities Dm, HTN, etc.

In OR patient patient is induced, unable to intubate/ventilate, emergency crycothyroidotomy is performed with 14g angiocath placed and jet ventilation initiated. ENT staff not in room at that time, but was called urgently and tracheostomy was performed.

You then receive patient in PACU from your attending and patient is noted to be hypotensive, tachycardic and tachypneic. You order stat ABG and CXR.

CXR looks like this:





Here's your patient:



What happened medical studs?
Who was the rocket scientist who decided to induce GA on a patient with a supraglottic mass without making sure that he can be intubated??
:D
 

G0S2

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Tension pneumo?
 
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cfdavid

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I was just writing about a pneumothorax, but I'm uncertain how that could have happened in this scenario unless he was punctured during a line placement.

Also, the fact that an emergency cricothyroidostomy was needed suggests something very emergent, regardless of the difficulty of intubating someone with a supraglottic mass (i'm assuming that wouldn't be too easy). So, perhaps the mass (or associated vessel) ruptured upon attempting to intubate, thus causing aspiration and thereby upping the anti??

But, this doesn't explain how the pneumo happened other than a missed line placement.

Also, I see the thoracostomy tube in what I'm assuming enters the 2nd intercostal space.

***Don't give this one away. Make us work for it.
 

G0S2

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That 2nd intercostal, midclavicular line there with stopcock is used to bleed off air, I believe.

Can jet ventilation cause a tension pneumo?
 

cfdavid

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That 2nd intercostal, midclavicular line there with stopcock is used to bleed off air, I believe.



Can jet ventilation cause a tension pneumo?
Agree on the chest tube. And I was wondering the same thing about the jet ventilation, which I am not familiar with. I'll look it up when I get back home, unless all goes as planned :D in which case I'll look it up in the a.m....LOL.
 

G0S2

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Agree on the chest tube. And I was wondering the same thing about the jet ventilation, which I am not familiar with. I'll look it up when I get back home, unless all goes as planned :D in which case I'll look it up in the a.m....LOL.
M&M states that one of the possible consequences of jet vent is a pneumo.

Oh and good luck tonight.
 

toughlife

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That 2nd intercostal, midclavicular line there with stopcock is used to bleed off air, I believe.

Can jet ventilation cause a tension pneumo?

Good.
 

toughlife

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I was just writing about a pneumothorax, but I'm uncertain how that could have happened in this scenario unless he was punctured during a line placement.

Also, the fact that an emergency cricothyroidostomy was needed suggests something very emergent, regardless of the difficulty of intubating someone with a supraglottic mass (i'm assuming that wouldn't be too easy). So, perhaps the mass (or associated vessel) ruptured upon attempting to intubate, thus causing aspiration and thereby upping the anti??

But, this doesn't explain how the pneumo happened other than a missed line placement.

Also, I see the thoracostomy tube in what I'm assuming enters the 2nd intercostal space.


***Don't give this one away. Make us work for it.


No central line placement was attempted during the entire case. There is no thoracostomy tube in place either.
 
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fakin' the funk

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No central line placement was attempted during the entire case.
So jetting can cause PTX even if the angiocath is in the tracheal lumen, OK. What if your seal is loose or the jetting is misdirected, can you get pneumomediastinum or subQ emphysema too? (I hate those neck fascia layers)
 

G0S2

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So jetting can cause PTX even if the angiocath is in the tracheal lumen, OK. What if your seal is loose or the jetting is misdirected, can you get pneumomediastinum or subQ emphysema too? (I hate those neck fascia layers)
M&M also mentions subQ emphysema.
 

DO4lifer

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a little too aggressive on jet ventilation...pneumo

although nobody wants to underventilate.
 
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