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Here's is a case for the medical students

Discussion in 'Anesthesiology' started by toughlife, Jan 2, 2009.

  1. toughlife

    toughlife Resident
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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:

    [​IMG]


    Here's your patient:
    [​IMG]



    What happened medical studs?
     
    #1 toughlife, Jan 2, 2009
    Last edited: Jan 2, 2009
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  3. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    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
     
  4. G0S2

    G0S2 SDN Angel
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    Tension pneumo?
     
  5. cfdavid

    cfdavid Membership Revoked
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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.
     
  6. G0S2

    G0S2 SDN Angel
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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?
     
  7. cfdavid

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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.
     
  8. G0S2

    G0S2 SDN Angel
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    M&M states that one of the possible consequences of jet vent is a pneumo.

    Oh and good luck tonight.
     
  9. Arch Guillotti

    Arch Guillotti Senior Member
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    Jetting can give you one or even two pneumos.
     
  10. toughlife

    toughlife Resident
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    Good.
     
  11. toughlife

    toughlife Resident
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    No central line placement was attempted during the entire case. There is no thoracostomy tube in place either.
     
    #10 toughlife, Jan 2, 2009
    Last edited: Jan 2, 2009
  12. fakin' the funk

    fakin' the funk ASA Member
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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)
     
  13. G0S2

    G0S2 SDN Angel
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    M&M also mentions subQ emphysema.
     
  14. DO4lifer

    DO4lifer Gold Member
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    a little too aggressive on jet ventilation...pneumo

    although nobody wants to underventilate.
     
  15. toughlife

    toughlife Resident
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    What do you see on CXR?
     

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