Interesting CPR...

[canjosh]

Alright, I gotta run this one by you guys. Preface: I'm a paramedic working in a small suburban ED.

We get this 70'ish male CPR in progress by EMS, attempted ET intubation x 1, then went with a Combitube. Pt has implanted pacemaker/defibrillator. EMS got a pulse back while still in the pt's house. Norepi gtt started by EMS also. EMS noted while in the truck that the pt's face began to rapidly swell. They lost a pulse, and he arrived to the ED pulseless, internal pacer firing and defibrillating occassionally. I noticed the appearance of the face immediately and also noted severe swelling to the neck, which actually made it impossible to locate structural landmarks of the neck/palpate carotids, etc. I actually thought the pt was oriental, due to his apparently prominent periorbital structure. Combitube appeared to be providing effective ventilation, =BS, +chest rise/fall, condensation in the tube, CO2 detector--very obvious change, was not difficult/unusual to bag per RT. So we get some drugs on board, about 6-8 minutes later we get a pulse back. I cycle the BP and start a second PIV. As the BP cuff inflates, I notice a very rapidly moving 'wave' of something moving through the subcutaneous tissue. Physician standing right behind me (FP trained, not EM) sees it at the same time. My first thought was that it appeared to be extravascular fluid. Pt's SBP was around 110 at first and gradually fell. This 'swelling' quickly filled bilat UE's, and very impressively affected the scrotum (literally at least a couple of grapefruit in size) RT empirically needle compressed, but didn't find air. Pt arrested again, and the doc called it. The overall feeling was that the subcutaneous stuff was air. CXR showed inflated lungs. The physician (should be in FP, not the ED in my opinion) really didn't have a clue, but she guessed at first that his trachea was ruptured by the combitube or by attempted EMS laryngoscopy...? The only other thing I can come up with is esophageal or gastric rupture. Any ideas? I have personally seen gastric rupture apparently secondary to improper combitube use once at this small ED. Anybody else seen this complication?

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[12R34Y]

I wouldn't think that gastric or esophogeal rupture would give the man grapfruit size testicles nor make his entire face/neck and upper extremities get huge (there's just not that much air in the GI tract).

Secondly, it does sound like some sort of tracheal rupture/tear/perforation. What you described to me sounds like subcutaneous emphysema, (I've seen people bloated up like ticks with arms out to the sides )

did it have the usual kind of crinkly/rice crispy/squishy kind of feel to it?

that'd be my guess. interesting.

later

 

[12R34Y]

Oh, and why would they start a NOREPI drip? Never heard of that post-code. Unless, they knew he was really septic and that's why he coded and was super hypotensive after resuscitation.

but, typically post-code from the usuals (sudden cardiac death out of hospital) I never knew many services to start norepi gtts in the field?

later

 

[docB]

That really sounds like sub cu air. I've had a few instances in codes where they blow up like that right after intubation because the pos pressure ventilation pops a bleb or the cpr pops something. Now as soon as I see that I needle and place b/l chest tubes. You don't want to get an xray and say "Yup, shore 'nuff was a tension that killed her." Even if the needle doesn't find air you should still place the tubes. In fact because you've needled the chest even if there wasn't a pneumo before there will be after that. I'm saying this for the in hospital crowd and not EMS but the learning point is a good one. Now for this case the CXR did not show PTX. Assuming the film was adaquate (I'm sure it wasn't done at 30 degrees or upright. If you really want to know about a pneumo sit 'em up.) that makes tracheal tear more likely. That could give you massive sub cu air without dropping the lungs. Chest tubes wouldn't have helped but the pt was screwed anyway.

Another good point to know especially for codes on the floor where chest tubes are hard to find and they've never heard of a pleuravac is that if you think you've blown a lung on a tubed patient and the pt is crumping just vent the chest quick and dirty. It's not the tubes sucking out the air it's making the holes in the chest wall to allow the pos pressure vent to force the air out that prevents the tension. I have had to use the #11 blade from a central line kit to vent several times. They never seem to have a #20, #10 or #15 (all of which would be preferable) but they usually have a line kit. You need to remember that the knife is in there because they won't remember.

 

[canjosh]

Oh, and why would they start a NOREPI drip? Never heard of that post-code. Unless, they knew he was really septic and that's why he coded and was super hypotensive after resuscitation.

but, typically post-code from the usuals (sudden cardiac death out of hospital) I never knew many services to start norepi gtts in the field?

later

Yes it was norepi, per their medical direction...skipped right over dopamine. Maybe they're on to some new study--who knows...?? And I was always taught to sit on my hands after getting a pulse back...especially considering this guy likely had an ischemic event to start the whole thing. Honestly, the med control for the area (very large city, plus suburbs) is pretty poor in my opinion.
Yes, it was subcutaneous emphysema. At first I thought it was fluid, but I agree with your assessment of it being air. This guy would have gotten bilateral chest tubes for sure at a trauma center, or maybe any other hospital for that matter. But, the ED physician is the only doc in the house during the night, and this particular one is FP trained. Don't know when she last did an emergent chest tube, but I'm relatively sure she's not comfortable/competent.
It just seemed odd to me that the subcutaneous air problem only manifested it self when a pulse was present. Literally within 30 seconds of getting a pulse back. Is there a simple explanation for this aspect?

 

[canjosh]

Thanks also to docB for the reply. I've actually done just as you suggested: opened a central line kit just for a knife. Much to the nursing supervisor's dismay I might add.
Her: Do you know how much that just cost!!??
Me: It's only money.

 

[docB]

Thanks also to docB for the reply. I've actually done just as you suggested: opened a central line kit just for a knife. Much to the nursing supervisor's dismay I might add.
Her: Do you know how much that just cost!!??
Me: It's only money.

I actually go right for the kits right off. They've got a big angiocath which I can get at to needle the chest quicker than anyone on a floor can find a big angiocath ("Doctor will a 22g work?" ). Then if you get 'em back they need a central line anyway. I love putting lines in people with b/l chest tubes. Even I can't screw that one up.

 

[nuke laloosh]

I have seen massive subq air once before from a tracheal tear as a result of combitube placement. That's what it sounds like to me, particularly since it was bilateral.

Don't think it had anything to do with getting pulse back -- more likely happened to get pulse back with ACLS while at the same time blowing a bunch of air through a new hole in the trachea.

Doubt it caused him to code again, either, unless it was so big you couldn't adequately oxygenate. Doesn't sound like it from your description. Sounds like he died from a giant MI.

You know if he's getting an autopsy? Otherwise it's all speculation.

nl
em pgy-3

 

[a_ditchdoc]

I have seen what you described twice. The first was in a patient with a small caliber GSW to the right shoulder that apparently caused a tension pneumo. The needles we carried were too short to reach the pleural cavity. By the time we got this guy to the hospital, he looked like Mr Olympia. His lips had curled upward, his arms were straight by his side, his fingers had swollen to massive proportions, and he bacame impossible to even compress. It was the only patient I have ever feared would explode. We did manage to get longer 12ga caths after that.

The other was due to agressive intubation which caused a tracheal tear and false passage. Of course, the results were immediate as her head began looking like a basketball aftr the first few ventilations. If you hear gristly sounds when you intubate, you may consider being a little more gentle.

As far as the pulse returning, it was probably coincidental. However, one explanation could be that a fairly small leak in the lung created tension within the chest and after it released into the subcutaneous tissue, the pulse would have returned and ventilaton would have effectively resolved the pneumo by inflating the lung and pushing air from the pleural space into the subcutaneous tissue.

Let us know if you find out what caused this, I'd be interested in knowing.

 

[canjosh]

I'd be interested to know as well...but the ME declined to take the case. In fact, the pt had recently asked his PMD about donating his body to the medical school when he died. Unfortunately, he never completed the paperwork, so I don't think any of that panned out. I'm pretty sure the family wasn't interested in requesting an autopsy by the ME. So I guess we can only speculate.
I would certainly be interested to see more data about the Combitube now that it has been around for a few years. It is relatively stiff, and I think most people are just pushing 'em in without much thought to head positioning etc. Perhaps people aren't being thoughtful about the possible complications of forcing the combitube. Personally, I'm wondering when the LMA will become common as a field and ED adjunct.