trauma PEA

[rohit76]

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Suppose you are running trauma code (PEA).
CPR is in progress and patient is intubated.
Can you put chest tube just because you think there is decresed breath sounds on one side?

 

[hubble]

Yes you can. you might even want to put in bilateral tubes. Would needle decompress first. Is this blunt or penetrating trauma?

 

[rohit76]

I am referring to Blunt trauma. If CXR is done and it does not show pneumo, I hope that should not go againt ER Doc.

 

[kungfufishing]

Blunt trauma arrest is probably just dead. Bilateral chest tubes might be worth a try, what are you gonna do, kill em?

 

[leviathan]

Blunt trauma arrest is probably just dead. Bilateral chest tubes might be worth a try, what are you gonna do, kill em?

Agreed.

 

[dchristismi]

Seconded. You aren't going to make them any worse. Not a whole hell of a lot else you can do in this situtation.

 

[Seaglass]

Or you could do US for PTX (more sensative than CXR) - that said they're usually just dead.

 

[spyderdoc]

I am referring to Blunt trauma. If CXR is done and it does not show pneumo, I hope that should not go againt ER Doc.

Who's to say that the guy didn't develop a tension PTX after the CXR was done? Anything is possible in a severely injured blunt trauma case...If clinical exam suggests tension PTX, you'd probably be faulted for not addressing it, even with a recent normal CXR.

 

[Mighty Mouse]

CXR is good to find a simple pneumo that is not causing overt signs or symptoms.

i once heard a doctor say, "if you use a CXR to find a tension pneumo, then you're a crappy doctor." point being, a tension pneumo is a life threatening event. needle them and ask questions later.

in a traumatic PEA arrest, you need to address any potential reversible causes in the famed H's and T's. that means needles/chest tubes. pericardiocentesis is even appropriate if you think tamponade could be an issue. ultrasound can help you with determining that. if no ultrasound in your department, i think doing it when all else has failed is good. i agree with those above...PEA isn't alive. you need to pull out any trick you've got to try and get them back to a perfusing rhythm.

 

[mikecwru]

CXR is good to find a simple pneumo that is not causing overt signs or symptoms.

i once heard a doctor say, "if you use a CXR to find a tension pneumo, then you're a crappy doctor." point being, a tension pneumo is a life threatening event. needle them and ask questions later.

in a traumatic PEA arrest, you need to address any potential reversible causes in the famed H's and T's. that means needles/chest tubes. pericardiocentesis is even appropriate if you think tamponade could be an issue. ultrasound can help you with determining that. if no ultrasound in your department, i think doing it when all else has failed is good. i agree with those above...PEA isn't alive. you need to pull out any trick you've got to try and get them back to a perfusing rhythm.

If you xray dead people, then you're a crappy doctor. Who would stop a code to xray while CPR is in progress?

I would suggest bilateral chest tubes, as the physical exam findings for ptx are not very sensitive (decr BS, etc) and the the findings of a tension are unreliable especially when the patient is hypovolemic.

So, pop the tubes in.

m

 

[Schnoffle]

Even if your original CXR looked normal before, there's no saying that the intubation didn't exacerbate a minor pneumo into a major one.

Pop em in; why not

 

[dchristismi]

Heh... when I was an intern, I had the "opportunity" to observe a code in the EP lab. (Cards was putting in a pacer when the patient coded.) They insisted on maintaining the sterile field during chest compressions, and actually DID shoot fluoro during the code to check tube placement, I think. It was more than a little ridiculous. That, and the attending cardiologist deferred to the 3rd year medicine resident to run the code. Got her back, but she coded again when we were halfway down the hall. My senior went back, but I didn't get to. Weird, weird, weird.

But anyway, it HAS been done, but I wouldn't recommend it.

 

[ParamedicMan]

So on a related note, say you got said patient back from PEA with blunt chest trauma. Bilat chest tubes with 800cc on one side, 100 on other, central line, ETT, etc. First pressure 31/18, after crystalloids, blood & epi 10 mic/min pressure >100 systolic. Patient codes two more times, get him back both times with about the same result. Patient then codes again right before moving to OR. At what point do you call it a day, or conversely, how long do you keep working it? No right or wrong answer, just curious what everyone's thoughts were about how long you keep

 

[dchristismi]

If they're out of the ED in the hands of a surgeon, it's not my call anymore.

If this is a kid, especially if they are, say, younger than 14, you pretty much go and go and go until you and your team are exhausted. If this is a young-ish person who might have a shot, give 'em a decent chance. Over age, oh 50? 70? Might as well throw in the towel.

For the record, the only ED thoracotomy patients I have ever seen who had good (ie neurologically intact) outcomes were both younger than 18. (They were both penetrating, not blunt, though.) There's something to be said for youth.

 

[EM Kane]

Before throwing in a chest tube, especially if the pt was tubed in the field, check how deep the ETT is placed. Just a thought if the questioned side is the left.

 

[leviathan]

Just don't run the code for a tension pneumo like these guys.
[youtube]pEO__aCN_5Y[/youtube]

 

[bartleby]

If a patient presents as a traumatic arrest little and you do not have a readily reversible cause, there is little point in continuing the efforts. The survival to discharge rate in cardiac arrests from blunt mechanisms is abysmal in general. For the purposes of deciding whether or not you have a pneumothorax or hemothorax significant amount because in the cardiac arrest, all you really need to do is quickly get your finger in each hemithorax. This is not the time for a dainty 10 minute chest tube insertion...codes are time for decisive action. The benefit of just performing the procedure it is a) therapeutic as well as diagnostic and b) in an arrest situation where your chance of survival rapidly diminishes, you do not want to be waiting for a CXR or fiddling around with the ultrasound machine. With a scalpel, cut your way down to the pleura quickly and pop through with a kelly. If you don't get a large rush of air or enough blood out to soak your shoes, move on. If the entire hemithorax is full of blood in a blunt mechanism, you're also done, because in this setting there isn't going to be a neat hole to put a finger into or staple shut till the patient gets to the OR.

 

[medivac]

That youtube video was painful. INTUBATE ALREADY! I especially liked where the instructor had to teach them how to read the monitor-no the bottom line is the sat monitor, the top line is your rhythm.

 

[leviathan]

That youtube video was painful. INTUBATE ALREADY! I especially liked where the instructor had to teach them how to read the monitor-no the bottom line is the sat monitor, the top line is your rhythm.

I especially like when he asks for the "shocking machine" so he can defibrillate the guy who is in PEA (secondary to a tension pneumo).