Israeli Paramedics Association
10
The Israeli Emergency Medical Journal
Chief Editor - Paramedic Neomi Zvi
Paramedic's Kingdom -->Case Report
Asthma ?
By
Paramedic Neomi Zvi
Night Shift , 1:30 am...... Israel
Ron and Ann - the volunteers - were placing and securing the 3 oxygen
cylinders after filling .
Samuel (the EMT) and me - were completing equipment and cleaning the
oil off the MICU's floor due to MVA pts we had.....
The dispatcher called us:
"Oz St. , No 1/90 , a night service's doc is calling you for a 64 years old
man with difficulty of breathing".
Ann jumped with horror look on her face:"It is my house's address.....it's
my father......"
On our way I questioned Ann about her father's health -
An Asthma pt , no Cardio-Vascular diseases , no Diabetes , no medications
except for Asthma - Ventolin , Theophylline , some Steroids occasionally.
"Lately" Ann said - "he had onsets more often for the last month "
"What his doc has to say ?" I asked .
"he said: Asthma - and added more steroids "
On the Scene:
Ann was really upset and I had to stop her from running upstairs - So - I
continued "nagging" her in the elevator: "Any allergies?" .."Nope" ........
"When did you saw him last ?
"About 4 hours ago , shortness of breath and weakness..."
The elevator stopped at the 6th floor .The apartment�s door was widely open
and As expected , Ann got in first .
The 64 y/o man was standing , leaning with his hands on the kitchen table ,
central and peripheral Cyanosis , drooling lather , sweating like hell ,,,,,,
Next to him - hysteric doc stammering: "He have Asthma...he have Asthma...."
and a pale lady (Ann's mother).
Absent of breath sounds , no Radial pulse ......Carotid pulse of 150- regular.
There was no use of trying to ventilate the pt. with BVM.
Complete Bilateral Atelectasis.
There was no question that he is going to be intubated.
We couldn't set him down (he was fighting us ..) so I opened an IV while
standing , and we could lay him down only after the 5 mg of Midazolam
IV was given.
"Doc , was he like that when you came? " I asked ....the doc mumbled
something.... "did you give any medications ?" I continued..."Only Ventolin
inhalation...." answered the hysteric doc.... "When was it ?" .. "about 30
minutes ago" .... "D**n" .....
I asked Ann to take her mother and the doc away from the kitchen .........
but they were back in no-time.....
I kneeled behind the pt�s head , took the ETT and the laryngoscopy set .
Samuel prepared the Ringer's Lactate and Ron was desperately trying to
put the monitor stickers on the pt's wet skin.....
V.Tachycardia on the monitor .....no blood pressure......the Synchronize
Cardiovertion will have to wait after the Intubation� (* the consideration -
down the page)
He was still half awake ....his short neck and secretions didn't help either , but
the Laryngospasm was much less then I expected.
I 'ambushed' the Vocal Cords to be open , and placed the tube in the Trachea ,
a half a second before the pt succeed to grab my hand.
He was coughing lengthily .....
Ron connected the Beg-Valve + O2 to the E.T.Tube ....But - the resistance to
the ventilation was very high.
He could barely squeeze the AMBU (Artificial Manual Breathing Unit)
�Step by step� I said to Ron while fixating the ETT. �Start with small volume and
increased it gradually� � �if in one minute from adequate ventilation he won�t
change his V.T , I�ll convert him�
After few ventilations -
Prominent rales were audible along with regions of tubular breath sounds
throughout upper third of the lung�s fields - and absent of ventilation sounds
from that point down.
Ann�s mother was crying and the doc was moving round us stepping everything.
Samuel loss one's patience and ordered the Doc: "Sit down here - hold the ETT
tightly here , don't push it in , and don't pull it out , got it ? "
The Doc obeyed and I thanked Samuel sooooooo much.......
I asked the doc again about the clinical findings on arrival , and he muttered:
"Asthma....."
"I got that already , doc , now - please - WHAT DID YOU HEAR THROUGH
YOUR STETHOSCOPE ?" ..."Almost nothing...." mumbled the doc.....
The effectiveness of the ventilation increasing a little more..
The pt. was still in V.Tachycardia , no BP , Cyanosis and he was
trying to extubate himself.
Samuel gave me the second 5 mg Midazolam I asked for.
Activating Record , charging 100 J , Jell , confirming synchronization , placing
paddles.......making sure no body touch the pt.....declaring: "Shock".........
final look at the monitor screen........and:..........
I rapidly removed the paddles off the pt's chest.....- At the last moment -
the rhythm has changed ......he spontaneously converted to Sinus Tachycardia
of 120/minute........
I discharged the shock by changing the energy level and put down the paddles.
"Continue Ventilation" I ordered Ron . "Check for BP, please" I asked Samuel
while he was making sure that the doc will hold the E.T.tube again.......:-)
According to Ann's mother - he woke up from sleep - couldn't talk or breath -
so she called the doc. "Fever at the past week / two weeks ?" - "Yes" - "No
chance of Chemicals inhalation ?" "No".> "No chance of Trauma?" "Nope"
Still in shock..... No Radial pulse .......the Systolic Blood Pressure was about
55-60 mmHg..... the Atelectasis was a little less severe......
I decided to connect the PEEP device to the "T" connector of the BV . I aimed
it to 3 cmH2O only - for the mean time.
I opened a second IV line , connected a 3 tops set - one infusion beg of
Lidocaine 400mg/100cc , Microdrip set and put the minimum maintenance
dose of 2mg/min (without giving an IV push dose first !) and another infusion
bag of Dopamin 80mg/100cc with Nephro dose of 5mcg/kg/min.
Fluids went through the first IV line.
I sent Ron to the MICU and Samuel ventilated.
Reevaluation:
Appearence: Under influence of Midazolam (Versed/Dormicum/Midolam) ,
Peripheral Cyanosis , Wet and Cold Skin.
Airway: secured by ETT.
Breathing: Ventilated with BV-to-ETT , 95% of Oxygen , PEEP of 3 cmH2O
Auscultation: Rales and tubular breath sounds down to the mid-lungs-line ..
Absents of Breath sounds at the lower half
Percussion: Dullness and flatness at the upper half
Palpation: decreased fermitus
Right-to-Left shunting of blood through collapsed and/or filled alveoli - a major
mechanism for arterial hypoxemia....
It is not the same 'old Cardiogenic Pulmonary Edema' we all know so well
(Left-to-right shunting)
ARDS ?!? and If it is ARDS - possible reasons ?
No Capnometer is available in this MICU.
Circulation: Shock.
Carotid Pulse of 117-120 - good , compatible to the monitor rate . Femoral
Pulse - thready , Radial Pulse - absent .
3 leads monitor: Sinus Tachycardia of 117-120/min , regular.(converted from
V.T spontaneously -supported by Lido drip and ventilation)
BP: 70/40 mmHg (supported by Fluids , Dopamine and Ventilation)
12 leads ECG - haven't done yet
SaPO2 - can't read due to shock.
***************
Ron was back from downstairs with the bed and spare Oxygen cylinder.
I raised the PEEP to 4 cmH20 .
The Doc said: "I must go"....... "Okay" Samuel said - "Just leave your name
and number of license". The Doc was shaking I think , but the look Samuel
gave him convinced him not to ask why....:-) (I had to turn my face so the doc
won't see me smiling)
It took us a while to move the pt through the small and narrow elevator.....
Samuel was driving to hospital , Ann's mother sitting next to him
Recheck - ETT still in place , the cuff , Atelectasis only at the lungs bases -
more on the right, effectiveness of ventilation improves , raising the PEEP to
5 cmH20 , BP is 80/- (Systolic) , Closing the Dopamin drip , Peripheral Cyanosis
still shown , skin a little less cold then before - and the pt. is awake again trying
to pull out the tube.
Another 2.5 mg of Midazolam IV......
Inspection:
No Edema at the extremities , Flat Jugulars >
Central Trachea ? - can't check now because of ETT and Bilateral Atelectasis.
(Atelectasis cause lag of Trachea on affected side)
I got authorized to delivered the pt. straight to Respiratory Intensive Care Unit
(it is not acceptable - but - I won't tell you what I did for that....)
In the Hospital:
We helped the Respiratory ICU nurses to move the pt. and changing equipment.
Radial pulse present , Systolic BP of 90 mmHg , S.tachy of 110/min , regular
and PEEP of 5 cmH20 , ventilated.
I took double caution when I reported the expert....I better have a gooood
reason to bring a pt. to Respiratory Unit without going through the ER.....
Two MDs checked the pt. , preparing for central line (CVP) , drawing blood
from vien and artery as well
I was doing the paperwork when the ICU doc called me to see x-rays:
(Posteroanterior & Anteroposterior chest Radiography ) :
The doc placed the x-rays on the light-board and asked:
"What do you see here ?"
"The ETT in place , Diffused Filtrate , ARDS ? Atelectasis of the bases -
more on the right".
"OK , butThere is more - see here?" pointed the doc "The silhouette of the lower
part of the Trachea is turning a bit to the right and so is the Heart, ARDS alright ,
besides - this kind of Diffused Filtrate can characterized few situations....."
I said: "I thought it might be septicemia due to viral / bacterial or
gram-negative........or....." I looked back to see if Ann is around........
"or....." continued the doc "it might be cancer..."
Sigh.......
****************************
(*) The consideration were:
A) I assumed that the V.Tach (and there was no question it was a V.T and not
SVT with aberrant conduction) - in this pt - is due to severe Hypoxemia and
Anoxia because of Breathing system Failure . Of course - I could be wrong......
B) The Cardioversion is much less successful when Hypoxemia and Anoxia are
in the background.
C) The Hypoxemia is a very good reason for the V.Tach to deteriorate to
V. Fib whether you defibrillate or not.
D) There is no alternative way to ventilate that particular pt so a non-paramedic
personal can use.
E) To charge the L.P 10 will take about the same time it can take to intubate
the pt.
F) I had to sedate the pt. anyway
G) I couldn't cleared diagnosis of Total Upper Airway Obstruction till
Laryngoscopy
Paramedic Neomi Zvi - June 2000
Urgent- The Israeli Emergency Medicine Journal , Volume No 10