Question for more experienced ICU RN's

Specialties MICU

Published

I had a bizarre code today with a bad outcome, and I'm not sure what happened. General background is pt had a pneumothorax, found unresponsive, brought to Er, pt was intubated in the field, major ischemic stroke, chest tube placed. I get him less than 24 hours after being found down, take him to the dreaded MRI, lay him flat, and notice his abdomen is blowing up like a beach ball. Abort MRI, doesn't look so good, run through the hallways, he's now brady'd down to 30's. Start CPR (all the ribs crunch) and doctor come's in and says family says to please stop. He had so much subq air, it was wild. He crinkled from neck to groin. No autopsy was requested, so I'll probably never know what happened. Does anyone have any idea what might've happened? Thanks

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the abdomen filling with air probably means that the ETT got dislodged and was above the cords in the hypopharynx, hence, no oxygenation and air in the stomach. the subQ emphysema, probably from the cracking ribs during CPR, combined with aggressive bagging. very unfortunate outcome.

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What sunny said. Sounds like your ETT was no longer in place and you were ventilating the stomach instead of the lungs

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Did you happen to see what your Ventilator displayed during this time. It is very possible that the ET tube was dislodged, but between the ET tube securing device and alarms/settings on the ventilator you would have thought that it would be unlikely, but patient bradying down and then CPR is classic ET tube dislogement . What was his/her SP02 at this time? Doesn't seem like things always go wrong during an MRI.

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He wasn't vented at this time, we were bagging him into the MRI machine when this started. If the ETT was dislodged, I can see blowing his belly up, but his entire abdomen and subq air at his clavicles? I'm just wondering if the chest tube, pulled out some, although it was sutured in and intact during postmortem care. Maybe the pneumothorax expanded? There was no tracheal deviation. I don't know what his numbers were, I saw his belly, his color and started running! Who knew how light those beds suddenly become when you're pumped full of adrenalin?! I guess I'm afraid I did something to hasten his death although with the size of his stroke, he was on borrowed time.

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I don't think you did anything wrong, things just happen sometimes. I would think if his pneumothorax expanded into what you suspected was a tension pneumothorax you would have certainly noticed when you were bagging him because that would have gotten much harder for you to squeeze the BVM, and the pneumo expanding or the chest tube out still doesn't explain the belly getting bigger. You think you would have to go with the ET tube being dislodged.

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the subq air could be from the pneumo expanding (I assume the chest tube was not hooked to sxn at that time), and gas dissecting into subq tissue . . . can easily happen, especially with vigorous bagging. with intubated patients, we always drag a doc along on transports for situations such as this

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Specializes in PICU, ICU, Transplant, Trauma, Surgical.

I agree with the air leak explanations above. It sounds like he had free air elsewhere (peritoneal.. mediastinal...) which may have caused the crepitus you felt during compressions. And to the above poster who gets to bring a doc with to MRI... I wish I could be so lucky! Transports to MRI/CT I've done with traumas in ER, sure the doc comes.... but in the PICU, hasn't happened yet (scary, right!) Usually it's the RN, a tech (or lead depending stable vs. unstable) and RT if pt is intubated.

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Woulda helped to throw a CO2 confirm on the ETT when bagging to tell if you had it in the right place, prior to the coding. I've been up near 24 hours here, but sounds like a legit idea.

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