When is When: Withdrawing Interventions in PFC

Episode overview

About This Episode

Medics add interventions easily. Prolonged field care is where those interventions start charging rent. Dave walks the unwind.

A cut endotracheal tube used as a cric can come out if the patient no longer needs it. Unhook the bag. Moving air through the tube, following commands, and a normal breathing pattern are good signs. Cuff down: if he cannot breathe around it, edema or a flap may be waiting, and pulling can lose the airway. Suction above the cuff first. Dress the site after. Do not pull the bookmark on a partial responder still in shock just to save narcotic. Uncomfortable and awake beats a lost airway.

Chest-tube logic is the same. Serous output and stable oxygen are a pull conversation. Blood, pus, or a leak plus climbing crepitus means the tube stays. Heimlich is enough for many. Suction, if used, is about 20 cm of water — a straw, not wall suction. No underwater seal is a sucking chest wound you created. A chest wall you cannot seal is bagged. A prophylactic fasciotomy without wound-care capacity can bleed and fluid-shift the patient you were trying to save.

PFC Podcast · prolongedfieldcare.org · @prolonged_field_care

Takeaways

• A cric can come out if the patient no longer needs it. Positive pressure off, breathing through the tube, follows commands, normal pattern, cuff down and air moving around the tube. Fail that last test and you may be looking at edema or a flap.

• Suction before you drop the cuff. Dress after you pull. Whatever is sitting on the balloon goes into the lungs. Occlude the site for cough and speech. If he obstructs again, adjuncts first, then back in.

• Do not trade the airway bookmark for narcotic savings in a partial responder. Shock patients who drop their GCS after you pull are a different problem than the isolated femur you over-sedated. Uncomfortable and awake beats lost airway.

• Chest tube suction is 20 cm of water, not wall suction. Heimlich is enough for many. Serous and stable oxygen is a pull conversation. Blood, pus, or a kazoo plus climbing crepitus means the tube stays. No seal equals a sucking chest wound you created.

• Some interventions you should not start if you cannot finish them. An unsealable chest wall is bagged, not endlessly patched. A continuous leak with crepitus is surgical. A prophylactic fasciotomy without wound-care capacity can bleed and fluid-shift a patient you were trying to save.

Chapters

• 01:17 Adding interventions is easy. Unwinding them is the PFC problem.

• 02:17 The oversedated femur: ketamine, narcotic, snoring, cric

• 03:46 Same patient in a trauma bay — RSI, then do they still need the tube?

• 05:19 Yes, you can pull a cric — if the airway is not the problem you are about to recreate

• 06:29 Off the bag, follows commands, breathing pattern

• 07:10 Cuff down: can he breathe around it?

• 09:01 Suction above the cuff before you deflate

• 09:42 Ketamine no-man’s-land between analgesia and sedation

• 10:41 Fentanyl for the cuff, not another snow

• 14:05 If the airway is quiet, leave it until everything else is mitigated

• 14:16 Do not pull the bookmark in a partial responder

• 28:07 What is coming out — serous vs blood vs pus

• 28:30 Empyema tubes that stay for months

• 28:33 Air leak on a Heimlich: kazoo is fine, crepitus is not

• 29:02 SpO2, mental status, oxygen need before a pull

• 29:37 Heimlich vs three-bottle suction

• 30:51 Improvised single-bottle underwater seal

• 31:16 No seal, and you just made a sucking chest wound

• 33:34 Chest wall you cannot seal: positive pressure, or a cric

• 35:41 Finger thor converts tension to open. The tube is a valve and a measuring cup.

• 37:36 Continuous air leak and climbing crepitus — second tube, surgical problem

• 39:25 Sudden crepitus with an advanced airway: dislodged cric vs tracheobronchial injury

• 42:11 Fasciotomy: indication vs the wound you cannot dress