Several points here…
Stanley has trust issues.
The Ss of a single-car mvc apply here. Most mvc involve two cars smacking each other. Single-car mvc are often triggered by a medical problem – seizure, syncope, sugar, stroke, suicide, stupid (drugs, speeding, etc). Reportedly, there was a witnessed tonic-clonic seizure that caused the crash.
It’s unusual for an adult to arrive with a 6.0 ETT. Something probably happened during the intubation. Ask EMS. If the airway pressures, sat, end tidal co2 are ok, the small 6.0 tube is ok. If you’re having trouble ventilating / oxygenating the patient, the tube should be changed asap. The 6.0 was adequate for this patient. We changed it to a 7.5 over a bougie later in the ED.
The idea of “intubate a trauma patient with a GCS of some-low-number” is outdated and stupid. The need for airway protection and respiratory support cannot be dictated by a single measurement. If we follow this guideline, virtually all intox patient with minor head trauma will be intubated unnecessarily. Surgeons freak out over this all the time.
The entire right side of the lung is whited out. This generally means one of two things – (1) lung collapse because the lung is not being ventilated. Typically, this is because the ET tube is too deep and usually affects the left lung (the ETT is commonly advanced into the R main bronchus, and almost never the left), or (2) there’s a hemothorax or pleural effusion. Check the ETT position, suction, repeat a cxr. Rarely, the lungs may be collapsed because not enough volume is being delivered by the vent. Put a sono on the chest, see if there’s fluid in the R pleural space. Ask EMS what happened during the intubation, esp about vomit, food, blood – things that may obstruct the bronchi / bronchioles.
We put a sono on the chest. We didn’t see fluid. After we suctioned and re-positioned the tube a few times, the repeat films look better (see below).
Once the patient is intubated, you’re basically trapped into doing a pan-scan on this patient. Intubation / sedation greatly diminishes (and some would say, removes it entirely) the clinical exam. You have no idea if a patient has belly pain, etc. It is much more labor-intensive to avoid the CT (and re-examine / re-sono the patient frequently) than to go ahead and do the pan-scan.
The patient had no traumatic injuries. The patient was extubated after 1.5 days and discharged a few days later.
Repeat cxr after suctioning and an ETT change.
