Bleeding from ETT during code

[iaskdumbquestions]

I've been involved in a few codes (medical not trauma) where ~20 minutes in there starts to be some blood coming from the ETT (previously easily to ventilate with appropriate end-tidal). After another 10 minutes the bleeding worsens to the point where we have to suction frequently and ventilation becomes very difficult. Nobody has been able to tell me why this is happening. I've heard flash edema (not sure why it'd be bloody), trauma from compressions causing ptx (in which case I don't know why we aren't decompressing), but nobody really seems to know for sure.

Assuming proper ETT placement given previous ability to ventilate easily, does anybody know why this is happening?

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[agent_purple]

I've been in a few codes before and have seen the same thing in almost all of them. I had heard that it could be from a punctured lung via ribs breaking, but I'm sure there can be a ton of reasons.

 

[dannyboy1]

That’s usually a good sign to call it

 

[anbuitachi]

I've been involved in a few codes (medical not trauma) where ~20 minutes in there starts to be some blood coming from the ETT (previously easily to ventilate with appropriate end-tidal). After another 10 minutes the bleeding worsens to the point where we have to suction frequently and ventilation becomes very difficult. Nobody has been able to tell me why this is happening. I've heard flash edema (not sure why it'd be bloody), trauma from compressions causing ptx (in which case I don't know why we aren't decompressing), but nobody really seems to know for sure.

Assuming proper ETT placement given previous ability to ventilate easily, does anybody know why this is happening?

I assumed rib puncture

 

[Psai]

DIC from being dead

 

[iaskdumbquestions]

I've been in a few codes before and have seen the same thing in almost all of them. I had heard that it could be from a punctured lung via ribs breaking, but I'm sure there can be a ton of reasons.

Would make sense. But then if for whatever reason the team will continue the code, wouldn't it make sense to decompress the chest? Otherwise they'll just get a tension pneumo and that's the ballgame.

DIC from being dead

Also possible.

 

[PainDrain]

Pulmonary hemorrhage from cracked ribs and lung trauma. Seen it several time, especially in the elderly.

 

[rakotomazoto]

A fire fighter once told me that if you're not breaking ribs when doing CPR on an older patient, then you're not pushing hard enough. Rib fractures and pulmonary trauma are common. It takes a fair amount of force to keep some circulation going. It is possible to have so much blood in the airways that ventilation is essentially not happening, even despite frequent suctioning. Seen it that bad a couple of times.

On a slightly related note, if you haven't run across any of the automated chest compression devices out there, watch this:

I saw one in action for the first time as a med student in the ED. They are pretty brutal compared to human-delivered chest compressions.

 

[Mman]

as mentioned, it's not a pneumothorax and doesn't require decompression, it's probably just pulmonary contusions from getting their lungs squished by the compressions. Not a big deal in terms of oxygenation/ventilation in a code. If you stop chest compressions, the bleeding will stop eventually (either from being dead, or if you are alive from not continuing to beat up the lungs. Otherwise just suction them as needed.

 

[kidthor]

On a slightly related note, if you haven't run across any of the automated chest compression devices out there, watch this:
I saw one in action for the first time as a med student in the ED. They are pretty brutal compared to human-delivered chest compressions.

In that video they take an absurdly long time to initiate chest compressions with that thing. It's a classic case of "better" being the enemy of good.

 

[deleted697535]

A fire fighter once told me that if you're not breaking ribs when doing CPR on an older patient, then you're not pushing hard enough. Rib fractures and pulmonary trauma are common. It takes a fair amount of force to keep some circulation going. It is possible to have so much blood in the airways that ventilation is essentially not happening, even despite frequent suctioning. Seen it that bad a couple of times.

On a slightly related note, if you haven't run across any of the automated chest compression devices out there, watch this:

I saw one in action for the first time as a med student in the ED. They are pretty brutal compared to human-delivered chest compressions.

Worse outcomes with Lucas. Takes a slick team to put it on in decent time

 

[deleted697127]

Worse outcomes with Lucas. Takes a slick team to put it on in decent time

I watched one come into the trauma bay as an intern that had slippped off the guys ribs and was positioned over the upper abdomen... or had never been on his chest who knows. Either way, it made me pretty skeptical of their use

 

[It's lupus!]

Lucas has so much potential but seems to fall flat the majority of the time in execution.

Sent from my Pixel XL using SDN mobile

 

[anbuitachi]

A fire fighter once told me that if you're not breaking ribs when doing CPR on an older patient, then you're not pushing hard enough. Rib fractures and pulmonary trauma are common. It takes a fair amount of force to keep some circulation going. It is possible to have so much blood in the airways that ventilation is essentially not happening, even despite frequent suctioning. Seen it that bad a couple of times.

On a slightly related note, if you haven't run across any of the automated chest compression devices out there, watch this:

I saw one in action for the first time as a med student in the ED. They are pretty brutal compared to human-delivered chest compressions.

In that video they take an absurdly long time to initiate chest compressions with that thing. It's a classic case of "better" being the enemy of good.

What i watched that video and wasn't sure if it was a real person or a mannequin cause they took so long to start chest compressions. Its like everything was being done in slow motion. Even putting in that EKG sticker took way longer than needed.

 

[rakotomazoto]

Anytime I have seen it used, there seemed to be too much time and energy spent on getting the thing in place properly, rather than just getting someone compressing the chest. I only picked that video because it popped up quickly on google and does a good job of showing how terrifying it is to watch that thing mash down on someone's chest.

It could be useful in a situation where you don't have enough people to run other aspects of the code like starting lines or administering medications because people are tied up in CPR.

 

[Tony C anesthesia]

I've been involved in a few codes (medical not trauma) where ~20 minutes in there starts to be some blood coming from the ETT (previously easily to ventilate with appropriate end-tidal). After another 10 minutes the bleeding worsens to the point where we have to suction frequently and ventilation becomes very difficult. Nobody has been able to tell me why this is happening. I've heard flash edema (not sure why it'd be bloody), trauma from compressions causing ptx (in which case I don't know why we aren't decompressing), but nobody really seems to know for sure.

Assuming proper ETT placement given previous ability to ventilate easily, does anybody know why this is happening?

Someone was doing good chest compressions, broke some ribs!!!!

 

[RoyBasch]

I have noted this not infrequently in the ER, I suspect it is a direct result of trauma from CPR (multiple rib fractures, pulmonary contusions, hemorrhage) with DIC. Typically the ETT is so fouled with blood that EtCO2 doesn't work/register anymore. Even with frequent suctioning eventually ventilation becomes difficult. Usually means this patient isn't coming back.