Emergency (2013); 1 (1): ***-*** This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 104 Emergency (2014); 2 (2): 104-105 PHOTO QUIZ Confusing Hypoxia in a 21-Year-Old Intubated Multiple Trauma Patient Parvin Kashani1, Sahar Mirbaha2* 1. Department of Emergency Medicine, Loghmane Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2. Department of Emergency Medicine, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran Figure1: Spiral axial chest computed tomography scan  Cite this article as: Kashani P, Mirbaha S. Confusing hypoxia in a 21-year-old intubated multiple trauma patient. Emer- gency. 2014;2 (2): 104-5. Case presentation:1 21-year-old man was brought to the emer- gency department due to multiple trauma (MT) caused by a motor-car accident (MCA). On arrival, the patient was intubated by prehospital emergency medical services (EMS) and had a Glas- gow coma scale (GCS) score of 6 on 10 (Due to intu- bation, verbal score was omitted). Physical exami- nation revealed blood pressure of 150/70 mmHg, oxygen saturation (O2sat) of 60%, and pulse rate of 110/min. Examination of the tracheal tube site re- vealed incorrect esophageal placement. The patient was intubated again and his O2sat improved and reached approximately 96%. His pupils were reac- tive and of the same size. The Doll’s eye was normal, and plantar reflex was neuter in both sides. Neither *Corresponding Author: Sahar Mirbaha; Department of Emergency Medicine, Shohadaye Tajrish Hospital, Tajrish Square, Tehran, Iran. Mobile phone: +989121549405; phone/fax: +982122721155. Email: mirsa317@yahoo.com Received: 1 April 2014; Accepted: 9 April 2014 expanding hematoma nor emphysema was ob- served in his neck. Laceration was noted on his left ear, but otorrhagia and tympanic perforation were not found. The lung sounds were normal in both sides. Extended focused abdominal sonography for trauma (e-FAST) examination revealed the absence of free fluid in the abdomen and pericardial space. No deformity of limbs was noted and the distal pulses were palpable. The patient’s O2sat decreased during his admission to the emergency department, and further examination indicated obvious de- creased sound in his right lung that could not be reversed by needle thoracostomy. On reviewing his previous chest computed tomography, an obvious questionable pathology was detected in his right side Figure 1. What is your diagnosis? A This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 105 Kashani and Mirbaha Diagnosis: Massive blood clot in right main bronchus Case fate: There was a transaction in the right bronchus path, which required pushing of the tracheal tube to the right bronchus and passing of the suction catheter through it. A big clot was evicted and the patient’s O2sat improved dramatically. Discussion: The occurrence of respiratory distress is serious. The mortality rate of traumatic patients presenting to the emergency department with respiratory dis- tress is approximately 50% (1). The causes of hy- poxia occurring soon after intubation can be found in the acronym “DOPES,” which denotes displace- ment of the endotracheal tube (ETT); obstruction of ETT; pneumothorax, pulmonary embolism, and pulmonary edema; equipment and ventilator prob- lems; and, finally, stacked breaths (2-4). The most important issues that should be checked when this problem is detected are as follows: first, the severity of the problem should be determined (do you need to start immediate resuscitation?) and then MASH, i.e., movement of the chest during ventilation, arte- rial blood gas (ABG) sample, the skin color of the patient, and hemodynamic stability, should be as- sessed (2, 5, 6). The ventilator must be disconnected and high-flow 100% oxygen should be administered using a bag valve. After ruling out tension pneumo- thorax, the other possible causes should be consid- ered (2, 4). A responsible physician should deter- mine whether the problem is related to ETT or the patient. To ensure the right place of ETT, the end tidal CO2 (ETCO2) should be checked. In addition, to ensure that ETT is not obstructed, a suction catheter and/or a bougie can be passed through it. The placement of ETT must be visually checked, prefer- ably by bronchoscopy, or alternatively, by laryngos- copy, from the top end (although this is far from 100% reliable). If hypoxemia is not critical, particu- larly, if endobronchial intubation is suspected, then chest radiography should be considered to check the ETT position (5, 6). Airway obstruction may be related to different fac- tors, including kinking or bending of ETT; tube ob- struction with foreign bodies, mucus, blood, etc.; and extrinsic compression (3, 6). Severe mucus plugging may redound to worsen gas exchange, in- creasing inspiratory pressure and causing difficulty in breathing, and if not treated quickly, it may cause infectious complications and mortality (4, 7). Fur- thermore, establishing good hydration, damping of inspired gases, chest physiotherapy, and postural drainage plus manual lung hyperinflation are con- sidered as traditional and safe methods for the pre- vention and treatment of atelectasis in most of the patients (5, 7). Acknowledgment: We would like to express our special thanks from emergency department staffs. Conflict of interest: There was no conflict of interest. Author’s contribution: All authors contributed in drafting /revising the manuscript, study concept or design, and interpre- tation of data. References: 1. Alimohammadi H, Baratloo A, Abdalvand A, Rouhipour A, Safari S. Effects of Pain Relief on Arterial Blood O2 Saturation. Trauma mon. 2014;19(1):e14034. 2. Stone RH, Bricknell SS. Experience with a new device for clearing mucus from the endotracheal tube. Respir Care. 2011;56(4):520-2. 3. Johnson KM, Lehman RE. Acute Management of the Obstructed Endotracheal Tube. Respir Care. 2012;57(8): 1342-4. 4. 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