Airway access and trauma patient .
 

Since the board has been discussing airway management I would like to start a thread on airway management of patients who have suffered injuries above the neck. (Particularly blast and ballistic injuries that are encountered on the battlefield)
Any case reports both personal and anecdotal I would be grateful to hear about.
My own experience in airway management has been working EMS in Atlanta GA., and in the OR and ER. I have had little initial airway management experience of maxillofacial traumatized patients. So if you have experience in this area please jump in and share your case reports.
Thanks Roger

If suction won't let you see-look for the bloody bubbles in the back of throat during exhalation...

Eagle

lets change it up alittle...here is a pic of a blast injury to the face....how would YOU handle it beginning with finding him to time of definitive care.
be specific and detailed on your 'field' mangement

Swatsurgeon - Not to interject too much but I've seen this case several times on the internet. All the pictures previously appeared to be in the ER and this one looks like he survived to be admitted. Does anybody know the real story (the most plausible one I heard involved crimping a blasting cap with his teeth) and what the final outcome was? And just to pay my dues - a crichothyroidectomy, IV. O2, try to clamp any major bleeders, kerlex for contamination prevention, and evacuate ASAP. Maybe try to block the back of the throat to control fluid entering upper airway though I'm not sure about gag reflex. Looks like the hospital did a trach so I might be on the right track. 18D is the one MOS I never got around to. Inquiring minds, etc, etc. Peregrino

Suicide attempt with shotgun? [going back to corner now]

glad to hear my patient made the internet...wonder how that happened...illegal to say the least I did not block out his eyes/etc on this site for obvious reasons.
Any recall of the sites where you saw this. I don't think (?) I've used it on any other sites????
Anyway he did make it to a hospital...but if this occured in the field (it did) and you saw him what would you do....
ignore the ED backround, think of it as the 1st medical facility in theater....2 docs, a few RNs and PA's etc.
this was an explosion (M-80) at the mouth.

there is no cric in the pic....it's an oxygen tubing being held under what remains of his chin.
So, what do you do in the field with this guy?

1.)Cric unless airway anatomy allowed an ET to be placed quickly;

2.) trendelenburg to allow blood to drain away from airway;

3.) pack oozers and clamp spurters;

4.) (2) IV's LR or BRP titrated to BP;

5.) sedate if pt not unresponsive;

6.) EVAC to bright lights and cold steel.

I would only add to that C-collar and long spine board. Hope your suction doesnt crap out and haul tail to the ER!

Most of the runs in my day were 30+ minutes from the closest ER so I would be looking to the sky for help.

By M-80 are talking about a firecracker or ???


As far as shotgun blast I recall an EMS conference where one of the speakers detailed a run with an attempted suicide by shotgun. They thought he was dead as it cleaved of the entire face but there were bubbles. He said he basically used the bubbles as a guide and got him tubed. I think later it was talked about on a tv show or video and they said the Pt lived ??

1/8th stick of dynamite is the way it was explained to me.

Crip

I've had to follow the bubbles down on a COPD Class 1 while CPR was being done. Suction was doing nothing, she pretty much drowned.

As for this pt, I wonder if a Combi-Tube would be of any use...

*In-line cervical stabilization
*Attempt digital intubation or surgical cricothyrotomy if sufficient cartilaginous rigidity to allow it or surgical tracheotomy if not ; hyperventilate and assess by way of auscultation, ETCO2 levels, Pulse Oximetry, Conjunctival O2 Tension levels.
*Maintain a high index of suspicion and assess for Thoracic ( pneumo/hemopneumothorax/tension)and intracranial injury(sedate/succinylcholine/pancuronium/lidocaine).
*Direct pressure applied to major vessel exsanguination or surgical ligation if possible.
*Large bore IV access X2
*Foley

prehospital
in line
A: intubate or circ( if no inline: upright not on his back, so blood gos a way from airway)
B: O2 100%
C: pack the wound it cric or tube IV line no IVF if not in shock.


ED
intubate and CAT then OR for debr/DCS.

in som days reopen.

Good guess. Been there. Basically everything was gone from the tip of the nose to the pharynx including approx 3/4 of mandible.


In swatsurgeon's case study and added caveats I would respond as follows:

I. Determine level of consciousness and proceed to II immediately.

A. Conscious, determine ability to communicate/cooperate

1. Can communicate/cooperate

a. Reassess body position. Sitting position may be best to aide in draining blood/body fluids away from airway. On this point, position in pic is correct even in the field.

2. If uncooperative provide restraint as needed so airway and breathing do not become compromised.

a. Reassess body position. Prone, right or left side may be best to aide in draining blood/body fluids away from airway. Trendelenburg if danger of patient aspiration is minimal.

3. go to IV.

B. Unconscious

1. Reassess body position. Prone, right or left side may be best to aide in draining blood/body fluids away from airway. Trendelenburg if danger of aspiration is minimal.

2. go to IV.

II. Check airway.

A. If airway is patent go to III.

B. If airway not patent.

1. Position head/neck to establish an open airway

2. If 1 fails attempt to insert mechanical airway in this order of preference

a. oral airway

b. nasal airway

c. endotrachael intubation: personally, I'd go with nasal intubation, even if blind insertion but I have a ton of experience doing this. Not recommended for newbies.

d. crich/trach depending on skill and available resources. Remember these are invasive procedures and you have to quickly weigh risk vs. benefit.

3. go to III.

III. Breathe

A. If breathing is present,

1. Add oxygen if available.

2. return to I.A. or I.B

B. No breathing, begin artificial respiration using airway established in II.

1. Add oxygen if available.

2. If breathing is restored return to I.A. or I.B

IV. Control bleeding

A. Use direct pressure on oozers.

B. Use clamps on bleeders and spurters.

Note: Take care not to obstruct airway. Use of Kerlex, Kling, and packing may be best done at “Bright Lights and Cold Steel”.

V. Monitor all the above

A. Check/treat for shock

B. Establish IV with LR or D5W.

C. Transport/Evac STAT.

D. Titrate sedation/pain meds as needed.

good setup of case A. is it from a protocol?