Airway access and trauma patient .

[JAGeorgia]

Originally Posted by JAGeorgia

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

Patient survived but required extended psych consults and considerable reconstructive surgery. Mandible was rebuilt using sections of rib. In the end he could eat/chew, communicate (trouble with D, L, N, T sounds and the like), and smile again.

[jatx]

Originally Posted by JAGeorgia

b. nasal airway[/INDENT][/INDENT][/INDENT][INDENT][INDENT][INDENT]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

Dad, didn't you teach Senator Bill Frist to do this when he was still a "newbie"?

[JAGeorgia]

Originally Posted by jatx

Dad, didn't you teach Senator Bill Frist to do this when he was still a "newbie"?

Never had the honour of meeting the gentleman. Actually, it was Senator Tom Coburn during his residency.

[JAGeorgia]

Originally Posted by 52bravo

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

Extracted for my own lecture notes while teaching at various schools of Respiratory Therapy and in clinical settings a number of years ago. Basics are basics but I welcome suggestions regarding newer techniques and technologies. If a consensus is reached I would be happy to put together a decission tree that could be printed, laminated, and tossed in an aide bag.

In a similar vein, would anyone be interested in "Physical Assessment of the Chest" geared for use in the field when all you have is your head, hands, eyes, and ears (e.g. sans chest x-ray, CAT scans, or even a stethescope)?

I would greatly enjoy a collaboration on that as well.

I'll watch for response.

[JAGeorgia]

Originally Posted by JAGeorgia

Extracted for my own lecture notes ...

It is more accurate to say extracted from memory since actual lecture notes have long since turned yellow and become brittle. I don't suppose there's a MOS for Conservatoire of Antiquities is there?

[swatsurgeon]

Originally Posted by JAGeorgia

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.

JAGeorgia,
excellent!! cervical 'immobilization with anything and to the best of ability, IV bags, rolled towels, KID, etc and if possible, clear c-spine clinically.
Points to remember....if the airway is working (it was here) leave it alone!!! upright position mandatory....do think about associated thoracic, neck, head injuries. Was an M-80 in the mouth, did cric him in the trauma room, upright and with some lidocaine but wide awake to continue a patent airway. On scene, they tried to lie him flat...mistake!!, tried to fit a collar....mistake, tried to hold firm pressure on neck (patient felt more dyspneic with this).
Overall this can be civilian or military trauma and needs to be dealth with the same. I'll post a follow up pic post reconstruction of a lot of missing pieces.
Good discussion on Rx......

SS

[jasonglh]

Just curious what was the problem when they tried to apply a c-collar?

Would putting him on a LSB tilted to the left side have been better to prevent aspiration?

The only way I can think of to protect c-spine in transport would to have been to use a short spine board (we dont have anymore) or to use a KED. But I would have used a C-collar with the KED.

Sounds bad but working in civilian EMS it seems I spent as much time making sure I wasnt going to get sued as much as did worrying about the outcome of the patient. Not only do we have to worry about quality assurance from our own dept but from the destination ER as well.

[swatsurgeon]

problem with collar was that no one had the 'nerve'/testicals to put their hand under the flap of tissue, elevate it and get the collar on....Actuallyt, the medic did think about it and knew the breathing would be more difficult bolt upright, the patient was found in a tripod position, leaning his head down and neck slightly flexed....they put 2 big towel rolls on either side, taped them to a short board and got him in sitting on the stretcher. I shot a lateral xray then cleared him clinically and took off the rolls.

This illustrates how in both the civilian world and military world, not everything fits the books mold....weigh your risks and benefits and go with your instincts. I believe some of the 18D's and docs from the field will agree with this. Protocols fit ~75% of all patients, military, civilian , etc, this means 25% of the time it's you, your experience, some luck, alot of intuition and memory from a conversation you had sometime in your past with ssomeone that tried to educate you for just this problem and you laughed/blew it off thinking "I'll never see that!" well you may have just saved someones life by remembering that advice.

ss

[troy2k]

"cleared him clinically "

Doc, by this I assume you mean clearing the C-spine by clinical observation. As I recall, that consisted of:
1. The patient must be conscious
2. Ruling out pain with both flexion and extension
3. Ruling out Neurological deficits such as shooting pain or tingling in limbs
4. Ruling out palpable deformities to the C-spine

Does that sound correct? I would have sworn there were five criteria but that is all I recall.

[swatsurgeon]

the mechanism we use is:
-judgement on mechanism of injury and potential for c-spine injury
-palpation of c-spine with in-line traction held
- no midline pain or neuro changes with passive flexion , then extension (all atleast 30 degrees)
- no midline pain or neuro changes with active flexion and extension
- no midline pain or neuro changes with left and right lateral rotation
then we call it cleared.

[52bravo]

Originally Posted by swatsurgeon

Overall this can be civilian or military trauma and needs to be dealth with the same. I'll post a follow up pic post reconstruction of a lot of missing pieces.
Good discussion on Rx......

SS

please do post follow up and post reconstruction pic, like to se how he end up.

and a note at the my doc. school we have a book on face-injured patients it is from WW1. some good points on the airway, and cut down dont keep them on ther back, up right or on the Abdomen.
yes we have ET and combi tube bu not all time, so a simpel thing just to keep your patients on the abdomen will save lifes

Frank

[swatsurgeon]

here is the final recon picture...can't find my intra-operative pics......

[jasonglh]

Thanks for the pic that is fascinating. I'm guessing he lost most of his teeth as well?

On further study of the pic I wonder.......was his head shaped like an egg before?

[swatsurgeon]

he lost teeth, Upper and lower, 4 cm chunk of right mandible, some of his lip, wall of maxillary sinus and floor of orbit....
the physics of a blast are fascinating and understandable.

[Peregrino]

Still looks like you/your team did an incredible job putting things back together. Amazing how gore distracts from a dispassionate analysis. Obviously there was salvageable tissue that couldn't be distinguished in the photos.