Airway access and trauma patient .

[rogerabn]

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

[Eagle5US]

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

Eagle

[swatsurgeon]

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

[Peregrino]

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

[jatx]

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?

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

[swatsurgeon]

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.

[swatsurgeon]

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?

[Surgicalcric]

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.

[jasonglh]

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 ??

[Surgicalcric]

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

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

Crip

[24601]

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...

[Endorphin Rush]

*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

[52bravo]

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.

[JAGeorgia]

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

[52bravo]

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

[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]

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]

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]

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. :munchin

[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? :p

[swatsurgeon]

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]

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? :eek:

[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.

[ccrn]

What was he doing with an M-80 in his mouth?

I always ask-

[swatsurgeon]

Wrong Answer: simulating an iraqi RPG attack so we/I can learn form his injuries and better educate on this board...

Correct Answer: playing chicken


NOTE: the Wrong answer is not intended to make light of any action occuring during warfare

[ccrn]

By always asking I mean the pt when they come in. I hear some amazing answers (as do you).

Playing chicken as in lighting the M-80, putting it in his mouth, then putting it out or unloading it quick enough to not get hurt? Good God.

I leaned from this thread so thanks Doc. Ive seen plenty of blunt force trauma to the head but not blast injuries yet-

[JAGeorgia]

Wrong Answer: simulating an iraqi RPG attack so we/I can learn form his injuries and better educate on this board...

Correct Answer: playing chicken


NOTE: the Wrong answer is not intended to make light of any action occuring during warfare

I'm sure many of you have received some training in the South. My guess would have been a local favorite..."Hey Bubba, watch this!" Sadly that is too often more truth than humor. :mad:

Outstanding reconstruction work on this fellow. How did you close the 4cm gap in the mandible? Bone graft?