Impaled object management

[swatsurgeon]

here's a (?) common scenerio........especially around explosions.
I'm going to attach a few pictures of impaled objects
1) piece of shattered glass in the trachea; very few people wear neck protection
2) piece of a fan blade in the face: few people wear face protection
3) nail in the wrist; common with suicide bombers wearing the palestinian dinner jacket (c4 with nails, rivits, washers, ballbearings, etc.)

How do you field manage these......be specific..

T-2

[swatsurgeon]

Moved...for case #2 Click here

[swatsurgeon]

for scenario #3.. Click here!

[shadowflyer]

Originally posted by swatsurgeon
here's a (?) common scenerio........especially around explosions.
I'm going to attach a few pictures of impaled objects
1) piece of shattered glass in the trachea; very few people wear neck protection
How do you field manage......be specific..

T-2

I am in EMT-Intermediate school right now.

1. At the level of training which I have OPA or NPA would be used to manage airway, suction and make sure he is moving adequate air and his SPO2 is looking good.BVM with 15l/m 02 if needed or NRB if adequate tidal volume and monitor SPO2. Control bleeding on wound site wrap object and leave in place. Rapid trauma assessment, head to toe. Fixing things as I find them. 2 18g IV NS run them wide open Inital bolus of 250ml to titrate to mentation and keep a systolic above 90 -100 mmHG. Rapid Transport to bright lights and cold steel.

I know of more advanced airway procedures that could be used but I have not been trained on them yet.


Jason

[shadowflyer]

SWATSurgeon...am I on the right track with my TX?

JJ

[Ambush Master]

Swatsurgeon has gone on vacation. You may want to watch for him to "resurface" and launch a PM .

[Sacamuelas]

SS-
Great pics, threads. I am going to split them off into three separate threads if you don't mind. Will make it easier to keep up and make sure each case is worked to the end without being ignored. Will resize the pics to fit to make it easier to see as well. Great topics Sir.

If I may suggest... lets work the 1st case(impaled glass in neck) in this thread. I will copy over the listed treatment suggestions into the other threads to keep things tidy.

[shadowflyer]

Originally posted by shadowflyer
I am in EMT-Intermediate school right now.

1. At the level of training which I have OPA or NPA would be used to manage airway, suction and make sure he is moving adequate air and his SPO2 is looking good.BVM with 15l/m 02 if needed or NRB if adequate tidal volume and monitor SPO2. Control bleeding on wound site wrap object and leave in place. Rapid trauma assessment, head to toe. Fixing things as I find them. 2 18g IV NS run them wide open Inital bolus of 250ml to titrate to mentation and keep a systolic above 90 -100 mmHG. Rapid Transport to bright lights and cold steel.

I know of more advanced airway procedures that could be used but I have not been trained on them yet.




Jason

To quote myself ....I forgot to add a critical task. C-Spine control, with that type of blast injury there is high index of suspicion of C-spine/t-spine injury. The Secondary blast effect is what got the object lodged in his trachea and the Tertiary blast effect would have knocked him back thus having a MOI that would suggest C-spine/T-spine injury.


JJEdit for being a knucklehead....I completely overlooked that the object was in the trachea and the only time you remove and impaled object is if it occludes the airway. Learning...it is a wonderful thing.

[ender18d]

Thanks for posting the scenario!

I'm approaching the scenario as an 18D Q'd language school student.

(Note that I'm assuming from the pic that there is no major vessel compromise. Its also difficult to tell the exact anatomical position, but it appears that the wound is directly inferior to cricoid membrane....?).

BSI, Scene safe, MOI, C-spine, etc.....

OK, so there is a high index of suspicion for multiple shrapnel type injuries, so I'm going to be keeping an eye peeled for big bleeds etc..., but airway damage is the obvious life threat. While having someone maintain C-spine, I'd do my best to determine patency status of the trachea.

Everything boils down to a judgement call as to how close that glass is to the trachea itself. If the trachea is compromised, then the offending glass represents both a potential obstruction and a danger to any ET-tube/bulb that I might introduce. If the piece is extremely close to piercing the trachea, I'd remove it for the same reason. If I feel comfortable that stabilization will prevent tracheal rupture (the glass has some clearance from trachea and major vessels, which I believe is highly unlikely based on the pic... so this is more hypothetical), then I would stabilize it, maybe using a wrap of casting fiberglass (I've never seen it done, but wondered about this use for fiberglass). The wrap would be around the object but NOT a circumerential neck wrap.

I'd want to intubate/cric/trach (RSI PRN), in that order of preference, to ensure that my bulb seal reaches below the wound site. Its essential if there is a chance of tracheal rupture to seal the airway with the bulb below the wound site. Otherwise, the airway may no longer be patent, and the possibility exists for aspiration of continued bleeding. If I'm not removing the glass, intubation comes before stabilization.

02, BVM (PRN), finish surveys and bandaging/packaging/supportive care including IV's, and evac ASAP with any C-spine precautions I have or could improvise. I'm going to be watching the indicator-bulb like a hawk to ensure that no shards have wreaked havoc on my bulb.

[swatsurgeon]

I'm back........
overall management:
is the patient moving air??? yes, but with great difficulty.....
this is the one time I remove foreign bodies....yes, I lose the photo op but the glass/object is obstructing the airway and if you try to pass an ETT, it would rip the balloon everytime.

You are correct, it is located right through the crico-thyroid membrane. He did the work for you, push the ETT right through the wound, If it is difficult, try oral intubation, or the acid test, occlude the wound with something (vasaline gauze or the like, hold tight pressure and see if he is able to maintain his airway....not my first move but if you have no other choice you could see if he flys on his own....safest thing is a tube through the injury, which is what I did with him totally awake to assist in his own respirations. Once the tube was in place he stayed awake and wrote us a note!!! Did inject some lidocaine at the incision site after that for comfort and changed him to a trach tube, #6 cuffed, then scoped him to look for other injuries to posterior wall, and esophagus and locally explored the neck in the OR for vascular injuries (all negative).

[NousDefionsDoc]

He did the work for you, push the ETT right through the wound,

That's what I'm talking about. I like the way you think Doc!

[Guy]

Originally posted by ender18d

BSI, Scene safe, MOI, C-spine, etc.....

What is BSI?

[shadowflyer]

Originally posted by Guy
What is BSI?

Body Substance Isolation


Just gloves and eye-pro or face mask if it is needed.


Jason

[Guy]

Originally posted by shadowflyer
Body Substance Isolation


Just gloves and eye-pro or face mask if it is needed.


Jason

Did you see the ...............



Whenever I'm working, I wear eye-pro. Don't carry rubber gloves, at least not lately.

While at work...

1. Scene is SAFE.
2. Immediate EVAC.
3. A, B, C.

Sometimes #2 may come before #1 however, #3 will never be done unless #1 and #2 are completed.

[shadowflyer]

I did not catch that ...I guess my SA was lacking on that one. I was thinking....I am pretty sure Guy knows what BSI is ....maybe he had a brain fart or something.

I would be thinking along the same lines in a hostile AO.

Originally posted by Guy
Did you see the ...............



Whenever I'm working, I wear eye-pro. Don't carry rubber gloves, at least not lately.

While at work...

1. Scene is SAFE.
2. Immediate EVAC.
3. A, B, C.

Sometimes #2 may come before #1 however, #3 will never be done unless #1 and #2 are completed.