New Case

[swatsurgeon]

For 18D and the like and PA's....doc's hold your fingers/tongues for now:
Small arms fire. Soldier takes a round above the armor in the neck (we hope not). Able to function and return fire....seeks cover 25 feet away. Medic happens to be right there seeking the same cover:
Air bubbles from hole. Able to breath with LITTLE difficulty, can speak but with some difficulty from blood, no obvious expanding hematoma. Some pain in neck. [see picture].

Discuss your initial treatments and what is going through your mind: overall, how are you going to handle this case as presented from area of cover through evac and forward most medical facility.
We'll then pick it up from there.

ss

[desertmedic]

First thought is a tegaderm or similar occlusive dressing to seal the wound. Is there an exit wound? Would be prepared to intubate or cric. C-spine control would be nice but not necessarily plausible in this setting. Undecided on pain meds weighing Px level vs. anticipated level of respiratory distress. An access line or two would be nice depending on time/present location, if volume replacement is needed going with hypotensive resuscitation. Just my thoughts,

Desertmedic, NREMT-P

[swatsurgeon]

Originally Posted by desertmedic

First thought is a tegaderm or similar occlusive dressing to seal the wound. Is there an exit wound? Would be prepared to intubate or cric. C-spine control would be nice but not necessarily plausible in this setting. Undecided on pain meds weighing Px level vs. anticipated level of respiratory distress. An access line or two would be nice depending on time/present location, if volume replacement is needed going with hypotensive resuscitation. Just my thoughts,

Desertmedic, NREMT-P

No second wound (i.e. potential exit). Pain tolerable and descried as midline as well as to the right and 'behind' the trachea. Palpation of wound area puts the hole through the thyroid cartilage, no palpable hematoma, bullet, etc.

Patient awake, alert, still in the fight since evac not for 30 minutes.

So, Desertmedic, you placed an occlusive dressing and his neck begins to develop subcutaneous air and he doesn't like the full feeling he's getting and rips off your dressing....feels better without it he says. He lets you start a 16G IV site but no way to hook him up to IVF right now, he's not in distress, just pissed he's been shot, not light headed, not any more tachycardic than you are.

What is happening and what do we do for the next 30 minutes.

ss

[desertmedic]

Thought there might be a problem with subq air. If he isn't in any distress monitor airway and CV state, will sit on those. Still have concerns on potential c-spine injury, but if he is still in the fight should he be taken out of it? Not sure about that. Don't see a need for imediate pain management at this moment. Standing by to step on myself some more,

Desertmedic

[swatsurgeon]

Since this one didn't generate much interest except desertmedic........
patient makes it uneventfully to forward field hospital and gets xrays.
On exam, air from anterior wound, no other wound, no carotid bruit.
Patient getting anxious and still coughing up blood, so intubated.
See xrays: paper clip over entrance wound to assist in determining trajectory (left side of paperclip over wound) .
Next Step?

[trailrunner]

Before we move on to the hospital and treatment, etc., per, the first 30-45 min of this situation. What is the appropriate immediate response?

I am not medically qualified as a first responder, but I am curious on the right way to initial respond to this as someone who would want to help until a medic is found or transport to hospital is possible. I know more medical training is in my future to be able to do this "right enough" until better care is found.

As I understand the situation... adrenaline is kicked into high gear and possibly blocking any responses to pain, solider has to stay in the fight for the moment (and wants some heavy duty reprisal), rejecting closing up the wound because of build up and ease of breathing at the moment...

Am I to understand if the soldier can "work"... Let them work. The hospital will take care of the rest once the soldier is there? My part would be to make sure they get there pronto!

A couple of things come to mind after seeing this problem...

No exit wound, what stopped it? What is broke or near to breaking that I can't see and the soldier can't feel at the moment? How do I keep this soldier in the positive and not heading toward the negative?

The more you know...

[SeanBaker]

First off, thanks for posting a new case S/S.

At the EMT-B / CLS level...

1. Return fire; eliminate the threat.
2. Palpate / expose wound / look for secondary injury
3. Instruct pt to hold still, possibly lie down (METT-TC - cervical immobilization; philly collar is coming)
4. Depending on what I'm carrying, either insert a lubed (to seal) child-size ET-tube (small NPA?) through thyroid cartilage to secure airway OR tape kerlix to entry site w/ inspection/change of dressing q. 5m (absorb blood)
5. Apply philly collar
6. Evac - Urgent Surgical

What I'm thinking:

To have not exited the neck, projectile is a fragment, a ricochet, or lodged in the C-spine. The first two options provide a high risk of additional damage with movement d/t sharp edges and unknown location within the neck, while the third may be the most dangerous with potential for spinal cord injury either directly, d/t bone / bullet fragments or swelling. Airway has to be controlled. A lubed tube through the point of injury will provide a seal against additional bleeding into the airway as well as provide a measure of control against tissue swelling - situational intubation of a conscious casualty is a no-no at my level and doesn't seem to be indicated for anyone outside the hospital unless he codes. The alternative - kerlix taped to the injury site - will absorb the majority of the fluid (preventing it from entering the airway) while not causing the sub-cut air referred to previously. Philly collar is a necessity d/t injury site (civ. doctrine would also dictate backboarding, though that doesn't seem realistic for the situation).

I'm looking to learn, so please tell me if / how badly I've gone wrong...

[sofmed]

I hope you guys don't mind, but I'd like to resurrect this one. I haven't had the opportunity to deal with something like this (hope I don't have to) and I would like to hear more on what the proper tx and followup would be.

Mick

[linedoc]

As for the initial portion of this scenario my course of action medically would be:


1. Explain to the soldier why I am taking him out of the fight.

2. C-collar, at this point I don't know where the bullet/fragment is. Try to minimize potential for further injury.

3. Secure airway with a NPA through wound, and verify air exchange.

4. Get IV access, saline lock.

Hold PN meds as to not obscure mental status. Monitor vitals, mental status and obtain a good NV exam. Reasses airway and reassure PT.

Hold tight for dustoff.

[sofmed]

Originally Posted by linedoc

As for the initial portion of this scenario my course of action medically would be:


1. Explain to the soldier why I am taking him out of the fight.

2. C-collar, at this point I don't know where the bullet/fragment is. Try to minimize potential for further injury.

3. Secure airway with a NPA through wound, and verify air exchange.

4. Get IV access, saline lock.

Hold PN meds as to not obscure mental status. Monitor vitals, mental status and obtain a good NV exam. Reasses airway and reassure PT.

Hold tight for dustoff.

Would you use anything to guarantee a good seal around the NPA you've stuck in the wound...vasaline impregnated guaze, etc, or simply leave it as it is. I only ask because at SOFMS-P I was taught when dealing with a chest tube to use the impregnated guaze to ensure no air could infiltrate, either in or out around the tube. ??? I'm concerned about the subq being a problem and would like to know more, as I stated previously that I haven't had to deal with any neck wounds of this nature before.

Thanks!

Cheers.

Mick

[linedoc]

I would just use kerlix on the wound to soak up any blood that may potentially enter the airway, however little it may be. In a chest tube you are dealing with a defined space dealing with negative pressure. Sealing it 100% is a must to try to maintain the integrity of that defined space. I was taught to wrap the tube at the skin/tube interface with petro gauze and then suture tightly around it to promote proper seal.

With the neck injury it's a two way street. a little leakage that far down in the airway is the same as the adjunct itself. I do see what you mean about securing the space between the trachea and the tissue of the neck to prevent SQE, but I feel in that type of injury the bigger problem is the potential hole in the back of the trachea and the vessels/structures in the vicinity. The air has a way to escape in the front, moving with the least resistance.


I'm eager to see what the outcome is....

[sofmed]

Originally Posted by linedoc

I was taught to wrap the tube at the skin/tube interface with petro gauze and then suture tightly around it to promote proper seal. Bingo!!

With the neck injury it's a two way street. a little leakage that far down in the airway is the same as the adjunct itself. I do see what you mean about securing the space between the trachea and the tissue of the neck to prevent SQE, but I feel in that type of injury the bigger problem is the potential hole in the back of the trachea and the vessels/structures in the vicinity. The air has a way to escape in the front, moving with the least resistance.


I'm eager to see what the outcome is....

Thanks, Linedoc. Good tools for my 'toolkit'.

Mick

[Doc Dutch]

Swat Surgeon,

This is a great case. I am enjoying all of these posts and comments.

If I might, I would like to add a few things if that is alright.

First, get this young man out of danger and evacuate him to a safe area NOW!!! If it is in a combat zone, please do not let him go back out there. If he is in the United States and this happens out in the streets, get him to a level one trauma center. A respiratory death is closer than you realize.

We only have one airway and if you lose it, that could be it. He may not understand because he wants "payback" but he will go on to live many years with a wife kids, mortgage, grand kids, if you do this correct the first time. Remember, it was the cardiologist that invented the ABC's and they got it correct. Airway, Breathing, Circulation. Now, today "C" may first come in front of "A and B" but that is for blast injuries that rip legs or arms off or AK-47 injuries to femoral arteries that can get QuikClot, Hemcon, a tourniquet and pressure to the area. A surgical cricothyrotomy is nice to talk about and very dramatic, but in this patient, it is not a given and there are many injured structures just waiting for you to make a cut, release the clot, and then they will stat bleeding into the airway.

Moving on, the location of this injury is a zone 2 entrance and a zone 2 landing but you may need better access than just a standard anterior sternocleidomastoid incision. To get to this injury the anterior trachea will be easily repaired through the anterior exposed neck or SCM incision, but the zone 2 posterior trachea injury . . . the specter for the need for a median sternotomy lurks. It is in a bad location but I would start with the left SCM incision but have a chest surgeon in the back of my mind if I have to go into the chest for proximal control. Usually when the thorax surgeon returns my page I have fixed it, but this could still be trouble.

If this projectile not only injured the anterior trachea but also got the posterior trachea, then it may have injured the membranous trachea. You know what that means . . . the esophagus. It lies there behind the trachea in wait for the unsuspecting to miss an injury to it. A thorough evaluation must be done with endoscopy, gastrograffin (if you have time pre-op and if he is stable) and if not an open evaluation during your repair of the trachea with full anterior and posterior visualization and NGT placement with air pushed through a syringe to look for more bubble. CT scan would be nice but not necessary. Think about methylene blue in the esophagus by the NGT to look for a hidden injury.

Now, I want to share this with everyone as I remember a ghost from my past. The X-ray with the endotracheal tube is a wonderful x-ray that is highly instructive and if the hair on your back did not stand up looking at it then I am afraid you missed it. If there was an anterior and posterior injury, the person that intubated could have shovel nosed onto either edge of the injured trachea and dislodged the remaining attachments of the trachea thereby separating the proximal and distal trachea. (Whoever intubated this young man should go to church twice and the patient three times on Sunday.) The chance of getting the ETT into the distal trachea will be lost if the trachea is cut in half by shovel nosing it and with the bleeding that one stirred up with this attempt at intubation. Saw this once in a child sledding that was "clothes-lined" by barbed wire. The attempt at intubation in th ED and loss of the distal trachea was horrifying as the child had come in crying. Even a fast trip to the OR for a neck exploration by my attendings could not save this child as he lost his airway and coded within minutes and all of the messing around to figure it out while in the ED only lead to his death. Going to the OR then was just an on-table autopsy. This was a lesson I learned as a young intern. Consider when intubating using a bronchoscopy to follow the ETT down and across the injuries.

So, while Airway is critical, remember that if the patient is talking, breathing, holding his own and able to cough up the blood or sputum to protect his airway, but again, doing well, let sleeping dogs lie, get him out of the combat zone and get him to a trauma or combat hospital. Also, if they want to sit up, because they feel like they are choking when they try to lay down, please let them sit up. Do not force them to lay down despite what ATLS says. Hold off on occlusive dressings. A gauze to collect the blood is fine.

Finally, intra-op and post-op at extubation, think about recurrent laryngeal nerve injury. If both recurrent laryngeal nerves are out you could have the rapid need for a reintubation after a repair or you are back to a surgical airway. The vocal cords slam shut if both are out. Even if one is out, patients can struggle with their airway. Extubate with direct fiberoptic laryngoscope or bronchoscopy within the ETT and watch the cords.

As for thyroid damage, well, that is why Synthroid was invented.

Simply an incredible case, Swat Surgeon, with lots of teaching points!

Thank you,

Dutch

[linedoc]

Thank you for your post Sir, it was informative.

So, while Airway is critical, remember that if the patient is talking, breathing, holding his own and able to cough up the blood or sputum to protect his airway, but again, doing well, let sleeping dogs lie, get him out of the combat zone and get him to a trauma or combat hospital.

I agree 100%. As far as placing an airway adjunt in the wound..... In a situation where evac may not happen for another hour or two, worse case scenario, then would there be any major contraindications for securing this type of injury in that manner? (Surely insuring that the placement was not straight through the trachea, but rather actually down into the airway) The intergrity of the trachea was in the back of my mind concerning the fact that if this guy went out on us, that hole is my safest bet to get an airway.

[Doczilla]

I don't think I'd place an airway adjunct into the wound. You just don't know where you would end up. Though the bubbles indicate that the trachea has been injured, you don't know if the wound tract goes straight into the trachea or just nicked it. If you place an airway adjunct into the hole, it could easily miss the trachea and slide into the paratracheal space, or go all the way through and end up posterior to the trachea. Worst case scenario, you are partially occluding the trachea with the airway adjunct while ventilating soft tissue.

With regards to c-spine, I might collar him to keep him from making sudden movements that might complete the tracheal transection, but any neurological injury is likely to be evident at the time, and if not, extremely unlikely to occur with simple head movement. Full C-spine immob will potentially inhibit the patient from getting into position of comfort, which is where I want him if I'm not intubating immediately. The more comfortable he can get, the better he can breathe, and the less anxious he'll be.

'zilla