Protect Me! "Flights" #4 Recap

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Welcome to the Final Recap of our “Flights” Case Series!

Thanks to all those who participated in the discussion and to those who tuned into the “Flights” cases throughout the spring and summer.  We are always looking for new ways to do things so if you have any suggestions as to how we can make these better, let us know!

It’s been awhile since the final “Flights” case was posted so lets start with a recounting of the patients we were faced with:

Patient 1

You’re dispatched to a patient with a GSW. You arrive and find a young male patient who has a self-inflicted GSW to the face.  He’s crouched on his knees, leaning forward with blood pouring from complex facial wounds.  His mental status is intact but he will not lay flat or he becomes exceptionally agitated.  His vital signs are remarkable for tachycardia (132), tachypnea (24), and a marginal O2 sat (93% on RA).  He has a mandible fractured into multiple segments, multiple fractured teeth, unrecognizable nose and maxilla, and a left open globe with active bleeding.

Patient 2

Consider a patient with a stab wound to the left neck (right where Zone 1 and Zone 2 intersect).  He is awake, mentoring normally, and has vital signs remarkable for mild tachycardia (104), tachypnea (24), and poor oxygenation (92% on NRB).  You find a small amount of subcutaneous emphysema in the anterior neck without any active bleeding or carotid bruit.  You are informed by EMS on scene that the patient is significantly more hoarse than when they first arrived on scene.

Patient 3

You arrive on scene to find a 350 lb 65 yo patient in respiratory distress.  She has a prior history of having a reportedly mature tracheostomy and began having difficulty breathing after pulling out her un-cuffed tracheostomy tube prior to EMS arrival.  EMS has tried to put back in the tube without success.  There is a moderate amount of blood on her anterior neck from the failed attempts at replacement.  She is hypoxic to 84%, tachycardic to 156 and clearly in respiratory distress as EMS attempts to bag through the stoma site with a pediatric face mask.

For each of these patient’s, we asked you to give us your thoughts on how you might manage the patient’s airway.  Take a listen to the podcast below to hear how ACMC Medical Director Dr. Bill Hinckley, outgoing RAMD Dr. Andrew Latimer, and incoming RAMDs Dr. Charlie Kircher and Thomas Scupp would approach these patients.   These are challenging patients (with no clear answer on how one should definitely manage their airway), so if you have other thoughts or opinions please feel free to share in the comment section below.

Below are some of the critical takeaways we had for each of these patients

Patient 1

You have 2 big problems with this patient: 1.) airway control 2.) hemorrhage control.  As long as the patient is sitting up and has a way to suction themselves, their airway is actually decently patent.  However, depending on the amount of hemorrhage, you may need to control their airway in order to control the bleeding by packing the complex open facial wounds with hemostatic gauze.  If you decide to intubate this patient, an awake look is probably the way to go - topicalize with lidocaine (if available and time allows) and administer a sedative agent, when you know you can get a view of the cords, either pass the tube or administer a paralytic and pass the tube (2).  This is a patient in whom video laryngoscopy may be complicated blood and secretions.  Therefore, direct laryngoscopy may be the best first choice.  In addition, given the patient’s issues with laying flat and the desire to keep active bleeding out of your field of view, this is a patient in whom you could consider a tomahawk-style intubation.  Finally, oftentimes direct laryngoscopy is not challenging in these patient as a lot of the anatomy that usually blocks the line of sight is gone or destroyed to the point where it is mechanically easy to lift out of the way.

Patient 2

This is a patient who you want to intubate sooner than later.  The developing hoarseness implies a dynamic process that is distorting or otherwise impacting the patient’s airway.  The earlier you intubate this patient, the more likely you are to encounter normal anatomy.  In addition, this is a patient who would under ideal circumstance have a flexible fiberoptic intubation in the ED with visualization of the ET tube passing beyond the presumed trachea injury.  In the field, it’s unlikely you have that option.  If you have it available it would be reasonable to preferentially choose video laryngoscopy in this patient.  Given the concern for worsening an existing trachea disruption, it would be best to avoid large ET tubes as well as bougies.  Finally, after the patient is intubated be vigilant for the possibility of developing or worsening pneumomediastinum or pneumothorax.

Patient 3

Tracheostomies can be intimidating.  Trying to replace one can either be super simple or seemingly impossible.  For a good approach to tracheostomies and specifically to the stenosed tracheostomy site, check out this post from the Taming archives.  The first thing to know about this patient is whether or not the tracheostomy site is truly mature (how old is it?).  If it is mature and you are having trouble passing the old tracheostomy tube, consider placing a bougie in the airway and passing the tracheostomy tube over that or, better yet, passing an ET into the ostomy site (being aware that when you do so, you are already near the carina and therefore do not need to advance the tube deeply).  Once an ET tube is in place you can oxygenate and ventilate the patient and attempt replacement of the tube in a more controlled setting (i.e transport the patient to the ED where replacement can occur over a flexible fiberoptic scope.

References

1.) Figure 5. Zones of the neck. https://openi.nlm.nih.gov/detailedresult.php?img=PMC3214866_cmj-47-134-g005&req=4

2.) Weingart, S. Podcast 145 - Awake Look Intubation Lecture from SMACC. http://emcrit.org/podcasts/awakeintubation/. Accessed 7/28/16.