GSW to neck

[brock8024]

Here is another thing. Why not just try basic airway first. I mean he might be out of it, but why knock down a guy to try to tube him if you can vent him with just a BVM and oral airway. MAybe this is a time we do not need to jump to advanced airyway just use the basics.

[p3medic]

First, do no harm. Easier said than done. BLS the airway for a short rapid transport, and you have done no harm, per se, however with the above potential problems, all resulting in an unmanageable airway, early control is paramount, not unlike the airway burn patient. There have been several papers and retrospective studies on this very topic, and the consensus was that nasotracheal intubation had a high degree of success (Denver prehospital study) and RSI was highly successful, from several places, most recently Los Angeles(in hospital). Surgical airway, if it becomes necessary is an option, but one of last resort. Intubation through the wound tract is possible, if large enough, but with most GSW's in the US, its a small caliber wound. I have tubed a patient through a neck wound once, but it was a huge lac from a knife, and the anatomy was so blatantly obvious a firefighter could have done it.

Now, me personally? I guess it would depend on his LOC. Unresponsive, as in this senario, careful laryngoscopy and attempt to intubate, if too much muscle tone, or patient to light, perhaps some topical anesthesia and versed/fentanyl or etomidate, with sux drawn if needed. At the end of the day, this is a horrible airway problem, and despite all we do, things can go very, very, bad.

[Just Plain Ruff]

my suspicions if they are correct is that this patient was a goner from the get go.

Massive neck trauma, tracheal insult, bubbles from the wound all line up this guys stars in a way that whatever you do will be window dressing.

Oh what I would give for a fully equipped OR in my ambulance for this guy.

So what was his outcome?

I'm gonna bet my next paycheck that this guy didn't make it.

[firedoc5]

Similar situation. In my own car. Shots fired. Less that two block. First question? Where's shooter? Second question, where's shootee. Found mid 20 man sitting cross legged on floor holding neck. Very minimal bleeding. No obvious esophageal or tracheal trauma, Patient removed hand from GSW site, still very little blood. Good vitals, patient calm. Other "medic" runs in. The best way I could put it is that he "was all in a tizzy". My query? IV, KVO, NS, monitor vials. Patient remained ambulatory. The other medic, at least one large bore IV 16g, LR, O2 NRB.

Anyone's input?

BTW. The actual shooter was in his 80's. Shooting victim was trying to get his SS check, so the old man shot him. The older man dies two hours later AMI.

[Just Plain Ruff]

It's a shame you got there so quickly. But sounds like the nature of the call brought out the worst in that medic.

[Adonis]

Loved the input. I left out most of the info on the exact part of the neck and the type of gun so as to get varying info . It was actually my first GSW to the neck sadly this guy made it all the way through surgery but he died exactly 7 days later.

We had a very short transport time with this guy. Which you can see happing here most of the time on an Island this size. and the area i work is closer to the major hospital. (I don't normally work far areas). The time was about 10 mins.

This guy had it Simple to some extent but with his injury and not being to far away he had:

C spine, an oral airway suction and BVM.

large Bore Iv access

We actually got the bleeding under control with pressure and BP after quickly running a line in up to 110/70. Not sure to what extent the vascular damage was but something did hit his airway causing the bubbles. and he did bleed out a lot before we got to him.

The person who shot him did so accidentally or was a total waste at trying to aim.

seem this was a shotgun blast from right over his shoulder. most of the shot only grazed him. a little more to the left and he would have been dead on the spot.

But what did hit him was enough to damage his airway and some of vascular structure and tear away a small chunk to the right side of his neck. ( still bad I know) . He regained consciousness about the time we hit the doors at the ER. he was quickly put back down and intubated and actually was in a more stable state. thats why i thought he had a good chance if he made it that far.

They did manage to repair the damage to his neck but it seems he died of complications.

Thanks for the input.

[Doczilla]

I would not use the wound tract from the bullet. The fact is that you just don't know what tract the bullet took. Travel in a straight line should not be assumed, since bullets almost never do once they start traveling through human tissue of varying densities. If you stick the tube through that, you can't be sure where you are ending up. The bullet may have just nicked the trachea, and the dark space you see may or may not be the trachea. You could penetrate the trachea completely and end up on the other side. You are also putting a tube right into the part of the trachea which is least stable and least able to tolerate the force you will apply when sticking the tube in.

There is also the caliber issue that p3 medic mentioned. I have not seen a bullet entrance wound large enough to squeeze an ET tube through without forcing it or widening the hole. Even high-velocity rifles will leave a relatively small entrance wound.

Early definitive airway control is indicated to prevent occlusion by a hematoma, which will make later attempts at airway control (surgical or otherwise) difficult by distortion of anatomy. Thus the patient needs an airway as soon as possible, BEFORE they are in distress.

If someone successfully intubated this patient by nasal intubation or regular orotracheal intubation, they had better give thanks in prayer every day of the week and twice on Sunday. There is the very real danger of completing the transection of the trachea by regular intubation. Once this happens, the trachea can retract into the chest where it is not accessible by anyone. For this reason, you may consider surgical cricothyroidotomy without attempting oral intubation first. If the wound is too low to go through the cricothyroid membrane, then we will do an emergent tracheostomy.

The next question you have to answer: c-spine the patient or not?

'zilla

[Just Plain Ruff]

Doc, conventional wisdom says c-spine cspine cspine.

I'm gonna c-spine the guy unless I cannot see or gain access to his airway in a quick manner.

I would seriously consider stabilizing the heck out of his body and head and forego the c-collar due to the fact that if we crich'ed him or tracheostomy'd him we'd need that access and visualization that a c-collar would cover.

The underlying problem is just that we don't know where the bullet is. If the bullet is still in the neck and possibly resting against the cord then we don't want to move this guy much in terms of neck movement due to the distinct possiblity that the bullet would continue to place pressure or damage to the cord. When a bullet hits a body it often times will fragment and if those fragments are resting against the cord then we have the real possiblity of a cutting of that cord due to the jadded edges of the bullet.

Even with an exit wound, we are not guaranteed the entire bullet left the neck. If it fragmented then the possiblity is very real that the bullet fragment is still hiding around that neck.

So to make a long explanation short - I would secure the heck out of this patient. This would be a great case for paralysis to keep the patient from moving. If you can intubate the guy or crich or trach him then you will need to paralyze him anyway in order to keep him immobile.

Being an armchair quarterback to this call is good and it sound's like all that was done for him was appropriate and he died despite the fact that he seemed to be getting better.

He just didn't know he was dead yet.

[AnthonyM83]

Unless it starts compromising the airway, I would c-sprine.

I've seen literature against c-spine for GSW's to above neck and below neck provided good neuros...but this injury is actually AT the cervical spine area, so without knowing further I'd have to immobilize it.

[ccmedoc]

This patient could be immobilized and c-collared with the cric. Any packing done with trauma dressings and the such would stay in place, and you would still be able to visualize the airway through the hole in the front of the collar..thats what it is for. Besides making it easier to keep the tube you placed where it belongs, it may make it more difficult for the patient to reach it if he becomes aware.

I think the c-collar would be a benefit to the providers and the patient. Free up some space and hands for other things that, assuredly, would need to be done..