GSW to neck

[ERDoc]

I'd have to agree that the issue here is going to be airway control. This is a very tenuous airway from the sound of it. If you don't secure it at the scene, will he make it to the hospital? You might want to be careful how much pressure you put on the throat. The bullet may have damaged some of the supporting structure of the trachea/larynx and you may make it worse. The next question is, do you RSI this guy? Will your backup airways be adequate (think an LMA is going to be a good idea in this guys throat)?

[JakeEMTP]

Here we don't have the option of RSI. However, The patient is unresponsive. What's his GCS? I think I'd try and tube him. The airway is obviously compromised due to the observation of bubbles coming from the wound.

LSB, direct pressure, occlusive dressing, 2 large bore IV's, NS wide open, BVM, diesel bolus.

[Richard B the EMT]

This is not in our matrix, as far as I know, to respond a CFR-D Engine company to a shooting. The idea, though, of using an NYPD LEO for the same purpose does come to mind, however.

On the "Bad Idea" side of using a cop: I've had, over the years, Sargents and Lieutenants from NYPD ask me to delay heading to the trauma center, so they could have a suspect "line up" in the back of the ambulance. They say, do it now in case the patient dies. I say, no, transport now, that perhaps we won't have a dead patient.

EMS wins, patient wins, suspects get a delay, and NYPD is unhappy. They'll get over it. AGAIN.

[DwayneEMTP]

...The next question is, do you RSI this guy? Will your backup airways be adequate (think an LMA is going to be a good idea in this guys throat)?

Man, great question Doc...And me difinitive answer is...I don't know until I see the anatomy involved.

Having said that, and having never really thought of this before, with a gunshot wound and the resulting cavitation injuries, perhaps there are going to be issues surrounding the trachea that won't become obvious until I've begun to make my intubation attempt...hell.

Thanks for the thought Doc...My little pea brain so far has been prone to thinking "I WILL gett the tube. No question. But if I don't I always have my backup airways." But what if I don't....Man, I don't know.

I guess it boils down to this. If my unresponsive patient it asperating blood directly into his trachea below my dressing, I have to stick something down his throat. Even if I feel my chance for failure is high, making the attempt, having another competent medic standing as well, and having my rescue airways prepped is his only chance I think...Right?

What are the odds I can secure my tube directly through the wound as long as it still allows for adequate bleeding control?

Dwayne

[JakeEMTP]

Depending where exactly the wound is, and if I couldn't get the tube, I suppose I could do a surgical cric. I'm not sold on using a back-up airway such as a LMA, Combitube et al.

Thoughts Dwayne? ERDoc?

[Doczilla]

ER Doc's point is a good one. Backup airways, such as LMA, Combitube, King-LT-D, depend on some semblance of normal anatomy to work. With a penetrating injury to the neck, you've got tracts that shouldn't be there....

Here's another question: Do you attempt to intubate him, or go first and immediately to cric?

And why am I asking that?

'zilla

[DwayneEMTP]

ER Doc's point is a good one. Backup airways, such as LMA, Combitube, King-LT-D, depend on some semblance of normal anatomy to work. With a penetrating injury to the neck, you've got tracts that shouldn't be there....

Here's another question: Do you attempt to intubate him, or go first and immediately to cric?

And why am I asking that?

'zilla

Good God...The Docs are killing us...Cool!

Here's my thinking. Bubbles in the blood = damage to the larynx. Damage to the larynx = edema in, spasming of, or displaced anatomy which = go straight to the cric. That's my best guess as to why you'd ask that...

Having said that I'm thinking I'm still going to attempt to intubate. I can't offer any intelligent reason for this. My only thought is I need to see what's going on before I decide what to do. I can look with my blade and then decide to cric, but it doesn't make much sense to do it the other way....does it?

Now, having said both of the things above...I can't imagine you would have asked in the first place if the answers were that easy... :oops:

I am curious though, as the only indication I've seen/heard of for using cric as a first line airway intervention is complete destruction/obstruction of all or part of the airway superior to the site of the cric, which with the scanty info we've gotten so far might not be the case..

Dwayne

[chbare]

With the bubbling, we can assume a penetrating laryngotracheal injury. The actual integrity of the the trachea it's self is compromised. A backup airway will be of little use because the insult is most likely subglottic. This also puts us in a sticky situation regarding ETI. If the injury is low enough, even oral intubation may not secure the airway. Additionally, we need to worry about the possibility of a rapidly expanding hematoma and entertain the possibility of a complete transection if we are too aggressive in our delivery of care.

To answer ERDoc, this patient IMHO, does not meet criteria for RSI. In fact, with the information given so far, I have to assume he is unresponsive and possibly near death. I would assume a crash airway at this point. So, the real question in my mind is this: do we attempt to secure an airway via oral intubation or do we transition into a surgical option? Both options will present with significant risk and if we choose to go surgical, we may find ourselves altering our technique depending on the location of the insult or insults. Food for thought.

Take care,

chbare.

[mediccjh]

Depends on the trajectory of the bullet.

If the airway is intact, place a trauma dressing and use a C-Collar to hold direct pressure. Keep the patient sitting up to keep the airway clear, and stick a suction catheter in his mouth in case he needs it.

If the airway is not intact, what would our options be for a surgical airway? Once again, depends on the trajectory. As chbare said about hematomatoes, I think a surgical airway would be the best. You can still use a collar to control bleeding once the airway is secure; that's why they have the cut out in the front.

[brock8024]

I would like to know the path the bullet took. THis is going to let us know really fast what we need to do. I am with everyone else. I am torn between oral and surgical airway.

Here is my question. If the bullet took the right path and you can see the trachea could you just use the hole the bullet made. I know this sounds stupid and I might come under fire but if there is already a hole and I can see and know that is the trachea why not use that hole.

Ok if the bullet went in anterior aspect of the neck that wound involve the trachea, and big vessels. If it went more posteriorly it would involve big vessels and the spinal cord and bone.

I feel really stupid about saying using the hole that was made by the bullet but could you not do that. One of the doctors please tell me i am a idiot or not. Heck anyone can let me know. LOL