Interesting Airway Case

[flightmedic608]

I wanted to post an interesting airway scenario, not to elicit right or wrong answers but to allow people the opportunity to discuss their approach (with reasoning) to this specific airway.

Scene – 32 y/o male with a self inflicted knife wound to anterior neck (suicide attempt). The patient was awake with an 8 cm laceration through his Thyroid Cartilage above his Cricoid Cartilage that had transected his trachea, leaving approximately 2 cm portion of his tracheal ring in place. EMS had started an IV of crystalloid, placed a NRB over patients opening in neck (think of a trach mask – similar thought) and administered 4 mg of Zofran IV. Upon our assessment we found patient sitting upright, awake, non-verbal, vitals HR 110 sinus, BP 136/70, RR 14 SpO2 92%. Anterior neck presents as listed, with edema and oozing from around laceration site, the patient’s NRB was blood specked.

Questions to be answered:(1) Do you consider this patient airway stable (flight time to tertiary care is 17 min, ground time to local hospital is 20 min) (2) Do you feel as though you can maintain his present airway (3) If you feel that you need to intervene with this patients airway, why and what approach would you take – at your disposal are the following adjuncts: normal ETT kit, bougie, LMA, surgical cric kit Medications available: Fentanyl, Midazolam, Lorazepam, Morphine, Succinyhcholine, Vecuronium, Pavulon, Etomidate, you are also in an ALS ambulance with normal supplies (4) Are you concerned with the fact that he is a suicide attempt

I look forward to posts, I will respond with our approach to this airway after people have given some thought and discussion.

Sean

[ERDoc]

1. The airway is potenitally unstable. I would go with which ever facility is a quicker transport.

2. I would say that in the field, this is a watchful waiting scenario. If he is saturating and not in any distress I would not touch the airway at this point. This is one of those situations where you are in a bad position, but to push it and agressively manage the airway has the potential to make the situation much worse. As long as he is comfortable and not hemorraging into the airway, let it be. Be ready to intervene.

3. Ideally I would tube him awake, sitting up with a fiberoptic scope. With what you have available, I would attempt a normal tube first and if that doesn't work place the bougie through the "surgical" opening and introduce a tube over the bougie.

4. Any suicide is concerning.

[Just Plain Ruff]

This is the kind of airway and patient that makes many medics anus's pucker really really tight.

The airway is unstable potentially but for the time being it's stable. But with a suicide patient he's already proven that he's willing to try to kill himself and he had the plan and the action to do so, so he's more than able to try to finish the job if you don't preclude him from trying to attempt it again.

so you better darn well restrain this guy and make sure he can't reach his airway.

To put this guy in a helicopter is a huge NO NO in my part of the woods. Probably any where else too.

If we are going to intubate this patient you better have the most experienced airway manager available. You do not want a medic who may have intubated one or two patients in the past year trying to intubate this guy. That's a recipe for disaster because how are you gonna bag this guy when the first intubation attempt fails and he's paralyzed? I would try to wait until you get him to a very controlled environment such as the nearest ER or surgical suite with an anethesiologist or comparable level of airway support.

Somehow I suspect that this patient realized that he truly wasn't ready to die and recognized that he made a truly monumental stupid mistake and he won't do this again but maybe not. But what you need to fully realize when you are transporting this patient is that this can go from bad(currently) to amazingly worse in a very short time so you better have all your equipment laid out, your medications drawn up at the doses appropriate for this guys weight, the tubes appropriate for his size (one size bigger and one size smaller et al), you should have at least two if not three or four additional sets of hands in order to help restrain this guy prior to paralyzing and intubating him because I am absolutely sure that you don't want to transport this guy by yourself in the back of the ambulance.

This is one scenario that I would hope to not have to face alone with just my partner and myself.

[ERDoc]

To play devils advocate here, why would he be excluded from going in a helicopter?

[flightmedic608]

We, as I believe that most HEMS programs have a policy in place not to transport suicidal patients who are awake with the means to continue their suicidal intentions. There was a case in Germany where a suicidal patient transported from a scene (which the crew did not intubate/paralyze for crew safety) and he unbuckled from stretcher, grabbed flightmedic and went out back door of helicopter at 1000 feet.

[Just Plain Ruff]

Exactly, if the guy is not fully incapacitated then he doesn't go in the helicopters in our area. The way to complete a suicide successfully is to open the door of the helicopter and jump out. That will end his suicide plans quickly but I'm sure doc you already knew that hence the devils advocate play.

or the worst case scenario is he gets loose and attacks the pilot thus bringing down the helicopter and taking the pilot, medic, nurse and patient. A foursome so to speak.

[ERDoc]

OK, good. I just wanted to make sure it wasn't because of the airway issues.

[Just Plain Ruff]

Nah, my helicopter crews would paralyze this guy and aggresively manage his airway even before they would consider putting him in the bird.

If they couldn't intubate him they would surgically manage his airway.

But he Would NEVER get a ticket in the bird if he was suicidal alone.

[flightmedic608]

Not in this case, although some cases in regards to ariway management are thought out before beginning transport. I am waiting for more posts/thoughts on this subject...but a couple of things to consider (1) The tranchea is being held in place by approx 2 cm of tissue are you concerned about this (2) If you are going to intubate this patient at the scene are you considering paralytics?

Edited May 3, 2012 by flightmedic608

[Just Plain Ruff]

I'm just going by what the flight medics/nurses would probably do in my area.

I'm quite concerned by that 2cm of tissue. I'm going to transport this guy to the nearest hospital with anesthesia capability.