Interesting Airway Case

[flightmedic608]

Hi Kick, my comment "Not in this case" was for ERDoc about transport decision based on airway, not in regards to what your local HEMS program would do.

[systemet]

Good scenario.

* Obviously we need to be vigilant to assess for other injuries, or other mechanisms of self harm here. If he has a pressure and rate as reported, and we're not seeing visible external hemorrhage, he's probably not going to decompensate through hypovolemia, although it's always possible there's some sort of deep injury that we can't see.

* He's described as "awake, but non-verbal". Is this suggesting that he's refusing to talk to you, but appears otherwise alert -- or is this a suggestion that he has an obvious decreased LOC? Because, if so, that's not from the knife wound, given current hemodynamics. There's always the potential of some sort of coingestion in this population, even if they're GCS 15 on presentation.

* Ground, I'd restrain, sedate as required, and ride it out to the ER unless anything changes.

* Flying, I think you snow with some fentanyl and ketamine, and do what the doc suggested and place a bougie through the wound, very carefully, then place the ET tube directly into the trachea.

I wouldn't want to RSI this guy, because you can't bag valve mask ventilate him, and none of the alternate airways are likely to work here. At least with ket, you have a good chance of maintaining his respiratory drive.

[paramedicmike]

...grabbed flightmedic and went out back door of helicopter at 1000 feet.

Why was the flight medic not properly secured in his seat? I can only think of a handful of instances where I had to come unbuckled in the back. None of them involved routine care. I don't know the circumstances about what this medic was attempting at the time. It could've been that he unbuckled to help restrain the patient. The scenario raises a lot of questions.

As to the questions outlined in the OP:

(1) Do you consider this patient airway stable (flight time to tertiary care is 17 min, ground time to local hospital is 20 min)

No. I don't consider this a stable airway. Given the concerns surrounding the patient, his suicide attempt and the extent of the injury I would not be comfortable transporting him without sedation of some kind. With the sedation would add concerns about the patient's ability to manage his own airway.

(2) Do you feel as though you can maintain his present airway

Based only on the description offered I don't know that I would want to take that chance. However, I agree with ERDoc that the best bet here may be a watchful waiting scenario.

(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

Etomidate only. Or fentanyl/versed. I would not give this guy paralytics until after the airway was secured. I, too, would attempt an oral ETT placement. Failing that, bougie through the hole in his neck with the ETT placed over.

(4) Are you concerned with the fact that he is a suicide attempt

Yes.

[ERDoc]

Trying to think outside the box alittle, with an 8cm wound, you could probably just hold the hole open and have a secure airway. There isn't much in that area that can obstruct the airway. You've taken the tongue and vocal cords out of the equation so you are probably down to the cartillage rings and have a rigid tube that is open at the top.

[mobey]

Perhaps I have been listening to too much emcrit podcast, but I would try manage this guy more aggressively.

He is suicidal, and seems pretty serious. I am going to protect him and myself with chemical restraint. In this preticular case I'd opt for Ketamine as it will provide some analgesia as well as sedate him without having much effect on resparations.

Once he is disassociated I could either introduce a tube into the existing hole, or go to the cric membrane and make a new one. If all else fails.... I can put the mask back on and leave it the F alone!

With suicidal idealations, and an unprotected tracheal toilet I call this airway unstable.

[flightmedic608]

Great point Doc and that is how we approached this patients airway. We took into account (1) unstable airway (2) suicidal patient (3) 2 cm of tissue holding tachea (4) GR transport would be risky. We decided that taking an oral ETT approach while utilizing Etomidate and Fentanyl only would be the safest. Prior to administering any meditcation we prepared two "kelly" clamps and had my partner place sterile gloves on from the OB kit. Once the patient was given Fentanyl and Etomidate, my partner actually reached into the wound and held structure in place. I took the two "kelly" clamps and attatched one to each side of the trachea and securing to patient. We were very concerned about relaxing the patient and having the trachea detach and withdraw in to the thoracic cavity. Once both sides of the trachea were secure, I orally intubated the patient and "stented" the airway, ensuring the cuff was in position past the opening. Once the airway was secured, we gave the patient a long acting NMB for transport. This was a very interesting airway case and I am glad I have had an opportunity to share it with you.

Edited May 3, 2012 by flightmedic608

[ERDoc]

Very interesting case. It's one of those things where there are no right answers and many right answers.

[paramedicmike]

Thanks for sharing. This was definitely an interesting case to read. I'm sure it was even more interesting finding this patient after climbing into the back of the ambulance.

[flightmedic608]

Interesting would not be the word I would have used at the time. Looking back retrospectively, it is quite interesting.

[paramedicmike]

No. I imagine it wasn't. I had a somewhat similar case a few years ago. I would not have used "interesting" at the time, either.