Just Plain Ruff Posted May 3, 2012 Posted May 3, 2012 (edited) These are the think outside the box kind of scenarios that until you actually live them, they feel more like ones that you only hope you never get. There is an instructor in Springfield MO who uses these types of cases in his refresher courses all the times. Outside the box thinking is incredibly useful in developing exceptional paramedics. Great share on this one. Much appreciated. OK< for those crews who do not have access to Ketamine in their drug boxes what other medications would have been a good alternative for snowing this guy? What are some alternatives to managing this airway? This scenario has so much more potential to be a teachable thread. Edited May 3, 2012 by Captain Kickass
flightmedic608 Posted May 3, 2012 Author Posted May 3, 2012 I am glad that I had an opportunity to present a case that will allow discussion on airway management and the pharmacology associated with it. I agree there are numerous possibilities/solutions to this case. Like I stated in my initial post, there is not a right or wrong answer, I strongly believe in peer review and welcome the opportunity to learn from others.
paramedicmike Posted May 3, 2012 Posted May 3, 2012 Good questions, Mike. As mentioned before etomidate is a good choice. I also like the fentanyl/versed combo.
mobey Posted May 3, 2012 Posted May 3, 2012 I have done Fentanyl-only intubations as well, this would be a case where that is an option in my playbook.
Arctickat Posted May 3, 2012 Posted May 3, 2012 I'm coming into this late, I'd go with paramedicmike's treatment, save that we also have access to trach tubes. If the wound is amenable to using the trach airway I'd go with that rather than the ET. Even on the ground, I'd knock this sucker out with Versed/Fentanyl for his and my protection.
Asysin2leads Posted May 3, 2012 Posted May 3, 2012 Not to hard. Seal laceration with an occlusive dressing. This guy is going to probably buying a tube in the near future, so doing it now rather than waiting for complications involving laryngoedema or secretions is probably a good idea. Full precautions should be taken with the airway, in the back of the ambulance, with the bright lights on, using a bougie with an rescue airway device nearby, done by the most senior and skilled provider in the area. I'm not sure I agree with denying air transport based on suicidal ideation, with the physical and chemical restraints available to the average ALS provider, the patient's physical state should be able to be well-managed. What I was thinking about instead was the chance of an air embolism due to the deep neck laceration, and whether a change in altitude could possibly aggravate that. That would be a good reason to go by ground.
flightmedic608 Posted May 3, 2012 Author Posted May 3, 2012 (edited) Hello all, very good suggestions, a couple of thoughts in regards to intubating through the wound. Please scroll up and note that the trachea itself is connected merely by 2 cm of cartilage, manipulation of the trachea or intubating through the trachea may detach the remaining 2 cm of tissue completely. This is a case where there can be many avenues to take, and I am interested in hearing potential thoughts. And just for understanding purposes we dont deny gr vs air transport based on suicidal intentions, we have a policy in place that crew safety is first period, meaning that we may exercise judgement to intubate patient just for transport purposes. I look forward to more thoughts on securing this patients airway, Edited May 3, 2012 by flightmedic608
Asysin2leads Posted May 3, 2012 Posted May 3, 2012 Okay, I've got the scenario fully now. I think your EMTs actions were understandable, but not the appropriate course action. The only time you should be putting oxygen in through a hole in the neck is if you or a physician made said hole. I think the appropriate thing to do would have been to seal it with an occlusive, and then try assist breathing with a BVM. If he continued to deoxygenate, then you could try an NRB over the wound site, similar to someone who breathes through a stoma. If that worked, then I would investigate the possibility of managing the wound and introducing a true stoma, and then do BVM to stoma ventilation. I think though the best thing for this patient would be to effectively seal the wound, which would be a challenge in itself, and then securing the airway with a King airway. The trick would be to use just enough pressure to assure oxygenation at the alveoli, without disturbing the occlusive site. On that note, depending on the patient's mental state and ability to follow commands, the best thing might be CPAP. A relatively gentle inspiratory pressure pared with some PEEP might be just what this patient needs.
paramedicmike Posted May 3, 2012 Posted May 3, 2012 Just thinking about this a bit. I understand the reasoning behind the course of action that took place with the real patient. I'm just thinking that if there was so little tissue holding the trachea in place I'd be hesitant to orally try and stick a tube through which might end up pushing the trachea down anyway. If the wound was big enough it may do just as well with even less pressure to stick the tube through and down far enough to secure the airway. Obviously, the course of action by the OP was successful. Furthermore, I can't see the patient to really get a feel for how the anatomy was situated. So this is all speculation with no intended Monday Morning Quarterbacking by me. I'm just thinking about it.
Arctickat Posted May 3, 2012 Posted May 3, 2012 Hello all, very good suggestions, a couple of thoughts in regards to intubating through the wound. Please scroll up and note that the trachea itself is connected merely by 2 cm of cartilage, Hmm, I guess I was having trouble visualising it in my mind.
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