flightmedic608 Posted May 4, 2012 Author Posted May 4, 2012 I am enjoying the thought process on this case. This was definately one case that I wish I had pictures to present. I am not sure that I am clearly explaining how this patients wound presented. Imagine being in a cadaver lab, having access to the neck by a large laceration that transected the trachea and opening the neck so that the major vessels were exposed. The laceration to the trachea was wide enough that you could see into the tracheal rings. Asys, I understand the thought process you present about sealing the wound with an occlusive dressing, but it would not have been possibile. And the thought of NIVPP is a great one, but not only the concern of trying to stablize a very tenuous airway, we also had to take into account that the patient was a suicide attempt. HEMS has a very low threshold when transporting suicide patients who are awake. When we approached this patient as you can imagine, we discussed every aspect of the steps we were going to take, and we both agreed that stabilizing the trachea with external (sterile gloved hand and kelly clamps) was the safest route we had.
ERDoc Posted May 4, 2012 Posted May 4, 2012 (edited) I don't know asys, maybe we have different images of the wound. Next time pics or it didn't happen 608, lol. With that much damage to the trachea, the parts might not line up so that you can intubate. By sealing the wound you may be closing off the only worthwhile airway. Bagging the guy would put positive pressure on the tissues in the airway and could lead to subcutaneous emphysema which may compress the airway more. I think this guy has pretty much given himself a surgical airway, so why not use it. One issue I see with this is the fact that he has violated the platysma. Any of our newer providers want to say why this is a bad thing? EDIT: I didn't do a very indepth search, but I did find this article: http://www.springerlink.com/content/9w534236l5w6m100/fulltext.pdf Edited May 4, 2012 by ERDoc
flightmedic608 Posted May 4, 2012 Author Posted May 4, 2012 Lol will ensure that I have a camera with me from this moment on with all flights. Yeah, the approach of placing a tube through the laceration was presented in M&M, many ideas were put forth and one we thought about, but looking that destruction to the tracheal structure we thought it would be best to stent the airway....I will leave the platysma question for others....hint its an important muscle.
Asysin2leads Posted May 4, 2012 Posted May 4, 2012 I don't know asys, maybe we have different images of the wound. Next time pics or it didn't happen 608, lol. With that much damage to the trachea, the parts might not line up so that you can intubate. By sealing the wound you may be closing off the only worthwhile airway. Bagging the guy would put positive pressure on the tissues in the airway and could lead to subcutaneous emphysema which may compress the airway more. I think this guy has pretty much given himself a surgical airway, so why not use it. One issue I see with this is the fact that he has violated the platysma. Any of our newer providers want to say why this is a bad thing? EDIT: I didn't do a very indepth search, but I did find this article: http://www.springerl...00/fulltext.pdf Yeah, I think I'd need pics to really make an accurate picture. But from a purely BLS standpoint I think standard of care would say that neck wounds should be handled with an occlusive and normal airway management methods rather than what was done. But if that didn't work, sure, go for it, why not, after of course we contact medical control so we can put all the blame on the physician for what we did.
ERDoc Posted May 4, 2012 Posted May 4, 2012 I don't think in this case there is a standard of care. I don't think you will even find a consensus from physicians. Anyone want to volunteer for a double blinded placebo controlled study?
Kiwiology Posted May 4, 2012 Posted May 4, 2012 so if i understands correctly this bloke has partially severed his trachea? we had a case here about three years ago that stands out as being very similar to this; a guy who was shot thru the neck and in that patient the very brave (or totally fucking insane) Intensive Care Paramedic had a dig around the wound and clamped the trachea together then anaesthetised, paralysed and intubated the patient. despite being totally insane don't expect me to be that brave if the guy has a reasonable SpO2 and is in no immediate (like next few minutes) danger i would be inclined to simple management and quick transport to the surgeons
ERDoc Posted May 4, 2012 Posted May 4, 2012 I think GSWs are a little different. You have no idea how much damage was done or where it was done. Tip of the hat to that fuckingly bravely insane ICP. I had a bad airway in residency. This woman was driving and not wearing a seat belt. I don't remember the details of thee accident but she went neck first into the steering wheel. She comes in coughing up blood to the point it is interfering with her airway (vollies can't RSI thankfully). We knock her down and I put the scope in and all is see is blood. I start suctioning and it keeps coming as quick as I suction it. I'm out at this point and the anesthesia attending takes over. She suctions a lot and adjusts the laryngoscope. Finally she puts the tube in and gets it. I asked her how she could see the cords and trachea and how she did it. She looks at me and says, "I couldn't see anything but blood but I put the tube where the bubbles were coming from." That's why she was the attending.
flightmedic608 Posted May 4, 2012 Author Posted May 4, 2012 (edited) Bloke?,,,,,,,,I assume that means person lol. Yes, Kiwi and I know that my words are not allowing this wound the justice it deserves. It was not an easy decision we made to start down the airway algorithm, but we quickly wieghed options and made our decision. I think the best part of our decision making was the entire thought process of manually securing the airway with gloved hand and kelly clamps prior to attmepting to place an ETT. I think one of the largest worries we had, was the inability to BVM this patient if necessary. I am glad that the person I was working with at the time was someone I had been working with regularily for the two years prior, a lot is said for unspoken communication on scene. Edited May 4, 2012 by flightmedic608
Kiwiology Posted May 4, 2012 Posted May 4, 2012 I had a bad airway in residency when i was a registrar. This woman was driving and not wearing a seat belt being totally fucking retard. I don't remember the details of thee accident but she went neck first into the steering wheel. She comes in coughing up blood to the point it is interfering with her airway (vollies can't RSI thankfully). We knock her down and I put the scope in and all is see is blood. I start suctioning and it keeps coming as quick as I suction it. I'm out at this point and the anesthesia attending consultant anaesthetist takes over. She suctions a lot and adjusts the laryngoscope. Finally she puts the tube in and gets it. I asked her how she could see the cords and trachea and how she did it. She looks at me and says, "I couldn't see anything but blood but I put the tube where the bubbles were coming from." That's why she was the attending. consultant anaesthetist fixed that for you
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