Shotgun to the face

[Lacrosstitute]

Ok residents and staff/PP docs, I wanted to post a relatively interesting airway case-

Background: currently training at larger level 1 trauma center in Midwest. Anesthesia is paged to all traumas that come in simply for airway reassurance in case ER residents/staff can't secure airway or seems hairy in the first place.

Scenario: On senior call a few months ago, get paged on the trauma pager: "middle aged male, self inflicted GSW to head, ETA 5-10min." Now I have been to these before and seen a handful of GSW's to the head that have failed suicide attempts, and for the most part they are straightforward. This day was a bit different. In our dept, anesthesia senior on call always carries a bag of airway type goodies for floor intubations/codes, etc. This day, out of the blue, after receiving the page I decide to grab a retrograde wire and add it to the kit...you know....for the "oh shizzz" situations.
On arrival to the ER this dude takes me by surprise. Turns out he was being chased by the cops, goes poorly and gets caught in a ditch and decides to end his life right there with the shotgun he has in his car....pointing from chin upward. Guy rolls in on the paramedic stretcher awake, on all fours, bleeding profusely from his face.......his face mind you, is splayed COMPLETELY open. Think the scene when Arnold meets the Predator for the first time face to face, Predator takes off his mask and roars. Thats this guys face. HIPAA would have nothing if I posted a picture...unless you can identify people by their eyebrows. Get him on the trauma bed, get report, cops presume he is highly intoxicated (meth, PCP, EtOH, whatever this guys drug of choice), on closer inspection this guys mandible is GONE, likely back in the ditch with his car, but busted up maxilla is still there from the looks of things. The dude is completely unreasonable, can't control him and he is coughing up tons of blood every other breath. Even tying all his limbs down with restraints he continues to squirm and trying to break free. BP is high and sats on arrival are 89%

My question to all you readers is how would you attempt to safely secure his airway? Hopefully this becomes a fun discussion.

Oh and I only mention the fact that I got the retrograde wire for its use in difficult airways cases, never have used one in real life and didn't on this guy simply because he was uncontrollable, thrashing around and couldn't be reasoned with.

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[IlDestriero]

I actually had a few of these during my military days. I went straight to surgical cricothyroidotomy. Do not pass go, do not collect $200. Me on the airway, surgeon cutting down femoral lines, techs/nurses checking and hammering blood in existing PIVs. Though none of my patients were conscious.

 

[deleted171991]

I agree with IlDestriero.

The main question is how to sedate him safely, while maintaining airway reflexes and spontaneous breathing. Ketamine? Dex? Haldol? The former and the latter can be given i.m. for sure.

 

[IlDestriero]

Combative unstable trauma patients get Scop, sux +/- ketamine and an apology, if they survive.
We paralyzed and intubated so many patients just because they were uncooperative.
"Calm down man..."
"Fuçk it, tube him."
Every day.

 

[Arch Guillotti]

Classic case of "buyer's remorse". Gun slips forward enough to blow his face off but not to kill him. Sedation may be very difficult. Probably needs a surgical airway.

 

[sevoflurane]

Classic case of "buyer's remorse". Gun slips forward enough to blow his face off but not to kill him. Sedation may be very difficult. Probably needs a surgical airway.

Yup. Sometimes the action of pulling on the trigger makes the shotgun blast move more anteriorly on the face... missing it's intended target. This thread birngs back memories of several cases in my career.

 

[sevoflurane]

EDITED

 

[pgg]

Sevo, isn't that the guy who bit a blasting cap?

Guy rolls in on the paramedic stretcher awake, on all fours, bleeding profusely from his face

[...]

Even tying all his limbs down with restraints he continues to squirm and trying to break free.

Presumably he came in on all fours because laying supine he'd drown in his blood - did you then restrain him supine? Just curious how you got from point A to B in the preamble here.

Suction, another suction, another if you can, some ketamine, surgical airway. Fun stuff.

 

[Sublimazing]

We had one a couple months ago...exactly same thing. I was on airway so I was standing by ready to cric. An awake nasal fo was tried (our guy was actually compliant)...then it was realized (and if you look at this pic you'll see the same) you can just pull his tongue forward and see cords.

But yeah...this is a surgical airway otherwise.

 

[Planktonmd]

Sometimes bubbles are very helpful in finding the right hole!

 

[michigangirl]

I love bubbles. Its like a marquis in lights saying "go here friend!"

 

[Noyac]

Wet the pump.


Kidding somewhat.

 

[Lacrosstitute]

Great replies so far, thank you. My thoughts going through my head at the time were many of these exact posts. Honestly Sevo....you're not far off with this picture you posted, except the guy on that night only had a stub left for a tongue. First thing was getting this guy supine without collapsing his airway and having it clogged completely. Got him sitting upright on his butt and leaning forward which helped him out. Really no way to pre-oxygenate this combative guy and we all know there was no ability to mask the mush he had remaining above his clavicles, if it truly came down to that. Thankfully a nurse slammed in a working IV for us to use.
Im sure I'm like many other senior residents in the manner of thinking about scenarios like this (or other drastic ones) and mentally mapping out a plan of attack and discussing it with others during boring cases or simply outside of the OR with colleagues. Fortunately I had thought to myself before......"what am I going to do in the future when I'm all on my own and someone comes in with no face"......certainly an odd thought, I know.
So here is how it went down: Fortunately we had people with helping hands. We had this guy sitting up, O2 mask in front of him (while his extremities were restrained) at 15L. Trauma surgery gowned and gloved for emergent cric/trach if needed. Another resident ready for large femoral vein cannula. Iodine to the neck. Soft suction catheter lodged in his wide open mess of a face, another yankaur suction in hand to assist in what the permanent one didn't get. Had another experienced resident ready to DL while I gave 150mg IV Ketamine and had gauze ready to grab the remaining tongue nubbin to facilitate DL. Back up plan....let surgeon slash the neck. Once ketamine in, laid him back to 30-45 degrees. Told the other resident to put the tube where he saw bubbles. Patient took another breath in and I pushed hard on his chest during exhalation and bam.....full on bubbles come from the trachea up through the now rapidly filling cavity of blood. Tube goes in, suction through ETT as best as we can, hook up to O2 bag. Bilateral breath sounds and positive capnography. Use an ICU ETT stabilizing device while I suture the ETT to some semi stable skin flap for reassurance. Off to CT to get scanned.
Only thing I might have changed would see if he would have potentially tolerated some lidocaine injection to the trach site to see if awake trach by surgery team was even going to be feasible.

 

[Arch Guillotti]

Strong work.

Magill forceps can also be used to grab the tongue nubbin.

Pushing on the chest to force bubbles out is a ROKKSTAR move!

 

[ThoracicGuy]

Sevo, isn't that the guy who bit a blasting cap?




Presumably he came in on all fours because laying supine he'd drown in his blood - did you then restrain him supine? Just curious how you got from point A to B in the preamble here.

Suction, another suction, another if you can, some ketamine, surgical airway. Fun stuff.

No, this guy shot himself in the face after an argument with his gf. He was found leaning against a fence post awake. Ems had to bring him in sitting up so he was able to breathe.

 

[Noyac]

Looks like a Mallampati 1

Your wrong. That's a "0"

 

[sevoflurane]

Nice case. I'd actually make him a MP (-1) for lack of features.

 

[HenryH]

I'm not sure why I'm wanting to ask this, but after the injury... heals, what do these patients tend to look like? Does a follow-up, get-it-right-this-time suicide attempt typically occur in the months after?

 

[sevoflurane]

Years of reconstruction. Face prosthesis.

Depression can make some get it right I'm sure.

 

[Cytarabine]

I'm not sure why I'm wanting to ask this, but after the injury... heals, what do these patients tend to look like? Does a follow-up, get-it-right-this-time suicide attempt typically occur in the months after?

A good percentage of failed suicides don't reattempt. I think it's the majority. I imagine it would be higher in these patients, but that's only a guess

 

[G0S2]

I would just slap a wound vac on it.

 

[BuzzPhreed]

I had a case like this during residency. .38 special to the face. The ole "under the chin" instead of "inside the mouth". You have to point the barrel at your brainstem to be successful.

Patient's face looked like a starfish. Argued with the trauma attending in the trauma bay (next to my very passive attending) and eventually got the emergency surgical trach done there. Could've put a tube in. There was nothing to secure it to.

Plastics/ENT actually put the guy back together pretty nicely. He died in the trauma ICU about 10 days later. Elderly. Lots of co-morbidities. Guess he got his wish. Just took a little longer than expected.

 

[Ronin2258]

Looks like a Mallampati 1

When I was doing surgery, our trauma attending advocated just that, if for anything just to secure the airway quickly. ENT could then use the tube as kind of a landmark to start face reassembly. He will need a trach in the long run, but in the trauma bay and for stabilization I would not have a qualm about going from above in this situation.

The only question would be how destroyed the epiglottis is.

 

[SouthSideSteve]

Pent, sux, tube.

 

[sevoflurane]

Pent, sux, tube.

I hope this is a joke... which I'm sure it is.

So what happens when you try and follow the bubbles and you can't get through the cords cuz you can't see anything but hamburger... and then sedation with a full stomach leads to some MCD's on the cords and laryngospasm?

Can you effectively ventilate this patient in that situation? Questions you need to ask yourself if you are to sedate a patient that looks like this with a "follow the bubbles protocol".

I'm putting this out there just for completion of this thread only cuz I've seen 3 self inflicted GSWs to the face and one was a cric from the get go- bubbles coming out of a sea of blood and hamburger made of mandible, hard and soft palate + a vascular injury. It went easy with the cric and it put the patient at minimal risk.

I guess the point is... just cuz you see bubbles doesn't mean you're gonna hit a home run. They are certainly helpful when you see them though... at the least, it means your patient is exchanging from somewhere.

 

[VisionaryTics]

I'm not sure why I'm wanting to ask this, but after the injury... heals, what do these patients tend to look like? Does a follow-up, get-it-right-this-time suicide attempt typically occur in the months after?

I'm an ENT resident, and my program has a collection of these patients. We see them constantly, and every resident knows them well.

It's a multi-step process. We generally start with trach/PEG, wound debridement and washouts, plating of what bone is left, and local flaps to cover what can be covered. After this, they are generally very disfigured: eyes gone or orbits completely destroyed, palate gone, huge defects in mandible, tongue gone. We start with the eyes, and focus on creating solid bony orbits with bone grafts and plating. Then we reconstruct mandible, usually requiring big free flaps. Then we reconstruct midface, usually requiring more free flaps. Then local tissue arrangement, scar release and revision, etc to get eyes closing, tongue moving, oral competence, etc.

We have psychiatrists involved early, and we do not operate on patients who can't handle a free flap. It's hard to communicate to patients how big of an operation a major reconstruction can be (20+ hours in OR, 2-3 free flaps, etc), and how much post-op care there will be. Most patients require regular psychiatric care, but do well afterwards (no further suicide attempts). We have one who we will not operate on until he is compliant with psychiatric care. We have not had a patient "finish the job" (I asked attendings about this).

In terms of what they look like, never great. Some have reasonable function (not trach or PEG dependent, decent speech skills), but most have some type of deficit.