Airway Case!

[The Bunny]

Names have been changed to protect the innocent.

An otherwise young, athletic, and healthy woman is brought to the trauma bay by EMS with GSW's to the neck and right leg.

Exam: Vitals 150/90, 100, 25, 99% on 100% O2. GCS=15. C-collar. One entrance/exit wound left lateral neck, one entrance/exit wound right neck, both oozing blood. Clear lungs, coarse upper airways sounds. Hoarse voice. Anterior neck and chest subcutaneous emphysema. Right leg bullet wound. No other positive findings.

Radiographic exam suggests tracheal injury at the level of the cricoid.

What to do? What to do?!

I'll post what was actually done later.

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[InGasWeTrust]

Awake FOI with bronchoscope if available.

Obviously the airway needs to be secured, it appears this is an urgent need and not emergent. If emergent procede to RSI w/DL or cric/trach and pray for best.

Tell pt. what the plan is, use judiscious topicalization. Procede with FOI. It is good to have video capture to asses for injuries as you procede thru the trachea.


Interesting this almost exact same scenario happened a few weeks ago while I was on call. Patient tolerated it well, injuries were identified and documented, and airway was secured.

I have seen 2 of these get messy, as you have to locate the injury in the trachea to make sure you are "in the trachea", who cares if the tube passes the cords if the distal end of the tube goes through the injury site. So even a cric/trach cannot guarantee a secure airway, I have seen this first hand.

 

[Noyac]

Awake FOI with bronchoscope if available.

Obviously the airway needs to be secured, it appears this is an urgent need and not emergent. If emergent procede to RSI w/DL or cric/trach and pray for best.

Tell pt. what the plan is, use judiscious topicalization. Procede with FOI. It is good to have video capture to asses for injuries as you procede thru the trachea.


Interesting this almost exact same scenario happened a few weeks ago while I was on call. Patient tolerated it well, injuries were identified and documented, and airway was secured.

I have seen 2 of these get messy, as you have to locate the injury in the trachea to make sure you are "in the trachea", who cares if the tube passes the cords if the distal end of the tube goes through the injury site. So even a cric/trach cannot guarantee a secure airway, I have seen this first hand.

How are you going to see anything with blood everywhere when you do FOB? Are you hoping to find your way to the carina or further with the FOB?

 

[InGasWeTrust]

How are you going to see anything with blood everywhere when you do FOB? Are you hoping to find your way to the carina or further with the FOB?

Noy,
If you use a bronchoscope your field is both larger and clearer, in addition you can suction and irrigate. With just the intubating fiberoptic, you cant.


You are looking for a few things
1. The trachea...obvious
2. Where is the injury? Bleeding? Bullet?
3. Carina

 

[Noyac]

Noy,
If you use a bronchoscope your field is both larger and clearer, in addition you can suction and irrigate. With just the intubating fiberoptic, you cant.


You are looking for a few things
1. The trachea...obvious
2. Where is the injury? Bleeding? Bullet?
3. Carina

Yes
I missed the bronchoscope part. That was the second screw-up this morning. I always knew that I wasn't a morning person but this is starting to get scary.

 

[militarymd]

STP, SUX, DL, tube....trauma surgeon holding a scalpel, ready to go in case you screw up.

 

[The Bunny]

To continue....

The patient is transported to the OR by the trauma/ENT team. She is placed carefully on the OR table, monitors applied, O2 continued. No medications given. Vitals and exam unchanged.

The FOB idea was rejected for the reasons mentioned above. Plan for awake tracheotomy. C-collar is removed and in-line stabilization maintained. ENT team preps neck and performs laryngeal and local blocks. Patient remains stable.

The patient suddenly becomes more agitated. Airway sounds quickly become louder and more "wet." She gasps, "I can't breathe." She becomes even more agitated and starts to thrash about, silently. Fresh blood now spurts from the neck wounds, mouth, and nose, splashing everyone's face shields.

Now what?!

 

[InGasWeTrust]

Ill assume worse case scenario for funsies.....

An urgent airway has now become emergent therefore slice the neck and place tube

Points to consider if available/time/access
1. IM Sux....I know it takes a while, but it is easier to slice a non-moving bloody neck than a moving one

2. IM ketamine.....2 birds one stone

3. Brutane....yep, just jam a wad of 4x4's in the mouth and pin the pt. to the OR table

I assummed no access was present, you have a "nightmare" scenario in the perfect location with the perfect personnel, it is now time for everyone to execute....... albeit under a wee bit of pressure


Why not an awake FOI? Just seems that would be the go to plan sans not having the equipment ready.......

 

[militarymd]

STP, SUX, DL, tube....trauma surgeon holding a scalpel, ready to go in case you screw up.

___________________

 

[The Bunny]

The ENT team proceeds immediately with emergent tracheotomy. The patient thrashes even more. IV Succinylcholine, 100mg. The patient stops moving. Bleeding continuues briskly from mouth, nose, and neck. Suction. ENT team continues to work, and finds tracheal deviation, large hematoma. Propofol, 60mg. Pulse oximeter is now unreliable but shows readings below 70%. ENT continues working.

Laryngoscopy from above with a Bullard scope. Copious blood suctioned. Cords visualized after two attempts, 6.0 uncuffed ETT placed. +ETCO2, but with large leak. Changed to 7.0 cuffed ETT over a flexible stylett.

Tracheotomy continues under general anesthesia and is successful. The patient eventually goes on to have tracheal, esophageal, and vascular injures repaired.

 

[mysophobe]

Post-op care includes changing your shorts.