# Continuous Facial Bleeding with CSpine



## ChewyEMS13 (Feb 15, 2018)

Hey y'all. I've got a little scenario that came across my mind. I don't know how common it is (or we practical/possible) but humor me. Let's say there was serious trauma to the face or neck with the need for spinal immobilization. The bleeding keeps filling the upper airway and you continue to suction. My question is, what if a pt is on a backboard and needs spinal immobilization? Do you let them vomit/fill with blood and then suction? Do you roll the backboard so it is on its side? If they continue to vomit/bleed, do you transport with the backboard on its side? Just something that went through my mind. Thanks!


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## DesertMedic66 (Feb 15, 2018)

Patients should not be on backboards at all. Our protocol is to only use a backboard to move them to the gurney and then immediately take them off of it. 

If for some reason you have to backboard someone who is like this I would say to make sure the straps are secure, padding any voids, roll the backboard slightly and have continuous suction going. 

A patient who has severe bleeding that is creating an airway compromise will likely be RSIed.


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## rescue1 (Feb 15, 2018)

First off, the backboard is on its way out--it has no evidence of benefit to patients and, as you can clearly see with your example, lots of ways it can harm a patient. So hopefully you never actually have to use on in the field.

However, if you're in a system where you still have to backboard people, you are correct that you'd roll them on your side ASAP and suction from that position (don't wait for anything to fill up!). Airway > c-spine every time. 

To be honest, a trauma patient with an airway that ****ty needs to be intubated, sooner rather than later. If you work in an ALS system this patient would be tubed to secure the airway and could then be transported supine. Otherwise, yes, I'd transport them on their side to some extent while suctioning. I'd probably take them off the backboard though, even if they are in your protocols.


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## ChewyEMS13 (Feb 15, 2018)

Yeah, I agree. I'm in EMT-B class, and on the facial trauma chapter. They are_ very _adamant that any pt suspected of spinal injury should be c-collared and backboarded. And I agree that they would be intubated.. I admit I was tunnel visioned reading my emtb book; it never involves ALS interventions. It almost assumes you're on your own the whole scenario


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## rescue1 (Feb 15, 2018)

ChewyEMS13 said:


> Yeah, I agree. I'm in EMT-B class, and on the facial trauma chapter. They are_ very _adamant that any pt suspected of spinal injury should be c-collared and backboarded. And I agree that they would be intubated.. I admit I was tunnel visioned reading my emtb book; it never involves ALS interventions. It almost assumes you're on your own the whole scenario



My EMT class was adamant about a lot of things that were 100% wrong haha. It's unfortunately part of the joys of EMS education. 
There are definitely 911 systems that have few or no ALS resources though, so it's a good question to ask.


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## CALEMT (Feb 15, 2018)

Whats going to kill them quicker? A _possible_ cervical spine injury? OR a compromised airway?


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## VentMonkey (Feb 15, 2018)

CALEMT said:


> Whats going to kill them quicker? A _possible_ cervical spine injury? OR a compromised airway?


A compromised airway as a result of a _possible_ cervical spine injury.


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## ChewyEMS13 (Feb 15, 2018)

CALEMT said:


> Whats going to kill them quicker? A _possible_ cervical spine injury? OR a compromised airway?



Exactly. That's what I'm assuming. If a pt is responsive, can an advanced airway intubation be used, or does a pt have to be unresponsive to get one. It may be improbable, but the image I have in my head is a responsive pt with continuous blood flow to his upper airway. If you can't intubate a responsive pt, the "answer" would still be the recumbent pos.?


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## CALEMT (Feb 16, 2018)

VentMonkey said:


> A compromised airway as a result of a _possible_ cervical spine injury.



I didn't ask the almighty whirly bird paramagician... 



ChewyEMS13 said:


> If a pt is responsive, can an advanced airway intubation be used, or does a pt have to be unresponsive to get one.



Try stuffing your finger down your throat and see if you can do it without gagging. Thats essentially an intubation in a nutshell. With the exception of inducing patients, they have to be unresponsive. 



ChewyEMS13 said:


> If you can't intubate a responsive pt, the "answer" would still be the recumbent pos.?



In layman's terms, yes. In EMS it's going to vary on what your assessment findings are, your index of suspicion for c spine injury, what level of c spine precautions you have them in, and how many hands you have at your disposal in the back of the rig.


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## ChewyEMS13 (Feb 16, 2018)

CALEMT said:


> your index of suspicion for c spine injury, what level of c spine precautions you have them in



So when desertmedic said that backboards are on the outs earlier, does that include c-collars? Are some cases of cspine imobil. okay with just a c-collar? The whole idea of spinal imobil. is just down right confusing to me. Plus, different companies have different protocols, so I'm starting to wonder now if it doesn't even matter if I have to follow a certain company's protocols. I may not want to use a longboard, but I might have to with Ambulance Company X, correct?


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## CALEMT (Feb 16, 2018)

When in doubt no one is going to fault you for following your local (county and/or state) protocols.


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## ChewyEMS13 (Feb 16, 2018)

For sure. Thanks for the tips! Much appreciated


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## EpiEMS (Feb 16, 2018)

@ChewyEMS13 

Couple of considerations as a BLS provider:
 - Airway is number one for this kind of situation. Roll 'em, suction, do what you have to. I would expect that the appropriate NREMT answer would be "Position the patient on their side, suction the airway, and provide rapid transport."
 - Backboards are basically done, except for patient *movement*



CALEMT said:


> Try stuffing your finger down your throat and see if you can do it without gagging. Thats essentially an intubation in a nutshell. With the exception of inducing patients, they have to be unresponsive.








The self-intubation starts around 2:58 
(Caveat: Lidocaine was involved)


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## CALEMT (Feb 16, 2018)

EpiEMS said:


> The self-intubation starts around 2:58
> (Caveat: Lidocaine was involved)



I knew this video would come up. He’s like the 0.1% that can do that to themselves. Plus he cheated with Lidocaine lol.


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## EpiEMS (Feb 16, 2018)

CALEMT said:


> I knew this video would come up. He’s like the 0.1% that can do that to themselves. Plus he cheated with Lidocaine lol.



I frickin' love this video. I show it to *everybody*.

Another other good one is Larry Mellick just missing a self-intubation.


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## hometownmedic5 (Feb 16, 2018)

The awake intubation isnt relevant here. That doctor didn’t “cheat” by using lidocaine, but it isnt fair to compare that procedure to intubating an awake, terrified, airway compromised patient with facial trauma(or any trauma really). While that procedure is awesome, it doesn’t have bearing on this conversation.

The patient halfway presented here needs to be intubated. Until that’s possible, maintain the airway as best you can with position, suctioning, airway adjuncts as tolerated. If they must be secured to a board, then yes they are going to need to be rolled, which is going to require padding and such.

Everybody who can read knows backboards are more harmful than beneficial and those of us who work in states that recognize this on a protocol level rejoice. However, there are states and counties and such that haven’t yet caught on. It’s not this students fault that their local ems system still requires this crap and that as a result, the schools are still teaching it. Someday, they will be dragged into modern medicine, but for today this is what has to be done.


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## ChewyEMS13 (Feb 16, 2018)

@hometownmedic5 

So just for clarification, disregarding protocols in a purely hypothetical situation where I could do _anything _I wanted, a pt with a spinal injury can still be rolled onto his side without detrimental effects?


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## Jim37F (Feb 16, 2018)

My (new) county still uses backboards for full SMR transports....their answer is to tilt the entire board w/ patient onto the side (padding with towels and/or blankets to keep the board inclined ~30° (per the book, no one is actually trying to measure the angle beyond eyeballing it) and more towels blankets to pad the patient themselves).

The medics here can also "PATI" (Pharmaceutical Assisted Tracheal Intubation) and this case sounds like one they'd be quick to pull that trigger on.


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## ChewyEMS13 (Feb 16, 2018)

@Jim37F 

It just seems like local protocols are going to be the word of ems god whether I want to use a backboard or not, or what other ems professionals say. While the backboard may be on the way out, as @CALEMT started, it all boils down to protocol and medical direction


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## CALEMT (Feb 16, 2018)

EpiEMS said:


> Another other good one is Larry Mellick just missing a self-intubation.



Ironically I just watched an old video of him cardioverting a flutter. Love his channel.


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## EpiEMS (Feb 16, 2018)

hometownmedic5 said:


> While that procedure is awesome, it doesn’t have bearing on this conversation.



Totally, just made me think of a fun video - it's so awesome 



Jim37F said:


> The medics here can also "PATI" (Pharmaceutical Assisted Tracheal Intubation) and this case sounds like one they'd be quick to pull that trigger on.



Any idea what pharmaceuticals? Are they using a paralytic?


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## VentMonkey (Feb 16, 2018)

EpiEMS said:


> Any idea what pharmaceuticals? Are they using a paralytic?


I was curious as well, so I looked at their protocols. It looks like Etomidate and Succs. There’s no alternative paralytics listed, and their backup sedative in-lieu of Etomidate is Versed.


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## Jim37F (Feb 16, 2018)

EpiEMS said:


> Any idea what pharmaceuticals? Are they using a paralytic?


This is a pic I took of their "cheat sheet" posted in the ambulance: 
	

		
			
		

		
	






None of the crews I was with on my ride alongs did this, but a few other classmates said their medics did PATI a patient or two (the only intubation attempt on mine was for a cardiac arrest patient ...medic made 1, maybe 2 attempts ata tube befire letting his EMT partner drop a combitube instead)


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## EpiEMS (Feb 16, 2018)

VentMonkey said:


> I was curious as well, so I looked at their protocols. It looks like Etomidate and Succs. There’s no alternative paralytics listed, and their backup sedative in-lieu of Etomidate is Versed.



Ahh, should've thought of that. I didn't see any BLS protocols for Hawaii's services when I looked, just ALS.



Jim37F said:


> .medic made 1, maybe 2 attempts ata tube befire letting his EMT partner drop a combitube instead



You know, that reminds me, I heard somewhere that the EMTs in Hawaii were all actually AEMTs. Any truth to that?


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## Jim37F (Feb 16, 2018)

I know their state scope is higher than National Model, and they start IVs, beyond that I'm honestly not 100% sure what the state EMT scope is lol....they did me tion AMR has EMTs, AEMTs, Paramedics, and CUT Nurses though, and will run BLS/ILS/ALS/CCT units (City&County EMS runs 1 and 1, EMT and Medic, though 2 medics can work together.....Fed Fire is the only other ambulance provider on the island, I think they're dual fire medics)


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## RocketMedic (Feb 17, 2018)

Also, KED


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## EpiEMS (Feb 17, 2018)

@Jim37F gotcha - I’ll have to try and dig up some protocols on that!


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## MSDeltaFlt (Feb 25, 2018)

RocketMedic said:


> Also, KED



Exactly.  We're overlooking the BLS provider who is asking a BLS question on the BLS forum lobby here.

Rocket hit the nail on the head.  "Spinal restrictions" (there is no such thing as "spinal immobilization" unless a neurosurgeon uses a torque wrench to place a Cervical HALO on someone who has a significantly fracture cervical spine to prevent subluxation - believe me I know first hand) does NOT require all four limbs.  In other words, you can use a KED or some other form of short spine board and sit them up.

Now if your assessment reveals an obviously fractured pelvis, then you're stuck using the long spine board and you'll have to log roll them to one side.

Now for those of us who have been doing this WAY before the invention of Spider Straps here is a best practice idea to TRULY secure them to a long spine board.  This is way better than spiders or Kerlix(roll gauze).  3 inch tape.

Wrap 3 inch tape all the way around the patient and the spine board.  First at under the armpits because you will need a free arm for blood pressures.  Then the pelvis.  Then wrapping around the head and C-Collar.  Then the lower extremeties.  3 inch silk tape is not likely to cause a skin tear.  Definitely do not use duct tape.

I say 3 inch silk tape because it is wide enough and wrapped around the entire patient is strong enough that even a morbidly obese patient can be flipped facing the ground and not move even an inch.


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## Emily Starton (May 21, 2018)

I've watched the video and i also loved it.


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## NPO (May 22, 2018)

My service specifically recommends having the patient lay prone with their head hanging off the end of the mattress (if they are conscious). It allows for natural draining of the airway. Good for people who shoot off their jaws with a gun or firework or something like that.


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## EpiEMS (May 22, 2018)

NPO said:


> My service specifically recommends having the patient lay prone with their head hanging off the end of the mattress (if they are conscious). It allows for natural draining of the airway. Good for people who shoot off their jaws with a gun or firework or something like that.



Overlooking the practical Be-Lifting-Stuff* considerations here of "Aw, darn, now I have to clean up all that blood!"


*Alternatively, Be Cleaning & Lifting Stuff (B*C*LS  )


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## NPO (May 22, 2018)

Subjectivity, it's easier to clean the floor than the gurney.


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## EpiEMS (May 22, 2018)

NPO said:


> Subjectivity, it's easier to clean the floor than the gurney.


True that. And I can always put down a bucket!


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## NPO (May 22, 2018)

EpiEMS said:


> True that. And I can always put down a bucket!


Also, that little bit about having an open and patent airway is pretty cool too.


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## VFlutter (May 22, 2018)

If a patient truely has massive nasopharyngeal hemorrhage to the point of getting intubated then put the largest tube you can get in. Place a bougie and go for a 8.0/8.5. They will be coughing up clots for days and getting multiple bronchs or tube exchanges for occluded ETT.


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## inthefield (Jul 6, 2018)

What about putting on the collar, putting the patient on the backboard, and manually holding the patient while elevating one side of the backboard and suctioning? In theory you may be able to have the blood drain away from the mouth.


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## Sipps (Jul 26, 2018)

What about the lateral trauma position that we have been using in Norway? Can't post links since this is my first post


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## Carlos Danger (Jul 26, 2018)

ChewyEMS13 said:


> Hey y'all. I've got a little scenario that came across my mind. I don't know how common it is (or we practical/possible) but humor me. Let's say there was serious trauma to the face or neck with the need for spinal immobilization. The bleeding keeps filling the upper airway and you continue to suction. My question is, what if a pt is on a backboard and needs spinal immobilization? Do you let them vomit/fill with blood and then suction? Do you roll the backboard so it is on its side? If they continue to vomit/bleed, do you transport with the backboard on its side? Just something that went through my mind. Thanks!



An actual airway compromise always trumps a potential spinal insult.

Turn them on their side or even completely prone. Put the stretcher in a little t-burg. If they are breathing well, that may be the only prehospital intervention they need.


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