# Glass Ingestion



## RocketMedic (Dec 1, 2011)

A hypothetical...a 15 y/o male has decided to do something silly and eat glass. He managed to chew some and swallow at least two mouthfuls in five minutes before he alerted his family, who called EMS. Upon arrival, you encounter your patient in emotional distress, crying, complaining of 'heartburn' and abdominal pain 10/10, with obvious lacerations and bleeding to the mouth, tongue, and gums. Pulse is 110, strong, and regular, BP is 130/80, R16/regular, lung sounds clear and equal, BGL 100, patient denies any recreational substances and takes antidepressants for depression.

Here's my thoughts- we're worried about shards, and peristalsis is going to push those, but we really don't want our patient moving himself and digging them in more. Thus, I would reckon that full immobilization would be a good idea. Pain management is important, and if possible, I would like to dose our patient with fentanyl or morphine (with respect to his hemodynamic status). GI bleeding is a massive concern, so we're going to need IV access and potentially conservative fluid boluses. Suction for the airway, potential intubation in the event that the patient can't maintain his airway, and rapid transport. Huge, huge concerns for esophageal laceration and potential rupture, as well as tracheal ruptures. However, we really, really need to remember that the ET tube is our only real option- Combitubes and the like would be really bad.

Anything else? This is a bad situation, I reckon...


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## usafmedic45 (Dec 1, 2011)

I wouldn't restrain him unless he was combative.  It's just likely to make things worse.


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## RocketMedic (Dec 1, 2011)

True- would sitting be a better place? I don't really think it matters how he sits, but I really, really wouldn't want him moving from that spot once he finds it.


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## Sasha (Dec 1, 2011)

Why would you immobilize? We really need to get away from the whole "TRAUMA!!!!!!!!! backboard." mentality.

I am sensing a baker act in this guy's future.


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## DesertMedic66 (Dec 1, 2011)

Sasha said:


> Why would you immobilize? We really need to get away from the whole "TRAUMA!!!!!!!!! backboard." mentality.
> 
> I am sensing a baker act in this guy's future.



I don't believe has was under the impression of "OMG its a trauma we have to backboard". I think it was more of a Glass is in the kids stomach so we don't want him moving around alot because that would cause his stomach to move. so if we backboard him he wont have to move at all.


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## Sasha (Dec 1, 2011)

Backboarding is uncomfortable, I'd think they'd move a lot more, considering it's not true immobilization, trying to get comfortable as oppose to being allowed to rest in a position of comfort.

You can move a patient without backboarding them.


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## DesertMedic66 (Dec 1, 2011)

It is easier to move a patient from point A to point B using a backboard. So that would cause for less movement. But on the opposite side as Sasha said the backboard is uncomfortable so the patient would more then likely be fighting the straps which would cause for the abdominal to contract possibly causing more damage.

The draw sheet method isnt exactly the "smoothest" method. The sliding board is possibly a little "smoother". As for me personally, as far as moving the patient, i would use the break-away flat.


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## Sasha (Dec 1, 2011)

With patients who can't ambulate I honestly find using a draw sheet to be the easiest method. Even some of our patients who can ambulate, it's easier to pull them over or do an extremity lift than to take ten minutes for them to stand and then an additional ten for them to pivot.


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## medicdan (Dec 1, 2011)

Agreed. Why not put the patient in a position they are most comfortable in-- have them sit up on the stretcher, and secure them as usual, asking to move as little as possible, then draw-sheet over when you get to the hospital. 
Wise-members-- what other treatments are prudent in this case? Should medics be proactively giving a fluid bolus?


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## RocketMedic (Dec 1, 2011)

My concern isn't anything that a backboard would fix, but I am worried about the glass in the GI tract moving. Our patient writhing on the gurney would do that quite well, and although he can writhe on the board, that's what padding, restraints, and pain management are for. As long as I could immobilize this patient, I'm ok with it. My fear is that he moves and causes a shard to rip something it ordinarily would not have.

Long-term, he'd get endoscoped, and an almost-guaranteed ICU trip. Glass is a horrible thing to try and find in the body, and even removing it is a huge, huge struggle.


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## Handsome Robb (Dec 1, 2011)

I don't see a need for a bolus right this second, I do agree with gaining access so you have it in a pinch. 

Good BP, HR is slightly tachy but I'm guessing this is more from the pain than the patient actually compensating. The fact that he isn't vomiting leads me to believe that he hasn't actually lost that much blood into his stomach *yet*. Now with the potential vomiting from blood in the stomach I'm wondering if a prophylactic dose of Zofran or Phenergan would be appropriate? I know he isn't complaining of N/V but if he is bleeding in his GI tract he very well could start vomiting and with all that glass he swallowed I feel like that would be terribly painful and traumatic on the way back up. What say yee?


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## Sasha (Dec 1, 2011)

Rocketmedic40 said:


> My concern isn't anything that a backboard would fix, but I am worried about the glass in the GI tract moving. Our patient writhing on the gurney would do that quite well, and although he can writhe on the board, that's what padding, restraints, and pain management are for. As long as I could immobilize this patient, I'm ok with it. My fear is that he moves and causes a shard to rip something it ordinarily would not have.
> 
> Long-term, he'd get endoscoped, and an almost-guaranteed ICU trip. Glass is a horrible thing to try and find in the body, and even removing it is a huge, huge struggle.



You do understand though, that backboards aren't true immobilization? Your patient can still move? Have you never seen a drunk fight the backboard and manage to fanagle himself into a position where he could freely sit up?


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## Nerd13 (Dec 1, 2011)

NVRob said:


> I don't see a need for a bolus right this second, I do agree with gaining access so you have it in a pinch.
> 
> Good BP, HR is slightly tachy but I'm guessing this is more from the pain than the patient actually compensating. The fact that he isn't vomiting leads me to believe that he hasn't actually lost that much blood into his stomach *yet*. Now with the potential vomiting from blood in the stomach I'm wondering if a prophylactic dose of Zofran or Phenergan would be appropriate? I know he isn't complaining of N/V but if he is bleeding in his GI tract he very well could start vomiting and with all that glass he swallowed I feel like that would be terribly painful and traumatic on the way back up. What say yee?



Zofran or Phenergan would be one of my first moves I suspect. I am concerned about the traumatic effects of the glass going down but I'm twice as concerned about it coming back up...


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## DesertMedic66 (Dec 1, 2011)

Sasha said:


> You do understand though, that backboards aren't true immobilization? Your patient can still move? Have you never seen a drunk fight the backboard and manage to *fanagle himself into a position where he could freely sit up?*



Ive had patients fight on the backboard but i have never seen anyone get to the point where they could freely sit up on the backboard. We have the D-ring straps that cross over in the center of the chest and then the straps from the gurney itself that adds more straps over the chest (2 shoulder and then 1 lateral strap that goes all the way across the chest.


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## Handsome Robb (Dec 1, 2011)

Sasha said:


> You do understand though, that backboards aren't true immobilization? Your patient can still move? Have you never seen a drunk fight the backboard and manage to fanagle himself into a position where he could freely sit up?



No offense but that sounds like a terrible strap-job. We deal with intoxicated patients on a daily basis and I've never heard of this or seen this happen. 

In this instance, if the patient is writhing around as much as it seems is being implied he needs a hefty dose of fentanyl and if that doesn't make him comfortable I'd be giving him some versed to sedate him as well. Then use a backboard or scoop to move him. Heck at that point you might even be able to get a tube in him, although not the best way to go about it, if his airway truly is compromised.


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## Sasha (Dec 1, 2011)

NVRob said:


> No offense but that sounds like a terrible strap-job. We deal with intoxicated patients on a daily basis and I've never heard of this or seen this happen.
> 
> In this instance, if the patient is writhing around as much as it seems is being implied he needs a hefty dose of fentanyl and if that doesn't make him comfortable I'd be giving him some versed to sedate him as well. Then use a backboard or scoop to move him. Heck at that point you might even be able to get a tube in him, although not the best way to go about it, if his airway truly is compromised.



I'm not sure about the strap jobs, I'm talking about patients I've seen in the ER while dropping off/picking up. I haven't backboarded in probably over a year. Aaah IFT. 

But I have seen patients who are uncomfortable, who work themselves into different positions on the backboard, including someone who's sat up.


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## DesertMedic66 (Dec 1, 2011)

Sasha said:


> I'm not sure about the strap jobs, I'm talking about patients I've seen in the ER while dropping off/picking up. I haven't backboarded in probably over a year. Aaah IFT.
> 
> But I have seen patients who are uncomfortable, who work themselves into different positions on the backboard, including someone who's sat up.



In the ER that might be possible. When we drop off patients who are backboarded the first thing the ER does is remove all the straps and tell the patient to not sit up. 

IFT is weird lol. Im on a BLS unit. We do about 95% IFTs and then other "well i called my doctor because i think i broke my leg and he gave me this phone number to call". So we do get to backboard often.


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## icefog (Dec 1, 2011)

I would try to steer away from morphine - while it may reduce propulsive peristalsis, it considerably increases the intestinal tonus. You'd have to bring in atropine (or something else) to decrease the hypertonicity produced by morphine, but personally I'm not much of a cocktail guy.

I'd go with ketamine for the pain and butylscopolamine for relaxing the smooth muscles and killing the peristalsis.

Large bore IV access is a must, yup, but I'd just keep it open and, in case he's going into schock, just treat it as any other internal bleeding - permissive hypotension, no fluid bolus.


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## Sasha (Dec 1, 2011)

firefite said:


> In the ER that might be possible. When we drop off patients who are backboarded the first thing the ER does is remove all the straps and tell the patient to not sit up.
> 
> IFT is weird lol. Im on a BLS unit. We do about 95% IFTs and then other "well i called my doctor because i think i broke my leg and he gave me this phone number to call". So we do get to backboard often.



Oh no, they're definitely still strapped. 

We do a lot of injuries from falls but I have yet to backboard one. I don't see a point when they've been up and ambulating for 30 minutes after the injury. 

I'd still opt for a sheet pull or extremity lift and a "dont move."

Anti emetics are a good call. 

Sent from LuLu using Tapatalk


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## usafmedic45 (Dec 1, 2011)

Nerd13 said:


> Zofran or Phenergan would be one of my first moves I suspect. I am concerned about the traumatic effects of the glass going down but I'm twice as concerned about it coming back up...


Got any evidence to back up that stance or are you just assuming that all nausea is equal?



> I'd go with ketamine for the pain and butylscopolamine for relaxing the smooth muscles and killing the peristalsis.




Personally, I wouldn't given any anti-emetics or try to screw with gastric motility.  This is one of those "the less you do, probably the better" sorts of cases.  The actual risk from eating glass is pretty low as evidence by most circus freakshows, etc.  The human body's ability to ingest even rather freakish objects with minimal complication is rather amazing.  I had a patient who once ingested a fork.  I'm still trying to figure out how but her claim was confirmed by X-ray.


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## usalsfyre (Dec 1, 2011)

Has anyone thought to look in his mouth and down his throat to see if he's bleeding? Or are we just empirically guessing he's hemorrhaging? 

I'm with usaf. Less is more here. A lot of times we get in the "OMG emergency worst case scenario!!!" mindset when it's just not needed. If he starts to show signs of decompensating, treat. Otherwise benign neglect is probably a good treatment plan.


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## Brandon O (Dec 1, 2011)

usafmedic45 said:


> Personally, I wouldn't given any anti-emetics or try to screw with gastric motility.  This is one of those "the less you do, probably the better" sorts of cases.  The actual risk from eating glass is pretty low as evidence by most circus freakshows, etc.  The human body's ability to ingest even rather freakish objects with minimal complication is rather amazing.  I had a patient who once ingested a fork.  I'm still trying to figure out how but her claim was confirmed by X-ray.



Granted, but -- this is glass we're talking about. It's hard to envision exactly what form it got down in, and I doubt you could swallow it unless you chewed it pretty small, but even quite small pieces of glass can have very sharp edges. I would not be too worried about "grounds," which I'd expect to cause widespread but minor lacerations, but even one piece large enough to have a real edge could be devastating.

The fact that he's still presenting without any frank crashing, having presumably munched his lunch at least 5-10 minutes ago, is reassuring. compared to most of the "potentially unstable" patients we see I'd put him right near the top of the list. Although in most cases I'd agree with a conservative approach, I also want to put on the table the option of a very comfortable medic, with a broad scope of practice and close interaction with medical control, going whole hog -- paralyze and RSI, aggressive analgesia, and any other pharmacology as appropriate to try and reduce gastric motility.

Of course, you could also just park him on the stretcher and haul him off to the ED and maybe 9 times out of 10 that goes well. But remember that the next line in this story could have been, "then he tried to vomit and opened up a six-inch tear in his stomach and died in like ten seconds," and it's hard to say you didn't see it coming. Just some thoughts.

In any case I'd want serious pain management -- just try and imagine this -- and we should certainly be asking the question of why the dude is chewing glass.


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## usafmedic45 (Dec 1, 2011)

"The delivery of good medical care consists of doing as much nothing as possible"-  _House of God_


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## usalsfyre (Dec 1, 2011)

We're RSI'ing a stable kid with no signs of hemodynamic instability because of a "maybe"? 

Not me, thank you...


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## Handsome Robb (Dec 1, 2011)

usalsfyre said:


> Has anyone thought to look in his mouth and down his throat to see if he's bleeding? Or are we just empirically guessing he's hemorrhaging?
> 
> I'm with usaf. Less is more here. A lot of times we get in the "OMG emergency worst case scenario!!!" mindset when it's just not needed. If he starts to show signs of decompensating, treat. Otherwise benign neglect is probably a good treatment plan.



OP stated "obvious lacerations and bleeding to the mouth, tongue and gums" so I just kinda took that and ran with it. 

My statement about antitemetics was more of a question than anything. My thought was if he is bleeding in his mouth like the OP said that blood has to go somewhere, either spat/suctioned out or down to the stomach which could lead to vomiting. I thought about ingestion of caustic substances and the damage they can cause on the way back up, glass seems to have the potential to have the same risks. We can control the bleeding in his mouth but further trauma to the esophagus from regurgitating glass has the potential to cause bleeding that we can't access to control it...


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## usalsfyre (Dec 1, 2011)

How much blood? 

I see your point on antiemetics, but it's going to do damage one way or the other. Sometimes not doing a darn thing is the right action.


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## Brandon O (Dec 1, 2011)

usafmedic45 said:


> "The delivery of good medical care consists of doing as much nothing as possible"-  _House of God_



"They grow to enormous size in this part of France." -- _House of God_

Just throwing out ideas, folks... I'm a big fan of keeping the freak-out radar well-adjusted, but it's also good to remember that "currently fine" is not the same as "stable."


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## Handsome Robb (Dec 1, 2011)

usalsfyre said:


> How much blood?
> 
> I see your point on antiemetics, but it's going to do damage one way or the other. Sometimes not doing a darn thing is the right action.



Wasn't stated, guess I should have asked h34r: In my defense I did say I'd consider a bolus but not at the top of my list with the vitals presented to us.  I did also say analgesia and possible sedation if he remained agitated and squirmy though, doh! Now I'm just running myself in circles.


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## usafmedic45 (Dec 1, 2011)

> "They grow to enormous size in this part of France." -- House of God



Nicely played.  Pass the vinaigrette.   



> but it's also good to remember that "currently fine" is not the same as "stable."



"The only truly stable patients in any hospital are in the morgue."-  Me, paraphrasing my medical director who used to say "You aren't stable until you're ****ing dead."


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## fast65 (Dec 1, 2011)

Brandon Oto said:


> Granted, but -- this is glass we're talking about. It's hard to envision exactly what form it got down in, and I doubt you could swallow it unless you chewed it pretty small, but even quite small pieces of glass can have very sharp edges. I would not be too worried about "grounds," which I'd expect to cause widespread but minor lacerations, but even one piece large enough to have a real edge could be devastating.
> 
> The fact that he's still presenting without any frank crashing, having presumably munched his lunch at least 5-10 minutes ago, is reassuring. compared to most of the "potentially unstable" patients we see I'd put him right near the top of the list. Although in most cases I'd agree with a conservative approach,* I also want to put on the table the option of a very comfortable medic, with a broad scope of practice and close interaction with medical control, going whole hog -- paralyze and RSI, aggressive analgesia, and any other pharmacology as appropriate to try and reduce gastric motility.*
> 
> ...



Ummmm, no. Going "whole hog" on this patient at this point in time is dangerous and irresponsible; performing such invasive procedures based solely on a "maybe" shows a lack of judgement in my opinion. I'm all for looking a few steps ahead and jumping to the "end of the algorithm" when needed, but I just fail to see why you would consider RSIing this kid?

As far as what I would do for this kid, I'm going with a "less is more" approach. I'm going to put him in a position of comfort, establish IV access, and give him an emesis bag. If he complains of nausea, I'll consider some Zofran. I will not be backboarding him, it's going to be unnecessarily uncomfortable for him and if he does start vomiting, I would much rather have him sitting upright than have to tilt the backboard.


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## usalsfyre (Dec 2, 2011)

Brandon Oto said:


> it's also good to remember that "currently fine" is not the same as "stable."


A word here. Early in my career I had a number of "just fine" patients "up and crash" on me. As I progressed in my career I started noticing little things and I can't remember somebody unexpectedly decompensated on me. If some one is having a string of these it tells me they're not assessing very well.


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## Brandon O (Dec 2, 2011)

fast65 said:


> Ummmm, no. Going "whole hog" on this patient at this point in time is dangerous and irresponsible; performing such invasive procedures based solely on a "maybe" shows a lack of judgement in my opinion. I'm all for looking a few steps ahead and jumping to the "end of the algorithm" when needed, but I just fail to see why you would consider RSIing this kid?



Well, if you were going to argue for it (and I'm not exactly advocating this, so I won't), it'd go something like this: at least potentially, the kid now has a blade in his stomach which any movement -- either voluntary or involuntary (peristalsis, vomiting) -- could cause to induce major internal trauma. In that event, your "stable" patient would turn rapidly into a mess, and it'd be nice to have an airway before you had to go swimming in blood to find it. Moreover, the whole matter could have been avoided by removing the "movement" part of that equation and basically turning the guy into an easily-shipped brick.

I can't imagine anyone I know going this route -- it's certainly outside the box. But at the same time, if this kid was on my stretcher I'd have real, legitimate concerns about his continued stability until he left my sight, and I don't know any other way you could convince me that he's low-risk (maybe imaging to confirm no big pieces?).

The whole situation is somewhat comparable to spinal immobilization based on mechanism, which is ironic because I can't stand that. Life's funny.


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## mycrofft (Dec 2, 2011)

*Metacommunicationally speaking*

Anything cutting the mouth  THAT seriously would gash the esophagus, cardiac sphincter, then the stomach pretty darn badly. Pt would be down, screaming, with copious blood and saliva from mouth lacs, alternatively trying to double up on his side and futilely move to a hypothetically more comfortable position. Until he went into shock from peritonitis and pain. Then probably vomit blood.

Knock him out, supine and knees up on the litter, and into the rig, get two large bore lines with your best volume expander, and get to the hospital, where they will cut him open like cleaning a walleye while pumping blood and platelets in. Watch airway or go ahead and intubate.

If I recall, when you insult the GI tract like that actually it tends to go into ileus, does it not?


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## mycrofft (Dec 2, 2011)

*How to swallow forks.*

Fold the handle over towards the tines. Maybe with a little Crisco and ranch on the side.


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## fast65 (Dec 2, 2011)

Brandon Oto said:


> Well, if you were going to argue for it (and I'm not exactly advocating this, so I won't), it'd go something like this: at least potentially, the kid now has a blade in his stomach which any movement -- either voluntary or involuntary (peristalsis, vomiting) -- could cause to induce major internal trauma. In that event, your "stable" patient would turn rapidly into a mess, and it'd be nice to have an airway before you had to go swimming in blood to find it. Moreover, the whole matter could have been avoided by removing the "movement" part of that equation and basically turning the guy into an easily-shipped brick.
> 
> I can't imagine anyone I know going this route -- it's certainly outside the box. But at the same time, if this kid was on my stretcher I'd have real, legitimate concerns about his continued stability until he left my sight, and I don't know any other way you could convince me that he's low-risk (maybe imaging to confirm no big pieces?).
> 
> The whole situation is somewhat comparable to spinal immobilization based on mechanism, which is ironic because I can't stand that. Life's funny.



How do we know he has a "blade" in his stomach? I think it's more likely that he has a number of smaller pieces in his stomach, rather than a number of larger shards that could be described as a "blade". I realize that we're running the risk of lacerating the stomach, however, like you said we can prevent this by reducing movement. In the instance that a laceration does occur, I would imagine it would be a smaller laceration that would cause a gradual leak of the stomach contents into the abdomen, rather than a massive evacuation; as such, I just don't see that causing any immediate airway issues. 

Why do you think you would be intubating through a bunch of blood? Depending on how badly he actually cut up his mouth, I'm gonna say that we can manage that bleeding with a little bit of suctioning, he can probably even manage it by just spitting the blood into an emesis bag.


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## mycrofft (Dec 2, 2011)

*"How long is a piece of rope"?*

The bleeding is not adequately described. Could alsop be a polysurgery addict who cut his gums with a razor blade and claimed to have eaten glass (which is hard to see with X-ray) to get the surgery. A Munchausen. Looking for many surgical scars would be a good idea with any "swallower" just as a data point for the receivers, but "treat the patient", of course.
Most abdominal pain pts want to curl up or at least raise their knees when lain supine. A spineboard might be a differential, see if being placed and strapped supine  with legs flat makes them stop complaining.


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## Sasha (Dec 2, 2011)

fast65 said:


> How do we know he has a "blade" in his stomach? I think it's more likely that he has a number of smaller pieces in his stomach, rather than a number of larger shards that could be described as a "blade". I realize that we're running the risk of lacerating the stomach, however, like you said we can prevent this by reducing movement. In the instance that a laceration does occur, I would imagine it would be a smaller laceration that would cause a gradual leak of the stomach contents into the abdomen, rather than a massive evacuation; as such, I just don't see that causing any immediate airway issues.
> 
> Why do you think you would be intubating through a bunch of blood? Depending on how badly he actually cut up his mouth, I'm gonna say that we can manage that bleeding with a little bit of suctioning, he can probably even manage it by just spitting the blood into an emesis bag.



I agree. If he can swallow the glass it's probably smaller pieces. 

The stomach also isn't tissue paper, it's muscle. I don't think it would be as fragile as you seem to believe. 

Discussing this on with fast and thinking more, I'd probably walk the guy to the stretcher. I highly doubt the little movement from standing and taking a few steps would shred his stomach.

RSI doesn't come with out it's side effects and risks. It's not indicated based on presentation. You don't RSI "JUST in case".


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## mycrofft (Dec 2, 2011)

*Wonder if he  makes a grating noise when he swallows?*

A muscle separated from hydrochloric acid and enzymes and gut contents by flowing mucus. But you are right, no glass katanas erupting from his abdomen.
Going back to the OP, a spine board is probably not the thing to do.


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## Handsome Robb (Dec 2, 2011)

So to further the story. What's gonna happen to this guy for definitive care?


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## Sasha (Dec 2, 2011)

NVRob said:


> So to further the story. What's gonna happen to this guy for definitive care?



Psych hold.


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## the_negro_puppy (Dec 2, 2011)

NRB @ 15 L/m

Full spinal immobilisation

Activate nearest helicopter 




In all seriousness, get the pt comfortable whatever position that may be, give analgesia and transport. Manage any complications as they arise.


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## DV_EMT (Dec 2, 2011)

Rocketmedic40 said:


> Pain management is important, and if possible, I would like to dose our patient with fentanyl or morphine (with respect to his hemodynamic status).



Wouldn't it be good because pain medications are known to cause hypoperistolsis and therefore would slow overall digestion and in turn slow any chance of further damage to the lower GI tract?


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## Dwindlin (Dec 2, 2011)

NVRob said:


> So to further the story. What's gonna happen to this guy for definitive care?



Surgery will get called to admit.  Then :censored::censored::censored::censored::censored: about taking the admission until it goes to another service which they can simply consult to.  Then they will do serial abdominal exams to watch for peritonitis. After a few days whatever poor service had to admit the patient will try to punt to psych, who will also :censored::censored::censored::censored::censored: about it, but they aren't as intimidating as the surgeons and will ultimately shut-up and take the patient.


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## Sasha (Dec 2, 2011)

the_negro_puppy said:


> NRB @ 15 L/m
> 
> Full spinal immobilisation
> 
> ...



Id be really tempted to be more towards "oh it hurts? Well that's what you get for swallowing glass you dumb@ss"

He'd still get pain meds. But seriously.

Sent from LuLu using Tapatalk


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## mycrofft (Dec 2, 2011)

*Laudanum, or paregoric.*

Then bleed the evil spirits out of him.


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## Brandon O (Dec 2, 2011)

fast65 said:


> How do we know he has a "blade" in his stomach? I think it's more likely that he has a number of smaller pieces in his stomach, rather than a number of larger shards that could be described as a "blade". I realize that we're running the risk of lacerating the stomach, however, like you said we can prevent this by reducing movement. In the instance that a laceration does occur, I would imagine it would be a smaller laceration that would cause a gradual leak of the stomach contents into the abdomen, rather than a massive evacuation; as such, I just don't see that causing any immediate airway issues.
> 
> Why do you think you would be intubating through a bunch of blood? Depending on how badly he actually cut up his mouth, I'm gonna say that we can manage that bleeding with a little bit of suctioning, he can probably even manage it by just spitting the blood into an emesis bag.



I agree that the more reasonable outcome is much more likely; I'm describing a worst-case scenario. All I'm trying to illustrate is that we don't actually know what level of risk we're looking at, and can't know, which is always a situation that should make us wary.

As mycrofft mentioned though we should also consider the possibility that there is no glass. The whole history on this one is goofy.


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## usalsfyre (Dec 2, 2011)

At the hospital he'd likely get scoped to asses the damage and then a decision on "what next" would be made.


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## fast65 (Dec 2, 2011)

Brandon Oto said:


> I agree that the more reasonable outcome is much more likely; I'm describing a worst-case scenario. All I'm trying to illustrate is that we don't actually know what level of risk we're looking at, and can't know, which is always a situation that should make us wary.
> 
> As mycrofft mentioned though we should also consider the possibility that there is no glass. The whole history on this one is goofy.



Wary, yes. Stupid, no. 

I agree that we should be examining the situation at different angles and be prepared to handle any problems that may arise. However, we must not allow it to push us to make stupid decisions, and quite frankly, RSI'ing a conscious patient who is able to protect their airway based purely on a "just in case" thought process is just stupid in my opinion.


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## usafmedic45 (Dec 2, 2011)

> I also want to put on the table the option of a very comfortable medic, with a broad scope of practice and close interaction with medical control, going whole hog -- paralyze and RSI, aggressive analgesia, and any other pharmacology as appropriate to try and reduce gastric motility.



I also want to put on the table that you're medical director is likely to put your balls (and cert) in a jar on his desk if you are that "comfortable".


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## usafmedic45 (Dec 2, 2011)

> RSI'ing a conscious patient who is able to protect their airway based purely on a "just in case" thought process is just stupid in my opinion.



Stupid, not to mention pretty much the definition of malpractice.  In some states, it's also assault.


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## Brandon O (Dec 2, 2011)

All right, settle down, angry villagers, I concede.

Thanks to the OP for the scenario, it obviously brings out some interesting issues.


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## usafmedic45 (Dec 2, 2011)

Brandon Oto said:


> All right, settle down, angry villagers, I concede.
> 
> Thanks to the OP for the scenario, it obviously brings out some interesting issues.



No angry villagers.  Just a difference of opinion.  Hell not any hard feelings even....


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## Brandon O (Dec 2, 2011)

usafmedic45 said:


> No angry villagers.  Just a difference of opinion.  Hell not any hard feelings even....



Probably the same opinion, in fact; I'm sure I'd go with a conservative approach myself (although I really would want his pain managed). But it's always mind-expanding to think about options...


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## Tigger (Dec 2, 2011)

usafmedic45 said:


> Stupid, not to mention pretty much the definition of malpractice.  In some states, it's also assault.



If you really wanted to go down this route, you could ask the patient for consent though, right?

That doesn't necessarily make it a good idea of course.


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## Brandon O (Dec 2, 2011)

As a minor, consent would be from the parents. And in any realistic case, buy-in from med control.


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## Veneficus (Dec 2, 2011)

*wow...*

This has been quite an interesting read.

I have a few ideas...

Let's let the kid sit up and hold the suction to his own mouth, start an IV, hang a 1 liter bag and give him some fent and adjust his BP accordingly before driving him over to the local ED.

Once there, the bleeding can be controlled by local epi injection, epi soaked gause, or just plain gause like the dentist uses. 

Then he can have an xray to look for glass, as well as air in the abdominal cavity before sticking a scope down his throat and having an old fasioned "look and see." The endoscope also has a host of amazing attachments that can help. 

By that time, the bleeding and coag labs should be back and will add a few more clues.

Further treatment and referal dependant on what is found.

I would be careful about using serial abd exam for peritonitis. Many old school surgeons withold analgesia to do that, looking for peritoneal pain signs. While rather diagnostic, there is just something about taking a patient in pain and leaving them in pain to see if it gets worse in order to decide what to do next that just doesn't seem right to me.

Even if the above tests are not diagnostic, probably would't hurt to use some prophylactic ab to prevent a peritonitis, as well as and NG tube with an occasional lavage to look for new, or rebleeding that was fixed by endoscopy, from the stomach while doing an occasional hemeoccult test for blood showing up in the rectum.

Maybe go low tech and just watch vital signs, urine output, and serial platelets and coags.  

If serial exam is the way you want to go, perhaps serial ct looking for gut inflammation or distention. If you really want to to take it to the edge, a nonbarium oral and rectal contrast CT.

With the initial description given, it doesn't scream emergent laporotomy.

Or even the need for blood products at this point.

As soon as the kid is medically cleared, punt to psych. Not even worth bothering them for a consult at this point. They can put him on whatever flavor of psych med they like and adjust it later.


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## mycrofft (Dec 2, 2011)

*And/or emergency laparotomy.*

Had a guy simulate and alleged he had a glass tube broken in his urethra once...h34r:


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## Veneficus (Dec 2, 2011)

mycrofft said:


> Had a guy simulate and alleged he had a glass tube broken in his urethra once...h34r:



yea, my typing and spelling sucks. I know.

I should probably work on it, but i won't.


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## mycrofft (Dec 2, 2011)

*V, that wasn't a suggestion for misspelling punishment*

Honest!


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## MedicPatriot (Dec 18, 2011)

Honestly I probably would just provide them with a quick transport to a place that has greater surgical capabilities than I do. I would also consult w/ MD regarding medication advice. I do think Zofran would be appropriate but tbh I have a hunch that anti-nausea meds aren't going to do much if the GI really wants to get something like that out of itself.


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## usafmedic45 (Dec 18, 2011)

> Honestly I probably would just provide them with a quick transport to a place that has greater surgical capabilities than I do.



The thing is that this is not likely a surgical emergency.  This is one of those situations where people need to remember that you should never allow your heart rate to get higher than that of your patient (except at a cardiac arrest obviously).


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## Bosco578 (Dec 18, 2011)

Yup, but in my system rapid transport = *****y triage RN who will make the patient wait in the hallway with EMS  as they have no beds,have not had their breaks, are cold,tired,over worked.....blah blah blah, so much for patient care first........:unsure:


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