Glass Ingestion

[usalsfyre]

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.

 

[Brandon O]

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.

 

[usafmedic45]

"The delivery of good medical care consists of doing as much nothing as possible"- House of God

 

[usalsfyre]

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

Not me, thank you...

 

[Handsome Robb]

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...

 

[usalsfyre]

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.

 

[Brandon O]

"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."

 

[Handsome Robb]

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.

 

[usafmedic45]

"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."

 

[fast65]

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.

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.

 

[usalsfyre]

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.

 

[Brandon O]

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.

 

[mycrofft]

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?

 

[mycrofft]

How to swallow forks.

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

 

[fast65]

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.

 

[mycrofft]

"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.

 

[Sasha]

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".

 

[mycrofft]

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.

 

[Handsome Robb]

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

 

[Sasha]

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

Psych hold.