Airway Management for facial trauma

[EMSpassion94]

Traffic Accident, head on collision. Driver was unrestrained. 5 patients total, including the driver. Driver was ALS, other 4 were BLS. I grabbed c-spine on the driver, so I didn't get to see or assess his injuries, due to being in the back seat. Oh, guy is completely unconcious, by the way. AIC summoned the portable suction. Medics arrived from other company. Rapidly extricated him, which still having c-spine, is when I saw his face. Large laceration from an inch below his left eye, through his cheek, lip, teeth, and roof of his mouth. Everything was splayed open, and 6 or 7 of his bottom teeth were knocked father back into his mouth, hanging barely on by his gums. All of this was causing TREMENDOUS hemorrhage and serious airway compromise. By this time, another FF already had control of suctioning, but I didn't see them pulling the yaunker back out at ALL. I was always taught to suction less then 15 seconds. I advised her of this, and she removed the suction. Almost immediately his airway was compromised by the severe hemorrhaging, so we applied suction again. I know I was taught to apply suction for less than 15 seconds, but would this case be an exception? Which would be the one to worry about most; seeing that your patient doesn't become hypoxic due to over suctioning(because eventually, hypoxia kills.), or suctioning however long as needed so the patient actually HAS an airway, which will OBVIOUSLY kill them, if they don't?

Just a little information on the rest of the call. We air lifted the guy to a trauma center. Flight Medics showed up on scene, RSI him, couldn't get propper ventilation with their ET tube, so used one of our King LT's. Couldn't get IV line established, IO'd him, apparently THAT infiltrated, finally got an IV. Multi-system trauma, I also heard internal bleeding. Guy ended up being pronounced brain dead that night, pulled the plug two days later.

This was also my first "bad" call.

 

[abckidsmom]

Sometimes, and this may have been one of those sometimes, you just have to continually suction the airway to keep it clear. Suctioning the oropharyx (mouth) is not the same as having a yankauer all the way down to the epiglottis suctioning.

Sounds like a nightmare all the way around. Glad they got some kind of airway going for him...was there a reason why your crew didn't use a King airway? It's not completely ideal, but better than nothing.

First crazy scene is always hard to deal with, feel free to pm me if you need to talk about it, or talk with someone you were working with on the scene.

 

[EMSpassion94]

I do not know why my crew did not use a King. We just bagged him, it was hard enough to get an OPA in due to trying to maneuver around the bottom teeth to avoid a possible airway obstruction. We just alternated, bagging, suction, bagging, suction. When the Flight Medics got there, they tried to intubate twice with no sucess, so they used one of our Kings. Thanks, I think i'm handling it pretty well. It's been a little over a month, i'm not overly upset about the call or depressed. It happens. Just learnt from it and moved on. Still think about it now and then, but not to the point where it tortures me or anything. I look at it as a very good educational experience. That call had ALOT of "firsts" for me. First bad wreck, first BVM use, first medivac experience, first unconcious person, first King LT, etc. Sucky call, great learning experience.

 

[abckidsmom]

I do not know why my crew did not use a King. We just bagged him, it was hard enough to get an OPA in due to trying to maneuver around the bottom teeth to avoid a possible airway obstruction. We just alternated, bagging, suction, bagging, suction. When the Flight Medics got there, they tried to intubate twice with no sucess, so they used one of our Kings. Thanks, I think i'm handling it pretty well. It's been a little over a month, i'm not overly upset about the call or depressed. It happens. Just learnt from it and moved on. Still think about it now and then, but not to the point where it tortures me or anything. I look at it as a very good educational experience. That call had ALOT of "firsts" for me. First bad wreck, first BVM use, first medivac experience, first unconcious person, first King LT, etc. Sucky call, great learning experience.

Yep. You learn the most from those.

 

[18G]

Sounds like a mess!

Sometimes you need to continuously suction the airway when you have continuous bleeding. The 15sec rule is to prevent hypoxia but some cases you need to continuously suction and alternate with ventilations.

Where you guys using just one suction catheter or where you able to use two? That is a suggestion with massive bleeding in the upper airway. Also, would a large French suction catheter have worked to be held in place continuously to minimize the blood pooling when ventilations were being delivered? I don't know what kind (if any) mask seal issues you had but the french catheter can be tried too.

 

[EMSpassion94]

Sounds like a mess!

Sometimes you need to continuously suction the airway when you have continuous bleeding. The 15sec rule is to prevent hypoxia but some cases you need to continuously suction and alternate with ventilations.

Where you guys using just one suction catheter or where you able to use two? That is a suggestion with massive bleeding in the upper airway. Also, would a large French suction catheter have worked to be held in place continuously to minimize the blood pooling when ventilations were being delivered? I don't know what kind (if any) mask seal issues you had but the french catheter can be tried too.

We were just using one Yaunkuer. About the french, now that I think about it, that is quite a good idea. Never popped into my head before. He was hemorrhaging so bad I don't know if a french would have been able to keep up, but I will remember this for future reference. Thanks!

 

[usafmedic45]

We were just using one Yaunkuer. About the french, now that I think about it, that is quite a good idea. Never popped into my head before. He was hemorrhaging so bad I don't know if a french would have been able to keep up, but I will remember this for future reference. Thanks!

Then pull the Yankeur off, shove the suction tubing into the oropharynx and bag over it. I've had to do that before.

BTW, it sounds like this guy would have been :censored::censored::censored::censored:ed regardless of what had been done with his airway. Don't beat yourself up too bad over it. Learn what you can and move on.

 

[usalsfyre]

To quote usafmedic45, "sometimes you have to skip to the end of the algorithm". This doesn't sound like a case where the airway could be managed by basic adjuncts. Do what you can, adapt, and overcome.

 

[firetender]

Sometimes the best we can do is to juggle with fatal possibilities until one gets the better of us.

 

[usafmedic45]

Sometimes the best we can do is to juggle with fatal possibilities until one gets the better of us.

I like your quote better.

 

[LondonMedic]

Positioning can always help. It's a pain in the arse to ventilate or intubate in the lateral position, but once this guy is strapped to a scoop or board a bit of head down and left lateral will let gravity take care of a lot of the fluid.

 

[cherpy66]

airway

i had a similar call. i was working in riverside for AMR on an ALS unit. we went on a rollover tc into a building. 2 confirmed ejections. on scene, my patient, was underneath his car after being ejected. i pulled him out and cspined him. he was breathing. i looked at his face and he had no jaw, and not much left going for him. he was very critical with multiple obvious facial fractures. all me and my medic could do was suction. he only had a hole where his oro airway was, and i couldnt find his naso. suction suction suction. he coded on the hospital, and his wife was dead on scene. moral of the story is buckle up haha. no but we couldnt intubate or anything. couldnt even get an iv. i gave him the best therapy out there, DIESEL!!!!!!!!

 

[usafmedic45]

no but we couldnt intubate or anything.

It's patients like that which show why non-visualized airways (Combitube or King Airway) and surgical airways should be part of everyone's protocols.

 

[Tigger]

It's patients like that which show why non-visualized airways (Combitube or King Airway) and surgical airways should be part of everyone's protocols.

Are there really places out there don't have non-visualized airways available even for ALS providers? That thought is terrifying. Sometimes there is limit to what suction can do (like beef stew).

 

[usafmedic45]

Are there really places out there don't have non-visualized airways available even for ALS providers? That thought is terrifying.

No, but there are a lot of ALS providers who view them as an affront to their clinical "prowess". Somehow a dead patient is less insulting.....

 

[Tigger]

No, but there are a lot of ALS providers who view them as an affront to their clinical "prowess". Somehow a dead patient is less insulting.....

No argument from me there. That said I think some of that attitude is propagated by some receiving hospitals yelling at the medics for not intubating someone.

I have been in the hospital more than a few times where the RRT or ED doc has gotten the tube when the medics were unable to get it and the results were not pretty, even if the supraglotic airway was correctly placed. Having a combitube in is better than three failed attempts at intubation with the patient losing oxygenation each time right?

 

[usafmedic45]

That said I think some of that attitude is propagated by some receiving hospitals yelling at the medics for not intubating someone

The only time someone should be harshly criticized is for bringing someone in with an unsecured airway. Personally- as an RT- I don't care if it's via a Combitube or ETT or a crike.

I have been in the hospital more than a few times where the RRT or ED doc has gotten the tube when the medics were unable to get it and the results were not pretty, even if the supraglotic airway was correctly placed. Having a combitube in is better than three failed attempts at intubation with the patient losing oxygenation each time right?

Yes, it is.

 

[LondonMedic]

Have you looked at what equipment is considered a requirement for intubation in hospital and compare it to what you have available?

In the UK, the Difficult Airway Society have defined the standard equipment list. You will (or should) find all that equipment as a minimum in any location where intubation is expected - the Theatres, ED, ITU and often HDU.

Recommended equipment for routine airway management

• Facemasks
• Oropharyngeal airways: three sizes
• Nasopharyngeal airways: three sizes
• Laryngeal Mask Airways
• Tracheal tubes in a range of sizes
• Two working laryngoscope handles
• Macintosh blades: sizes 3 & 4
• Tracheal tube introducer ("gum-elastic" bougie)
• Malleable stylet
• Magill forceps

Recommended equipment for management of unanticipated difficult intubation

• At least one alternative blade (e.g. straight, McCoy)
• Intubating Laryngeal Mask Airway (ILMATM) set (size 3, 4, 5 with dedicated tubes and pusher)
• Tracheal tubes – reinforced and microlaryngeal size 5 & 6mm
• Flexible fibreoptic laryngoscope (with portable/battery light source)
• Proseal laryngeal Mask Airway (ProSeal LMATM)
• Cricothyroid cannula (e.g. Ravussin) with High pressure jet ventilation system (e.g. Manujet) OR
• Large bore cricothyroid cannula (e.g. Quicktrach)
• Surgical cricothyroidotomy kit

 

[mycrofft]

London Medic, does that Society sell T shirts?

Sorry, just a good visual...
When I used to ask my professors who had combat experience (hence, lots of bad trauma) what skills they wanted all of their medics/field guys to have, the ablity to open a diffcult airway was #1.

Thier website:
http://www.das.uk.com/home

 

[Katy]

BTW, it sounds like this guy would have been :censored::censored::censored::censored:ed regardless of what had been done with his airway. Don't beat yourself up too bad over it. Learn what you can and move on.

This.