Continuous Facial Bleeding with CSpine

ChewyEMS13

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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!
 

DesertMedic66

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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.
 

rescue1

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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.
 

ChewyEMS13

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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
 

rescue1

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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.
 

CALEMT

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

ChewyEMS13

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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.?
 

CALEMT

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A compromised airway as a result of a possible cervical spine injury:cool:.
I didn't ask the almighty whirly bird paramagician...

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.

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.
 

ChewyEMS13

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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?
 

CALEMT

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

EpiEMS

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@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*

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)
 

CALEMT

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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.
 

hometownmedic5

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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.
 

ChewyEMS13

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@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?
 

Jim37F

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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.
 

ChewyEMS13

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@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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