Glass Ingestion

[the_negro_puppy]

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.

 

[DV_EMT]

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?

 

[Dwindlin]

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.

 

[Sasha]

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.

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

 

[mycrofft]

Laudanum, or paregoric.

Then bleed the evil spirits out of him.

 

[Brandon O]

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.

 

[usalsfyre]

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

 

[fast65]

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.


Sent from my iPhone using Tapatalk

 

[usafmedic45]

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".

 

[usafmedic45]

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.

 

[Brandon O]

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

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

 

[usafmedic45]

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....

 

[Brandon O]

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...

 

[Tigger]

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.

 

[Brandon O]

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

 

[Veneficus]

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.

 

[mycrofft]

And/or emergency laparotomy.

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

 

[Veneficus]

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.

 

[mycrofft]

V, that wasn't a suggestion for misspelling punishment

Honest!

 

[MedicPatriot]

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.