GSW to neck

[chbare]

I would not use the wound tract from the bullet. The fact is that you just don't know what tract the bullet took. Travel in a straight line should not be assumed, since bullets almost never do once they start traveling through human tissue of varying densities. If you stick the tube through that, you can't be sure where you are ending up. The bullet may have just nicked the trachea, and the dark space you see may or may not be the trachea. You could penetrate the trachea completely and end up on the other side. You are also putting a tube right into the part of the trachea which is least stable and least able to tolerate the force you will apply when sticking the tube in.

There is also the caliber issue that p3 medic mentioned. I have not seen a bullet entrance wound large enough to squeeze an ET tube through without forcing it or widening the hole. Even high-velocity rifles will leave a relatively small entrance wound.

Early definitive airway control is indicated to prevent occlusion by a hematoma, which will make later attempts at airway control (surgical or otherwise) difficult by distortion of anatomy. Thus the patient needs an airway as soon as possible, BEFORE they are in distress.

If someone successfully intubated this patient by nasal intubation or regular orotracheal intubation, they had better give thanks in prayer every day of the week and twice on Sunday. There is the very real danger of completing the transection of the trachea by regular intubation. Once this happens, the trachea can retract into the chest where it is not accessible by anyone. For this reason, you may consider surgical cricothyroidotomy without attempting oral intubation first. If the wound is too low to go through the cricothyroid membrane, then we will do an emergent tracheostomy.

The next question you have to answer: c-spine the patient or not?

'zilla

I tend to agree. The surgical option in spite of our reservations is most likely the safest. In the hospital setting, fiberoptic techniques may be considered; however, this guy will more than likely require a trach.

I would C-spine simply to prevent compromise of the airway and prevent movement of injured tissues and blood vessels.

Take care,

chbare.

[p3medic]

Without actually seeing this injury, I would reserve the surgical option as a last resort. You are looking at distorted anatomy already, we know there is a perf of the upper airway by the presence of an air leak. Cutting into a neck with a vascular injury, expanding hematoma and a damaged trachea is a bad idea. There is little downside to attempting to secure the airway from above, if the trachea is so unstable from the initial injury that it might drop into the chest, manipulation of it during a surgical procedure is going to be no less dangerous. This patient is unconsious, so in all likelyhood we can perform a gentle laryngoscopy and get an idea of what we are dealing with. I'm leary of using a paralytic in this patient who is still breathing, if meds are needed I think a topical anesthetic and some sedation with versed/fentanyl, or etomidate might give us enough relaxation without stopping this patients own breathing. Another important question that hasn't been answered is what is the level of the injury? Is it at the larynx, or well below? If we intubate the patient, how deep to we need to place the ett?

As for the doc's question regarding c-spine, I say no. I have no issue securing his head to the board, but I have no intention of covering his neck with a collar.