Heavy rescue scenario

[KosherMedic]

You have a patient who was struck in the left side of the head by a heavy section of pipe on a pipeline project about 30 mins by helicopter from the nearest hospital. The patient was guiding the pipe that a backhoe was moving without a tag line when the backhoe tipped a bit because of uneven ground causing the heavy pipe to strike the patient.

The patient presented alert after being initially unconscious, bleeding profusely from mouth with many missing teeth, suspected jaw fracture, and periorbital bruising on left side. Patient is normotensive and not exhibiting signs of shock. Patient has closed fracture of left humerus. Patient is maintaining own airway and welcomes your frequent suctioning. Verbal communication with patient is very difficult. Patient is brought to your remote worksite clinic by the EMT on scene with full spinal precautions in place.

The helicopter is on it's way, but it is just a pilot and you will have to accompany patient to the hospital.

You are an advanced life support provider. What do you do for this patient?

(This is a real situation that I was not involved with that happened recently.)

Imagine a piece of 12" x 40' pipe being lifted by that machine and the pipe swinging into the face/side of your patient. Ouch!

[tniuqs]

Loss of C.

Bleeding in an Airway.

Fractured Mandible.

Fracture Humerus.

This guy should be chewing on plastic (minimum) RSI or a surgical airway if he is going in by air in a small fling wing bird. There really is no down side to providing a secure airway, then "buddy" then can receive therapeutic doses of happy juice so he doesn't have too much pain.

In this situation with Loss of C and possibility of a head injury, well even small doses of analgesia in an unprotected airway could further comprise if just left to Basic Life Support (as in 3/4 prone) ... but that brings up another query if the patient is spinal restriction was he transported on his back with a fracture humerus and compromised airway from bleeding ?

Call for a Griffin / 412 ... LOL (inside joke)

I have worked on Pipeline and these are not light pieces of gear MOI is nasty squared, getting smacked with a 12 inch diamiter x 40 ft pipe, well "buddy" is lucky he is still alive.

BTW Does the destination / receiving facility have a Trauma Team notified ?

cheers

[KosherMedic]

Loss of C.

Bleeding in an Airway.

Fractured Mandible.

Fracture Humerus.

This guy should be chewing on plastic (minimum) RSI or a surgical airway if he is going in by air in a small fling wing bird. There really is no down side to providing a secure airway, then "buddy" then can receive therapeutic doses of happy juice so he doesn't have too much pain.

In this situation with Loss of C and possibility of a head injury, well even small doses of analgesia in an unprotected airway could further comprise if just left to Basic Life Support (as in 3/4 prone) ... but that brings up another query if the patient is spinal restriction was he transported on his back with a fracture humerus and compromised airway from bleeding ?

Call for a Griffin / 412 ... LOL (inside joke)

I have worked on Pipeline and these are not light pieces of gear MOI is nasty squared, getting smacked with a 12 inch diamiter x 40 ft pipe, well "buddy" is lucky he is still alive.

BTW Does the destination / receiving facility have a Trauma Team notified ?

cheers

Sorry, sir. No Bell 412CF (CH-146 Griffon) is available for your medevac. The choppa that shows up is so sucky that the patient on the spine board cannot be turned to the side to aid drainage of blood from the oropharynx. Yep, you're going to have to suction that airway all the way to town. The ALS provider had to ask the pilot to touch down en route to empty their suction device (sigh).

Yeah, that patient should have had their airway captured. The provider did not do that.

The facility you're en route to is only a small town hospital. Your patient is to be eventually picked up by a fixed wing air ambulance and flown about 2 hours to a trauma centre.

[tniuqs]

Sorry, sir. No Bell 412CF (CH-146 Griffon) is available for your medevac. The choppa that shows up is so sucky that the patient on the spine board cannot be turned to the side to aid drainage of blood from the oropharynx.

Yep, you're going to have to suction that airway all the way to town. The ALS provider had to ask the pilot to touch down en route to empty their suction device (sigh).

Yeah, that patient should have had their airway captured. The provider did not do that.

The facility you're en route to is only a small town hospital. Your patient is to be eventually picked up by a fixed wing air ambulance and flown about 2 hours to a trauma centre.

[KosherMedic]

I don't know what the flight crew did. I would have a very hard time not tubing that patient if I were a member of that crew.

[Dustdevil]

Thread title changed to reflect content. "What would you do" is specifically forbidden by the rules as a title.

Thread moved to appropriate forum. General Discussion is not a catch-all.

[mobey]

sorry to derail from the scenario...

I agree to intubate this guy, since boarding him is going to make a tracheal toilet.

Would anyone here put any sort of dressing inside the oropharynx? I mean, if you are suctioning copious amounts of blood, it may be correct to apply direct pressure?

[DartmouthDave]

Hello,

VS? LOC? Motor/Sensory assessment?

From the description of the injury airway sounds like an issues as noted by several posters. Even more so if you put the patient supine on a back board.

Now, I am just throwing this out there;

Could you transport the patient with a cervical collar on with the head of the stretch at 30 degrees of elevation (like Tniups suggested)? Or, as an other option lay the patient in the left (or right) lateral recumbent position? Thereby allowing safe clearance of airway?

Most cervical injuries are stable enough to allow HOB at 30 degrees (with a collar) in the hospital setting. A truly unstable c-spine in general presents with deficits and even ideal care (backboard) things typically worsen as edema develops. Slightly unorthodox but easier than having possible airway issues during the flight.

The reason I am throwing this out there is a LEMON airway assessment of this fellow shows three concerning issues. First, a jaw fracture with blood equals difficult airway. Maybe there is a high grade LeFort (II or III) fracture present. Second, it would be difficult to ventilate with a BVM if the RSI failed. Third, a supraglottic airway wouldn't be helpful here as well.

This leaves a surgical airway which put you in a crap situation. Even worse, a failed surgical airway. There is an interesting case in which a CalStar crew missed a tube. Went surgical. Missed that. Then got a tube which was useless due to a large bleed hole in the patient's neck. =(

There isn't a failure to oxygenate or ventilate here (with suctioning). So, a short hop to the local small hospital and possibly deal with things there if need be. Also, with a warning the small town hospital can call in extra staff (i.e. Anesthesia). Glide scope/bronchoscope or many other options. Tube there if needed.

Also, a more detailed trauma work up is needed before the fixed wing crew arrives. CXR. AP Chest. Pelvic. And, with luck a Head CT.

Cheers...

[mobey]

The reason I am throwing this out there is a LEMON airway assessment

LEMON??

I have, and would again put a pt in a KED and transported semi-fowlers with suction prn. As a bls crew you do what you have to.

As an ALS provider however I think I would be more aggressive. Perhaps an awake intubation could be attempted. A large dose of Fentanyl and maybe a whiff of Versed combined with some lido spray may be all it takes to pass the cords without causing total resp depression, or at least get the laryngoscope in to get a good assessment at what your working with.

[DartmouthDave]

LEMON??

I have, and would again put a pt in a KED and transported semi-fowlers with suction prn. As a bls crew you do what you have to.

As an ALS provider however I think I would be more aggressive. Perhaps an awake intubation could be attempted. A large dose of Fentanyl and maybe a whiff of Versed combined with some lido spray may be all it takes to pass the cords without causing total resp depression, or at least get the laryngoscope in to get a good assessment at what your working with.

Hello,

LEMON AIRWAY ASSESSMENT TOOL:

http://emergency-medicine.jwatch.org/cgi/content/full/2005/216/1

The STARS folks came by were I work and used it with the sims. Just an assessment tool that is all.

Cheers