There Will Be Blood...

If, like me, your nights are populated by a seemingly endless series of tormented, gory dreams, this case will provide fodder for another week’s worth...

It is a dark but, alas, not a stormy night.  Dressed in your sleek, black, Nomex flight suit, your leather combat boots and your absorbent, Spongebob underpants, you feel supremely confident and almost invulnerable.  Until...

Your radio crackles, and you are dispatched to an outside hospital to transport a young man with a self-inflicted gunshot wound to the face.  No other information is forthcoming, so you are left to stew in the juices of your own fertile imagination en route.  On arrival, you find an otherwise healthy appearing man seated on a stretcher, drooling copious amounts of blood and saliva into his NRBM.  He has a punctate wound below his chin, and a ragged hole where his left zygoma used to be.  Through this hole you can see broken teeth, fragments of his maxilla, and a lump of macerated meat that you assume to be his damaged tongue, all floating in a lake of up-welling blood.  He is conscious, though somewhat altered, but follows commands.  He attempts to speak, which results in a volcanic sanguinous eruption from his wounds.  “Silence!”, you command.  He follows your command, and, during the ensuing moment of peace, you note the following:

 Vitals:  Pulse 126, RR 32, BP 109/79, Pulse ox 95% on NRB

A quick survey finds no other injuries.  He has an IV in place.  Momentarily nonplussed by the horror of it all, you fall back on your training and quickly run through your Universal Airway Algorithm.  Is he a crash?  Not yet, but he has potential.  Is he predicted to be difficult?  Hmmm...let’s see...yep!  Difficult!

His LEMON, like its namesake, is both sweet and sour.  The anatomy for cricothyrotomy (SMART) is favorable, but all else is either hellish or occult.  Mouth opening is OK, but the view inside reveals a bloody mess with swelling of the sublingual space and a Mallampati score of IVbm (the “bm” modifier denotes either “bloody mess”, or the formalized initials of the expletive that you mutter as you consider your options).  MOANS?  How are you gonna get a mask seal when a substantial portion of his face is missing? RODS?  This is worth some thought.  You have no restriction of mouth opening, but his tongue is BIG.  An EGD may pass through, or may not, but once through it should allow for effective ventilation and reduce further aspiration of blood.  Further, if the EGD chosen is an intubating LMA or iGel, it will provide a potential avenue for blind intubation and facilitate fiber-optic guided intubation in the ED.  The “D” of RODS is troubling, but only for an instant – the distortion of his airway is all above the level where the cuff will form its seal.  As such, as long as you can get the EGD in place, it should function well.  You are have a potential back-up.

The clock ticks

This comfort is almost completely negated by your recognition that he has bled a LOT, and is still doing so.  You would like to pack his wounds to prevent exsanguination, but cannot do so without further compromising his airway.  The clock is ticking, and ticking fast.  You have zero confidence that you can transport him without first controlling his airway.  It is time to act.  In your mind, you speed along the meanderings of the Difficult Airway Algorithm and recognize that you are, essentially, forced to act.  The “forced to act” scenario is quite the paradox; on the one hand, it means that you are in dire straits, but on the other hand, it frees you from self-doubt and allows you to take desperate action unencumbered by fear of being second-guessed.  Your choices are greatly simplified:  You will take a single, best shot by RSI.  If this fails, you will immediately jump to the Failed Airway Algorithm, and either progress straight to cric, or mount the “bridge of hope”, and take a single shot at passing an EGD.  If this fails – straight to cric.

You prepare for all three.  There will be no time to search for the gear for your second and third options if your first attempt fails.  You explain the procedure to your compatriots.  You chose (wisely in this lone circumstance) your trusty, plain ol’ laryngoscope as the device of choice for this sloppy, optics-defeating blood-bath.  You ready your drugs, and prep his neck.  The first P of the 7-Ps is the most important, in my humble opinion.  Henceforth, it shall be the “Key-P” in my mind [N.B., this would also be a great name for a hip-hop artist].

Now, to this point, the cognitive approach to this situation has been flawless.  Upon recognizing that you are forced to act, you should experience a sense of clarity and steely calm once you know what must be done.

From here, we move from science to metaphysics...

During the final stages of preparation, you recognize that the patient is fully conscious, and terrified.  You turn to the patient, and explain the situation calmly and compassionately.  While you weren’t thinking of it at the time, it is possible that these are the last words this man will ever hear.  While you weren’t thinking of it at the time, you are ministering to his soul, not just to his body.  As a serious aside, my hair stands up (which is quite a sight) when I think of this simple have considered the patient’s feelings in a moment of crisis when a purely mechanistic approach would have been fully understandable.  As a less serious aside, when I think about this case, I picture the flight doc explaining the situation to the patient, and I visualize a halo appearing above his head that, like the round fluorescent tube in the work-light in my basement, glows weakly when you first turn it on, then buzzes and flickers uncertainly a time or two, then goes “bink!” and ignites into brilliance!  Can I get an “AMEN”!

I then imagine the patient sitting there and thinking, “I’m in pain and I’m scared to death, but I’m glad THIS guy showed up.”

Back to science...

The remaining Ps are attended to, intubating conditions are created via RSI, and with vigorous suction and superb blade technique the patient is intubated by DL without desaturating or becoming hypoxic.  Subsequently, his wounds are packed, the bleeding is checked, and his transport is completed without incident.

Bottom line:

1)  Apply the algorithms and they will lead you home.  Clear-headed recognition of a “forced to act’ situation led to the successful management of this case.

2)  When confidence in the initial method of management is low, have a double set-up, (or even a triple set-up) handy.  This is not the time to consider the cost of the gear that may not be used.

3)  It is not often that a regular, direct laryngoscope is the best device, but the “bloody mess” is one situation where it may be.  If in the trauma bay, I think that the smart thing to would have been to take that first shot with the Berci-Kaplan and a standard Mac or Miller is a great DL, and also has at least the potential to offer video augmentation.  On Air Care, though, plain ol’ DL was the right choice.

4)  Be kind.  ‘Nuff said.




I.C. Cordes is written by Steven Carleton, MD PhD, Professor of Emergency Medicine at UC. Also an instructor at The Difficult Airway Course, Dr. Carleton uses I.C. Cordes to cover challenging airway cases and the use of airway equipment old and new.