"Protect Me" - Flights Case 4

Welcome to the Fourth Case in our Air Care and Mobile Care Flight Orientation Curriculum for 2016! 

Every few weeks throughout the spring and early summer, there will be a series of posts and cases published to help spur some thought and discussion on the management of the critically ill patients we take care of in the pre-hospital environment.  These virtual flights will be used to highlight some key considerations in the management of blunt poly-trauma, severe TBI, penetrating trauma, STEMI, acute neurologic emergencies, and several other common disease processes seen on Air Care.

Comments will be open for 2 weeks after which time, a post containing expert commentary and curated commentary from the community will be published to reinforce the key learning points brought up in discussion.

It is a beautiful sunny Memorial Day and you arrive early for your C-pod shift, energized by the knowledge that you will be getting out early with time to enjoy the day. Your patients are an enjoyable mix of pathology and acuity and everyone is quite polite and gracious. The tones drop just before it is time to hand over the radio to the dedicated flight doc and you can’t but marvel at your good fortune. You grab the blood and head up to the helipad for your flight.

You step out into the bright sunshine and load into the running aircraft that is waiting for you to depart. You and your team take off and head East into the rural Ohio counties past the beltway under a pure azure sky towards the scene. Your pager alarms, informing you that you are responding to meet a squad for a “self-inflicted shotgun wound to the face”.  Instantly your stomach drops. You knew that it couldn’t all be beautiful and sunny today. You land on a grassy knoll next to a farm road near the squad, unload the stretcher and equipment with your flight nurse, and walk towards an ominous cluster of EMS and police personnel gathered around a patient sitting in the middle of the road. 

As you approach, you quickly realize that the male patient is actually crouched on his knees leaning forward onto his hands with blood pouring from a large and complex wound to his face with significant amounts of tissue and bone hanging and dripping onto the concrete. You hear a vague unintelligible gurgle and moan from the patient and the paramedic nearest to you turns and says that they have attempted to lay the patient down on a stretcher multiple times and that he became agitated and uncooperative. They have a monitor attached to him in his current position and you crouch down to examine your new patient.

Physical Exam

  • Vitals: P: 132, BP: 142/84, RR: 24, O2 Sat: 93% on RA

  • General: The patient (who appears in his 30s or 40s) is agitated but cooperative in his current position. He is leaning forward roughly 30 degrees onto his hands. There is a significant pool of blood around him on the concrete.

  • HEENT: Extensive trauma to the mid and lower face. What remains of the mandible appears to be in two pieces with one part of the bone twisted laterally and extending into the patients mouth. Multiple teeth appear to be hanging out of the airway attached to strips of skin. The submandibular structures are unrecognizable and you can see some exposed bone in the area of the hyoid from the patient’s right. There is extensive bleeding from this entire region that is dripping dependently onto the concrete. The nose and maxilla are unrecognizable with bleeding exposed tissue in the mid-face that appears grossly unstable. The left eye has an obvious open globe injury and the globe itself is partly out of the left orbit. There is extensive soft tissue swelling obscuring the patients thyroid cartilage and anterior neck. You do not see any evidence of trauma to the forehead or the rest of the patient’s scalp or posterior head and neck.

  • Cardiovascular: Tachycardic.

  • Pulmonary: Good air movement bilaterally with transmitted upper airway gurgling.

  • Abdomen: Soft.

  • Musculoskeletal: No gross abnormality besides that described above.

  • Neurologic: GCS 12 (E4V2M6). He is alert and oriented, briskly following commands, but cannot make intelligible sounds due to his extensive facial trauma.

Interventions PTA

  • None

Questions & Curveballs

Q1:  What do you need to consider in regards to the scene immediately upon arrival? What are the immediate life threats to this patient and how do you propose to manage them?

Curveball 1

Instead of the patient described above, lets say the patient you encounter has suffered a stab wound to the left neck.  

You begin your assessment of the patient by asking them their name.  The patient replies “John” in a slightly hoarse and muffled voice.  Inspecting his injuries you find a 1 cm stab wound in the left anterior neck just along the anterior border of the sternocleidomastoid and 3 cm superior to the clavicle (right about where Zone 1 and Zone 2 would intersect). On palpation you detect a small amount of subcutaneous emphysema along the anterior neck.  There is minimal active bleeding noted and no carotid bruit.  You ask the patient and providers on scene about the patient’s voice and they note that it is dramatically more hoarse than when they first arrived.  

VS: 134/76, 104, 24, 92% on a 15 L face mask

You have a 25 min flight back to UCMC from the scene

Q2:  How do you propose to manage this patient’s airway?  Are there certain airway devices that you may want to avoid using in this patient?

Curveball 2

Instead of the scene above, you rendezvous with a squad near a rural nursing facility to find a 350 lb 65 year old female in respiratory distress. She reportedly has a mature tracheostomy and accidentally pulled out her un-cuffed tracheostomy tube prior to arrival of EMS. EMS attempted several times to replace the tracheostomy tube without success. The patient is agitated, tachypneic, and pulling at the EMS providers arms as they attempt to bag the patient through her stoma by attempting to create a seal with a pediatric mask on her anterior neck. There is a moderate amount of blood to her anterior neck from the tracheostomy tube replacement attempt. The patient is attached to the monitor and has an SpO2 of 84% with a good waveform and is tachycardic to 156. The BP cuff will not record. 

Q3: How do you initially approach this patient and manage her airway? Please walk through your management strategy in detail including initial and backup plans.

*To help facilitate discussion, when commenting please precede your answer to a particular question with Q1, Q2, etc.