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  • GSW to the jaw....how to procede



    Strange scenario. Working at a community hospital, no trauma program. Large level 1 trauma center is about 30 min by ambulance. 25 yo male with a GSW to the jaw is driven in to the ER (ambulances would automatically take them to the city). You are called to the ED to "secure the airway" prior to transfer to trauma center. Pt is a healthy appearing male with a small (9mm if I had to guess) entrance wound through the left anterior jaw. No exit wound. Entire neck is swollen with tracheal deviation to the right. Patient is awake and mentating but very anxious. Opens mouth on command to about 5cm. How would you proceed?
    This article was originally published in forum thread: GSW to the jaw....how to procede started by squeezingthebag View original post
    Comments 14 Comments
    1. iceemike1's Avatar
      iceemike1 -
      Quote Originally Posted by Burnt2 View Post
      I mean I can place a double lumen with a fiberoptic scope, but I'm not that great at doing an awake fiberoptic bronchoscope on patients with marginal airways.

      In those situations I try to stick with the tools I'm best with.
      Do you mean confirm placement of a DLT or you actually use it to place the tube? I guess I'm just surprised you'd be content not feeling comfortable with one of the most important tools we have. Now, I realize it's becoming less used and I'm also guilty--I like doing lido atomizer + ketamine + breath a little sevo and take a looksie but there are some pts I even hesitate doing this to.
      Do other students or CRNA think fiberoptic is obsolete?
    1. jcaSRNA's Avatar
      jcaSRNA -
      Other than for confirming placement of a DLT, I've used it once in the last 4 years.

      Sent from my LG-D800 using Tapatalk
    1. Burnt2's Avatar
      Burnt2 -
      Quote Originally Posted by iceemike1 View Post
      Do you mean confirm placement of a DLT or you actually use it to place the tube? I guess I'm just surprised you'd be content not feeling comfortable with one of the most important tools we have. Now, I realize it's becoming less used and I'm also guilty--I like doing lido atomizer + ketamine + breath a little sevo and take a looksie but there are some pts I even hesitate doing this to.
      Do other students or CRNA think fiberoptic is obsolete?
      Just confirming placement of the DLT and occasionally trouble shooting issues with single lumen tubes.... never used it as a primary go-to for a difficult airway.

      I don't necessarily think it's obsolete, I was only superficially trained to use it for difficult airways; nor have I ever gained that degree of comfort with the scope for that use. I just don't use it enough for intubations ,which is a whole other difficulty level up from checking placement. Just being honest.


      ....I believe the rule is that in those situations you grab the stuff you are best with.

      Sent from my Nexus 4 using Tapatalk
    1. iceemike1's Avatar
      iceemike1 -
      Quote Originally Posted by Burnt2 View Post
      Just confirming placement of the DLT and occasionally trouble shooting issues with single lumen tubes.... never used it as a primary go-to for a difficult airway.

      I don't necessarily think it's obsolete, I was only superficially trained to use it for difficult airways; nor have I ever gained that degree of comfort with the scope for that use. I just don't use it enough for intubations ,which is a whole other difficulty level up from checking placement. Just being honest.


      ....I believe the rule is that in those situations you grab the stuff you are best with.

      Sent from my Nexus 4 using Tapatalk
      Sorry I reread my post and I don't mean it to be pointing fingers, it just got me thinking. Especially since we harp on skills that are being blocked by MDAs--I guess I was questioning more if this is one maybe I hold too high of value on now then? The glidescope/cmac/lightwand are excellent and are making FOI less necessary but for a truly difficult, awake intubation I'm curious what people think.
    1. ethernaut's Avatar
      ethernaut -
      On occasion, I'll use our portable FOB just to stay current with skills. No point in it collecting dust..like that old Bullard hangin around somewhere.

      Are those of you that aren't using FOB in routine practice, is it because you don't have one? Or higher-ups don't want resources/time wasted?
    1. gaspass3's Avatar
      gaspass3 -
      Quote Originally Posted by ethernaut View Post
      On occasion, I'll use our portable FOB just to stay current with skills. No point in it collecting dust..like that old Bullard hangin around somewhere.

      Are those of you that aren't using FOB in routine practice, is it because you don't have one? Or higher-ups don't want resources/time wasted?
      I assumed it was because the Glide covers so many airways now, that there is less natural opportunity.

      Sent from my SAMSUNG-SGH-I747 using Tapatalk
    1. pdsr's Avatar
      pdsr -
      Quote Originally Posted by iceemike1 View Post
      Sorry I reread my post and I don't mean it to be pointing fingers, it just got me thinking. Especially since we harp on skills that are being blocked by MDAs--I guess I was questioning more if this is one maybe I hold too high of value on now then? The glidescope/cmac/lightwand are excellent and are making FOI less necessary but for a truly difficult, awake intubation I'm curious what people think.
      The more options we have, the less likely we are to go straight to FOI, IMO. However, in certain situations, such as oral and upper airway tumors, I think it is still the best technique. Much better to be able to go around a large mass than to try to displace it to gain a view of the cords. I trained myself to use a fiberoptic scope, and gleaned a few good tips from others. It's not a skill that can't be learned on your own, but it does require practice. In a solo practice environment I think it is an essential element of your airway skills.
    1. Teillard's Avatar
      Teillard -
      Quote Originally Posted by jcaSRNA View Post
      Other than for confirming placement of a DLT, I've used it once in the last 4 years.

      Sent from my LG-D800 using Tapatalk
      If you use it to place DLT's, you have the skill set to do single lumen placements with it without too much trouble at all. Once you're facile with the FOB, the real art is the patient prep, and there's many ways to do that. That said, with all of the video assisted devices and LMA products available, the true awake FOB patient is becoming extremely rare, at least where I practice.
    1. ethernaut's Avatar
      ethernaut -
      Quote Originally Posted by Teillard View Post
      If you use it to place DLT's, you have the skill set to do single lumen placements with it without too much trouble at all. Once you're facile with the FOB, the real art is the patient prep, and there's many ways to do that. That said, with all of the video assisted devices and LMA products available, the true awake FOB patient is becoming extremely rare, at least where I practice.
      I think he said for confirmation, not placement.
    1. Teillard's Avatar
      Teillard -
      Quote Originally Posted by ethernaut View Post
      I think he said for confirmation, not placement.
      Confirmation and placement are mutually exclusive? If you confirm it's in the wrong place, or it moves from the right place, you need to use FOB to place it correctly. That can be far more difficult than placing a single lumen tube awake.
    1. Burnt2's Avatar
      Burnt2 -
      I had a choice between a video scope or a FOB for my practice; I went with the VL. if I get funds, I'll pick up a bronchoscope later.

      @teillard...IMO they are mutually exclusive, although not necessarily so. I do what probably the majority of people do, which is so a DL, place the DLETT, and then use the FOB to confirm placement/adjust. *Placing* the DLETT (or single lumen) with the FOB vs DL is much more difficult than just checking placement/repositioning.

      Sent from my Nexus 4 using Tapatalk
    1. nomadcrna's Avatar
      nomadcrna -
      I've done a number of retrogrades. Usually works fine and is quick. Having a glidescope around has really changed my difficult airway algorithm.

      Quote Originally Posted by neopusher View Post
      I was trained to do retrogrades as a flight paramedic. Only did one - on a massive facial trauma who already had pre-existing congenital maxillofacial abnormalities - and it worked great.

      It's a technique I will always be quick to consider in these types of scenarios.
    1. ethernaut's Avatar
      ethernaut -
      Quote Originally Posted by Burnt2 View Post

      @teillard...IMO they are mutually exclusive, although not necessarily so. I do what probably the majority of people do, which is so a DL, place the DLETT, and then use the FOB to confirm placement/adjust. *Placing* the DLETT (or single lumen) with the FOB vs DL is much more difficult than just checking placement/repositioning.

      Sent from my Nexus 4 using Tapatalk
      this
    1. Peaches's Avatar
      Peaches -
      Quote Originally Posted by squeezingthebag View Post
      J Dubb, if EMS responded the guy would have gone to the trauma center. Really now that he is here air vs ground is essentially the same because the hospital is really, really close. So, the reason I posted this is the course of action taken is not AT ALL what I would do in hindsight. First off we took him up to the OR (its a short trip). I was leery of the ability to do a good FOB because of the blood in the airway but for some reason (stupidly) thought glidescope might be better. Gave some Ketamine and Versed to get sedation and keep him breathing. Looked with GS....some coughing and literally couldn't see a single landmark, not even epiglottis. Other "provider" decides we should RSI do to "full stomach". At this time a general surgeon wanders in to see the guy (serendipitously....he was actually about to start another case). I tell him not to leave....impending trach. The other providers in the room were very excitable and I allowed myself to be rushed. In hindsight would never have relaxed this patient. Looked again with GS...nothing. Sats begin dropping. Attempt 2 person BMV...unsuccesful. Immediatly place a #4 LMA which I had at the ready. Still very poor ventilation, sats slowly dipping down, plan C....intubating LMA. Place a #4 Fast track. Unable to vent at all. Tell the surgeon to prepare for trach. As he starts prepping, succ wears off, pt begins breathing again and sats are back to 99% with gentle CPAP. Deciding this guy is going to buy a trach regardless we procede. Surgeon is trauma trained and does the trach in less than 3 or 4 minutes (I may be exaggerating but it was quick). This is an example of getting very, very lucky. My takeaways:
      1. Do not allow yourself to be rushed by the others excitability
      2. In a situation like this if the patient is stable....... Assemble all the required equipment AND personell. It was dumb luck that this surgeon was in house. 2 hours later and there could potentially have been no surgeon in house.
      3. Above all.......A spontaneously breathing patient is significantly harder to kill. I believe that he was swallowing blood the whole time in the ER, as soon as he was asleep his mouth filled with blood and secretions.
      4. Ketamine is a magical drug, I fully believe that had I given this guy a big dose of prop and I would still be waiting for him to start breathing.
      awesome... I'll remember this!