Please be aware that the image associated with this case is graphic based on the nature of this clinical scenario.
 
EMS Patch:“We are 5 minutes out with a 36 year-old male who was cutting a tree branch on a ladder about 6 feet off the ground when the chainsaw kicked back and struck him in the face. We found him on the ground after his wife called 911. He is constantly spitting up blood, is confused, and is trying to get out of the c-collar. Heart rate is 40. Blood Pressure is 110/76. RR 28. Oxygen saturation is 95% and he won’t tolerate any supplemental oxygen. See you in 5.”
 

 
In the five minutes you have before EMS arrives, how would you like to prepare?

 
Consider any/all of the following:

    PPE for you and your team
    Suction
    Primary method of securing airway as well as plans B and C
    Trauma team role assignments

 

 
 
EMS rolls the patient into the room in a c-collar and on a backboard while the patient continues to yell, spit up blood, and try to take his c-collar off.
 
This is what you see:
 
MR_facial trauma

“Figure 1: Preoperative clinical appearance.”, cropped by DF Savage, courtesy of Craft RO, Eberlin KR, Stella MH, Caterson EJ, via OPENi

 

 
 
Physical Exam
 
Primary Survey:
A: in c-collar with mouth full of blood, which patient is constantly spitting all over the room
 
Does this change your management?
 
YES! Each step of the primary survey is a HARD STOP meaning if that part of the exam is unstable you do not go on to the next step until you secure the current one.
 
You must stop and secure the airway at this point!
 
 
For the sake of the case, the rest of the primary and secondary surveys are listed here
 
B: tachypneic but bilateral breaths present
C: femoral, radial, and PT pulses intact
D: GCS 9
E: patient completely undressed, bleeding from mouth and face, covered in blood and dirt.
Vitals: HR 42 BP 108/72 RR 28 O2 sat 95% on RA
 
Secondary Survey:
 
HEENT: 20 cm laceration to left side of face from orbital rim to upper lip with exposed periorbital bone. Significant ecchymosis around , proptosis of , and chemosis of left eye. No septal hematoma
Neck: in c-collar, trachea midline, no cervical spine tenderness
Chest: bilateral breath sounds intact, no chest wall tenderness, equal excursion of ribs bilaterally
Abdomen: NTND, no ecchymosis
Pelvis: stable and no crepitus but right leg flexed at hip and knee, internally rotated and shortened
Extremities: no penetrating trauma, ecchymosis nor abrasions including in groin (as best as can be assessed) or axilla. Distal pulses intact.
Back: Diffuse superficial abrasions. No ecchymosis, penetrating trauma. No gross blood on rectal and tone intact.
Neuro: Uncooperative but spontaneously moves all distal extremities
 
 
 
Given what you know about this patient so far what possible technical challenges do you face attempting to secure the airway?
 
Difficulty with Pre-Oxygenation/BMV: MOANS

    M = Mask seal –> midface instability
    O = Obese or obstructed –> blood, trauma, foreign body, hematoma
    A = Advanced age
    N = No teeth
    S = Stiff –> noncompliant chest wall, noncompliant lungs

 
Difficult Laryngoscopy and Intubation: LEMON

    L = Look externally –> gross facial or neck trauma
    E = Evaluate 3-3-2 –> mouth opening, and submental and hoy-thyroid lengths
    M = Mallampati score –> helpful but not no time in this situation
    O = Obstruction –> blood, trauma, foreign body, hematoma
    N = Neck mobility –> manual cervical spine immobilization

 

 
 
What pharmacologic considerations must one make in this patient?
 
Analgesia and Sedation:

    The patient’s blood pressure, 108/72, and HR, 42 bpm, raise the concern that providing opiate analgesia may worsening the patient’s concerning vitals

 
Induction:

    Etomidate: While there may be some concern about using etomidate and subsequent adrenal suppression, given the nature of this patient’s injuries it should not preclude its use.

 

    Ketamine: Induction with ketamine does above the potential for hypotension and decreased respiratory drive associated with other induction agents, but it’s potential to raise intracranial and/or intra-ocular pressure make it a similarly precarious choice.

 
Paralysis:

    Succinylcholine: Fast on and fast off, great for trauma in this sense. However, again concerns about increased ICP and increased intra-ocular pressure should give you pause.
    Nondepolarizing Agents: Slightly slower onset and much longer duration of action make vec and roc a possible liability if unable to intubate or ventilate. However, they do avoid the increased ICP and IOP issues.

 

 
 
Now, what's the deal with the bradycardia in a trauma patient
 
The oculocardiac reflex! Stretch on the extraocular muscles results in stimulation of the vagus nerve and subsequent bradycardia. This is most frequently seen during ophthalmologic and maxillofacial surgery, but can also be seen with facial trauma and retrobulbar hematoma.
 
 
 
Details of this case modified from case report by Craft, et al. listed below and also the source of the photo.
 
Bibliography:
Craft, R. O., Eberlin, K. R., Stella, M. H., & Caterson, E. J. Management of extensive maxillofacial trauma with bony foreign body within the orbit from a chainsaw injury. Eplasty [serial online]. 2011; 11:, e44. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=22132249.
 
Fortuna, T. J., & Burton, J. H. Chapter 019. Trauma Airway Management. In A. B. Wolfson, R. L. Cloutier, G. W. Hendey, L. J. Ling, C. L. Rosen, & J. Schaider (Eds.), Harwood-Nuss’ Clinical Practice of Emergency
Medicine (6th ed.). http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=booktext&D=books2&AN=01817268/6th_Edition/3&XPATH=/OVIDBOOK%5b1%5d/METADATA%5b1%5d/TBY%5b1%5d/EDITORS%5b1%5d.
 
Ziccardi, V. B., Russavage, J., Sotereanos, G. C., & Patterson, G. T. Oculocardiac reflex: pathophysiology and case report. Oral Surg Oral Med Oral Pathol [serial online]. 1991; 71: (2), 137-138. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=2003005.

Leave a Reply

Your email address will not be published. Required fields are marked *

Subscribe to YaleEM via email

Enter your email address to subscribe to this blog and receive notifications of new posts by email.

Join 1,738 other subscribers