The Case:

Surrounded by nearly 2 dozen police officers with guns drawn, the “patient” was found sitting in the front seat of a stolen car, hemorrhaging from his mouth, neck, and head. Police reported the suspect had just shot his ex-girlfriend and the mother of his two children, before taking police on a 10-mile high-speed chase down a major highway and into a small affluent town.

That morning I was standing outside the Emergency Department (ED) waiting for my partner to turn over a patient when I heard sirens shrieking in hyper-yelp mode. I quickly turned to see this car-chase squealing past the hospital entrance and down the hill. I ran over to the sidewalk and saw the vehicle stopped at the end of the block surrounded by police cars, officers with their guns drawn and sirens blaring. The incident occurred so fast, it took me a second to figure out what was happening. I quickly ran back to the hospital to give the ED a heads-up and tell my partner to anticipate another call. While on my way back to the ED, we were “toned out” for a “shooting” in front of the hospital.

Our dispatcher notified us the scene was safe, so my partner and I jumped into our vehicle and drove a ~100 yds down the street. The volunteer ambulance was parked on the other side of the crime scene, nearly 250 yds away. We grabbed our gear and walked over to the scene, as our patient was being removed from the vehicle. We met the Basic Life Support (BLS) volunteers in the ambulance and found our patient obtunded, arms handcuffed across his lap, unable to maintain his own airway, and bleeding profusely from his mouth and head. The police officers who escorted BLS to the ambulance reported, after the suspect was stopped, he pulled out his own handgun, held it up to his chin and fired once, shooting himself in the head. A skull fracture was noted at the crown of his skull and blood was streaming down his neck and hemorrhaging from his mouth.

The Difficult Airway:

My partner and I have worked together for 20+ years, so there was not much discussion. The monitor was applied, vitals were taken, and we both went to work with one EMT to assist. The young police officer in the back of the ambulance was not comfortable unlocking the handcuffs, so my partner had to carefully insert an IV into the patient’s hand, as he was unable to access the patient’s forearm or antecubital fossa. Intraosseous Infusion (IO) was our alternative if the hand IV was unsuccessful. While inserting the IV, I prepared for a “difficult airway” rapid sequence intubation. I was anticipating a partial airway obstruction and difficulty visualizing the epiglottis from tissue displacement, hemorrhage, and edema. While preparing my tools, I instructed the EMT to suction patients mouth and then pre-oxygenate with a Nasal Cannula and Non-Rebreather Mask at 15L.

I prepared our GlideScope, Direct Laryngoscope, Gum Elastic Bougie Introducer, Supraglottic Back-up Airway, and Quicktrach if I encountered a “Cannot Intubate – Cannot Oxygenate” situation, all within arm’s length away. After my partner pushed our induction and neuromuscular blocking agent, I positioned the patient in a back-up, head-elevated (BUHE) position. Apneic oxygenation was followed by deep suctioning using a rigid catheter to help clear the airway. I then slowly inserted the GlideScope midline along with the rigid suction catheter. What I saw was unrecognizable displaced tissue, continued bleeding and significant tissue swelling. I continued to suction as I slid the blade towards where the epiglottis tip should be. I identified what appeared to be the opening of the larynx, so I moved the suction catheter to the left side of the laryngoscope blade and kept it in place. I picked up the 8.0 ETT with my right hand, pre-loaded with a rigid stylet. While in the process of inserting the ETT, my blade/camera grazed a piece of tissue/blood and my screen became immediately blurred. I quickly removed the video laryngoscope, leaving the suction catheter and ETT in place and inserted a direct laryngoscope with a mac #3 blade. As soon as I lifted the blade, I was able to identify the patients’ vocal cords and inserted the ETT. Fortunately, patients oxygen saturation remained at 100%. ETT placement was confirmed by auscultation, ETCO2 waveform and numeric. The ETT was secured with a tube-holder and patient was transported to our trauma center. Our patient survived his self-inflicted gunshot but remains in critical condition.

Treatment Discussion:

The protocols I was operating under, state, “The GlidesScope Video Laryngoscope (GVL) is the primary device used to perform Endotracheal Tube (ETT) intubation. In the event of an unsuccessful intubation on the first attempt, the patient shall be re-oxygenated (as needed) and GVL re-attempted.” So, in this case, by switching to DL after my first attempt, I did not follow our protocols but did what I thought would give me the best chance of success. The Glidescope Ranger is not the best choice for a traumatic airway. In fact, it’s a bad choice. A better device combines an inline video display camera with the familiarity of direct laryngoscopy technique, similar to the McGrath. So, during insertion, you can switch from VL to DL, or DL to VL during the same attempt.

The rigid suction catheter we carry is a Yankanuer, which was designed by Sidney Yankauer around 1907 to facilitate clearing the surgical field during tonsillectomy.  The tip of the Yankauer has small holes, to allow the removal of blood without traumatizing delicate tissue. The Yankauer catheter should be banned in prehospital medicine and replaced with large-bore rigid catheters like the DeCanto Catheter or Hi-D Catheter.  These catheters are designed to manage high-volume particulate matter without getting clogged.

Rather than inserting the ETT with a rigid stylet, I could have used the gum elastic bougie first. If so, when my screen became blurry, I could have continued to slide the bougie blind and felt for cricoid rings and/or hold-up. I ended up not using the bougie because during my preparation, the bougie was bent & twisted when I removed it from the package and I was unable to strengthen in out. If you carry bougie’s, be sure they are stored as straight as possible and are not twisted in the package.

In our state, surgical airways, using a scalpel are not permitted by pre-hospital providers. So Quicktrach is our only alternative if a patient requires a Cricothyrotomy. Our state recently approved surgical airways, which should be rolled out later this year after everyone is trained.

As always, please post your comments.

 

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