Volume 4, Case 7
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children}
University of Hawaiʻi John A. Burns School of Medicine
A 16-year old male arrives in the E.D. by private car after sustaining a gunshot wound to the face. The details of the incident are not clear. He is alleged to have shot himself in the mouth with a hand gun. However, several of his friends were handling the gun around the time of the incident which took place inside their car. Foul play cannot be ruled out. He is brought into the E.D. by his friends. He is in a standing position being held up by his friends. He is able to weakly ambulate to a gurney with assistance from his friends. He is now supine on a gurney in the E.D.
VS Temp not obtained, P 90, R 20, BP 125/80. He is poorly responsive, but is breathing spontaneously. He is not able to speak. Oxygen saturation on supplemental oxygen is 99%. Two IV's are established. Normal saline is infused. Breath sounds are coarse and somewhat shallow bilaterally. There is extensive bleeding from the face and mouth. O negative packed cells are requested until crossmatched blood is available. A lateral neck radiograph is obtained.
View lateral neck film.
There are no abnormalities of the cervical spine noted. No foreign bodies are seen. A surgeon in attendance discovers an exit wound in the right posterior neck. His oxygen saturation begins to decline and his respiratory effort declines. He is mask ventilated, and oral intubation is attempted, but upon insertion of the laryngoscope, he gags and coughs out blood, splattering it over several nurses and the physician intubating him. He is noted to have extensive intra-oral injuries making visualization of the airway difficult. After a second unsuccessful intubation attempt, a rapid sequence intubation is performed using vecuronium and a low dose sedative while a surgeon is standing by with a surgical airway set. Intubation is still not successful after several attempts, and mask ventilation with high flow oxygen is required to maintain ventilation and oxygenation in the 93% range. A surgeon initiates an emergency surgical airway.
Bleeding is encountered during the procedure and the surgeon requests an electrocautery unit. The electrocautery unit is able to minimize the bleeding and the tracheostomy procedure continues until a complication arises.
Can you predict what the complication is?
View the complication below:
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If you were able to anticipate this complication as the patient's resuscitation proceeded, then you successfully avoided this complication. This is a hypothetical case; however, its occurrence has been reported in the literature. Other non-reported cases are likely.
High-flow oxygen, necessary during the resuscitation of severely ill patients, is capable of rapid combustion in the presence of any sparks. In this case, electrocautery in the neck region is in close proximity to the high flow oxygen used for mask ventilation. The oxygen leaking from the mask and during exhalation through the ventilation device is sufficient to result in combustion when electrocautery sparks are produced. Electrocautery and heat cautery should not be used for an emergency tracheostomy or cricothyrotomy in the presence of supplemental oxygen.
Preparing for an emergency airway in a patient for whom oral tracheal intubation is not possible requires periodic familiarization with the emergency airway kits available in the E.D. Periodic case simulations should be used to train the entire emergency team to prepare for this emergency. Nurses who understand the consequence of using electrocautery in the presence of high flow oxygen will not allow electrocautery to be used if it is ever requested.
Case 16 in Volume 2 (Sweeping the Airway for a Foreign Object) discusses one approach for transtracheal ventilation through a cricothyrotomy catheter.
View transtracheal ventilation set-up.
While this diagram describes one approach for ventilating a patient temporarily until the establishment of a more definitive airway, proprietary emergency airway kits using dilators and/or Seldinger technique wires are available. Regardless of which method is preferred, the emergency team must familiarize themselves with an approach to an airway emergency where oral tracheal intubation is not possible.
References