As anyone who lives and works in Las Vegas can tell you, the pedestrian and motor vehicle traffic is nonstop 24/7. This means that EMS crews working in the Las Vegas Valley, including members of the North Las Vegas Fire Department (NLVFD), regularly respond to motor vehicle collisions and see injuries of all types. The following case highlights the potential for catastrophic outcomes sustained in such events.
Scene Survey & Assessment
During an early fall morning in 2011, a woman who had been working the late swing shift was driving home in her small sport-utility vehicle (SUV) when she struck the center median on a city street, causing her to lose control of her vehicle.
During subsequent investigations, the North Las Vegas Police Department (NLVPD) determined the SUV was traveling significantly faster than the posted speed limit. The impact rotated the vehicle 90°, and the vehicle rolled multiple times before it came to rest on the roof of another vehicle in the opposing lane of traffic.
Because the information provided by callers to the dispatch center presented the possibility of significant injuries and vehicular damage, multiple pieces of apparatus were dispatched to the scene, including a ladder truck, an engine and a rescue unit. When NLVFD personnel arrived, they immediately discovered a female in her early 30s restrained in her car. The scene had been secured by the NLVPD, and there was no anticipated danger to rescuers after the initial scene survey.
Upside down and prostrate, the patient had sustained major facial injuries from a collapsed A-post and roof that struck her in the middle of the face, causing extensive skull and facial injuries. Her injuries included severe traumatic brain injury—a Glasgow Coma Scale (GCS) score of 5—a floating midface and left-eye avulsion. As carefully and expeditiously as possible, the crews extricated the patient and placed her on a backboard while protecting her C-spine.
Their primary assessment revealed an obviously tenuous airway as a result of the patient’s altered mental status, a partially obstructed airway as a result of copious mid-facial bleeding and an upper airway structural collapse, including disruption of the hard and soft palates and nasopharynx.
As the lead paramedic/firefighter assessed the patient’s airway and began pre-oxygenation, the other rescuers continued the primary assessment, noting that the patient’s lungs were clear to auscultation bilaterally with normal but shallow excursion. The patient’s respirations at the scene were 6 beats per minute (bpm). Her circulation assessment revealed that radial and dorsalis pulses were present in both upper and lower extremities.
Because of the patient’s inability to protect her airway, her inadequate oxygenation and ventilation, as well as the crew’s prediction of a clinical course, the crew decided to secure her airway and transport her to the local Level I trauma center located at the city center approximately seven miles away.
The lead paramedic prepared his airway equipment and suction unit, and monitored the patient’s oxygen saturation and respiratory status to ensure that she did not desaturate or become apneic.
The EMS team prepared their airway adjuncts, including an oropharyngeal airway, King LT airway, bougie and suction device, because they predicted difficult ventilation and intubation. Southern Nevada Health District protocols currently support facilitated intubation using etomidate. After administration of etomidate, the lead paramedic allowed for any myoclonus and trismus to dissipate and attempted visualization of the patient’s airway using a Macintosh 3 laryngoscope blade. While his partner provided inline cervical stabilization, he noted a fair amount of blood in the hypopharynx and began aggressive suctioning in an attempt to visualize the patient’s vocal cords.
Using crew resource management techniques, the paramedic was able to perform bimanual laryngeal manipulation with his partners’ assistance, and ultimately, he was able to catch glimpses of a grade-2 glottic opening. Gently placing an endotracheal tube (ET) through the airway, endotracheal intubation was successfully performed and immediate end-tidal CO2 was monitored via capnometry after confirmation of proper tube placement.
After the ET tube was secured, the patient was loaded, and IV access was established. Fluid resuscitation was administered en route to the hospital.
On arrival at the trauma center, the patient received immediate advanced trauma life support-driven resuscitation. The attending anesthesiologist confirmed ET placement and positioning via direct laryngoscopy. Mechanical ventilation was started and fluid resuscitation continued via placement of a femoral central line for an initial systolic blood pressure of 55 mmHg. This subsequently improved to 94/74 and ultimately to 137/81 after the administration of 3% saline solution and two units of packed red blood cells.
The patient was tachycardic at 110 bpm, and her pulse oximetry was 100% on appropriate ventilator settings with a fractional inspired oxygen of 60%. She was afebrile. The patient’s GCS score had deteriorated to a 3, and decerebrate posturing of the left extremities was noted. Secondary examination revealed a 40 cm facial and scalp avulsion with a laceration extending from the nasal septum through the frontal sinuses over the left frontal and parietal scalp and posterior to the left ear. Brain matter was extruding from the frontal scalp defect.
The patient’s right pupil was 4 mm and reactive; however, assessment of the left pupil was unobtainable because the globe was avulsed to the lateral left scalp. No blood was noted in either external auditory canal. Oropharyngeal examination was limited due to midfacial destruction and bleeding. The remainder of the patient’s examination was unremarkable for any indication of major injuries requiring immediate intervention.
Computed tomography (CT) of the brain showed extensive subarachnoid hemorrhage, as well as intraparenchymal and subdural hemorrhage. A facial CT showed complete destruction of the left orbit, avulsion of the left globe with herniation of the left frontal lobe into the remaining cavity. Multiple other facial fractures were present, along with frontal bone and frontal sinus fractures. A CT scan of the C-spine indicated that the patient had sustained an atlanto-axial rotatory subluxation (C1 twisting on C2) without other definite cervical fractures.
Despite an obviously grim prognosis, the decision was made to do “damage control” (i.e., facial plastic, cranial, neurosurgical and spinal surgery to maximize her potential for a positive outcome). The patient was stabilized and entered the operating room (OR) with neurosurgeons and plastic surgeons attending with their respective teams.
While the patient was in the OR, surgeons controlled major bleeding and performed an emergency evacuation of subdural hemorrhage, along with a left frontal lobectomy in the area that was most traumatized.
The patient was subsequently transferred to the trauma intensive care unit (TICU) in the trauma center. While in the TICU, the patient developed abdominal compartment syndrome and required a return to surgery for a decompressive laparotomy. The patient returned to the TICU, but died approximately one week later, primarily as a result of her extensive neurological injuries and after her family decided to stop resuscitative measures.
This case presents the potential for crews to be confronted with patients that present with substantial challenges for airway management in a patient due to head and facial trauma. It also illustrates that proper preparation and anticipation of airway difficulties helps prevent adverse procedural outcomes.
This article suggests an algorithmic approach to difficult airway management, using a safety- and redundancy-based approach metaphorically tied to a similar approach used in the sport of skydiving. (See an algorithm for this at airway.jems.com.)
Although this approach is applied to rapid sequence intubation, its premises may be applied to drug-facilitated intubation as well. Field providers should remember that this particular algorithm provides a single approach to airway management, and that there are many others described in the prehospital literature.
This case reminds us, as EMS providers, how essential it is to always be prepared. Proper preparation can help increase first-time success even for the most challenging of airways. This article originally appeared in April 2012 JEMS as “Traumatic Airway: Algorithmic approach aids providers in managing severe case.”