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Tue Jan 9 21:04:59 GMT 2007

I agree Ron. An L.M.A is more than appropriate.
Thanks 
Anthony Caruso

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Ronald Gross
Sent: Monday, January 08, 2007 7:25 AM
To: traumalist
Subject: Re: "emergency cricothyrotomy"

Tough call, Lance, 'cause we weren't there, and that counts for a whole lot.
Now, having said that, first move was appropriate - pre-oxygenate.  While I
understand that the flight was going to be a long one, and I too would be
concerned enough, given the circumstances and presumed SCI with the
possibility of ascending edema and further respiratory compromise, to
consider intubation.  The good news is that the patient was - by your report
- maintaining his own airway with a SO2 of 94% on 60% mask.  Couple of
questions - did you or the doc have a bougie or LMA available?  How about a
CombiTube?  I think - and again being there is half the battle when you are
asked to be the Monday morning quarterback
- those might have been reasonable options in a fellow that was maintaining
his sats and was easy to breathe with a BVM. Given the fact that you are a
paramedic, and the doc was not able to intubate, forgive me for being a bit
harsh when I say that I think that he should have left his ego at the door
after 3 failed attempts and at least given you a look, as long as you were
able to maintain adequate oxygenation - and I must stress that last part of
the statement.  If you weren't then going to a cric would have been
appropriate. 

Just my long distance 2 cents.

Take care,
Ron 

>>> "LanceO Oosthuizen" <LanceO at sedibeng.gov.za> 1/7/2007 1:46 PM >>>
Hi All

I am an ALS paramedic from SA just south of Johannesburg. Just recently I
received a call of a male patient 29 who came off a quad bike in a remote
area just out side the town where I live. The mechanism was that he veered
off the road and hit a wire fence and well cemented pole next to the road.
He was not wearing a helmet.

O/A I found the patient lying supine about 4 m from the point of impact. The
patients vitals were as follows:

GCS = 12/15
BP = 110/45
Pulse = 64 bpm no significant pathology on the ECG tracing
HGT = 5.4 mmol/l
SpO2 = 94% with 60 % re-breather.

H-T revealed that the patient has no neurological function from the
shoulders down, even to deep pain stimulation. there were areas of mottling
and the patient had parasthaesia over the left anterior abdominal area.
There were abrasions to the hands and the left flank. The patient had an
ethanol smell on the breath and bystanders mentioned that he had been
drinking.

My immediate action was to control c-spine manually and fully immobilize the
patient, insert bilateral large bore I.V. lines. We were about 100 km from
the nearest facility with a neurosurgeon. My reaction was to task the
medical helicopter to cas-evac the patient to the hospital.

When the Chopper arrived the attending Doctor assessed the patient and
elected to RSI the patient, due to the distance (20 min flight) and patient
was intoxicated. After administering etomidate and sux  the Doctor then
proceeded the intubation, first attempt was unsuccessful the patient was
then pre-oxygenated to a sats of 99%. Second and third attempt was also
unsuccessful, but managing to pre-oxygenate the patient after each failed
attempt. He mentioned that the patient has a difficult air-way and was
difficult to visualize the cords.

After the third failed attempt the Doctor then elected for an "emergency
cric" on the patient. I requested one more attempt by my self and he refused
me to have an attempt, I made it known to him that I thought to go for an
cric was a bit of a harsh move now. None the less he still proceeded.
Several attempts were made at the cric, but with no success, I then stood in
and lost my temper a bit and told the Doctor to stand aside and that I would
take over now and attempt to intubate the patient orally. I managed to
intubate the patient on the first attempt visualizing the cords with ease. I
would score the patients air way a 2 for difficulty at the most as he did
have a rather large tongue and the epiglottis was also larger than usual.

I am just requesting the view of any one on this call, on the 24th January
2007 I will be attending a M&M on this matter.

Regards,

Lance
Critical Care Assistant Paramedic South Africa.

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