Dr Amy Armstrong amp Dr Fraser Waterson Request for Medic 1 Festive Friday night approx 1720 Initial info 43M prison inmate HMP Glenochil alleged assault with HI facial and L eye injuries ID: 1047369
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1. Medic 1/Airway M&MJanuary 2024 Dr Amy Armstrong & Dr Fraser Waterson
2. Request for Medic 1 Festive Friday night approx. 1720 Initial info: 43M prison inmate HMP Glenochil, alleged assault with HI, facial and L eye injuries Agitated and GCS 10 with SASCommenced transit to hospital however requested trauma desk escalation requested in view of HI/agitation, declining GCS and poor SpO2ACCP attended, persistent hypoxia/agitation/ difficulty ventilating Medic 1 requestRVP arranged J6 M9
3. On arrival:
4. ABC…A = threatened, noisy, plenty of blood evident - midline lower lip laceration oozing, anterior tongue laceration oozing, right nostril oozing & left eye bleeding, broken teeth evident B = spontaneously self-ventilating, RR30+, SpO2 81% on 15l O2 but not tolerating mask well, equal AE/expansionC = HR 120-140, SR on monitor, BP 128/94, easily palpable radial pulse D = GCS 9 (E3, V2, M4, left pupil not visualised due to swelling/bleeding)E = incised wound to left neck (?Zone 2), significant L sided facial swelling & eye injury to medial canthusTop to toe by ACCP prior to our arrival - no injury suspected below clavicles (visualised front/back/sides, only area not exposed perineum)3 x prison officers in attendance, no notable PMH per them and NKDA
5. So…Team Lead: AA (cons)Airway: FW (ST7)Drugs: JS (ACCP) Airway Assistant: RM (CN)
6. DSI Agreed to first look and suction in view of bleeding and anticipated airway difficulties, patient in ramped/optimised positionFIRST LOOK VL 4, G1, airway soiled ++ (blood), tissue visible between cords Suction to good effect, unable to pass bougie - transient drop in SpO2 to <80% (though note subsequently identified that BP cuff and SpO2 probe on same side so ?accuracy)Withdrew to BVM - bagged back to SpO2 91% (> starting sats)SECOND LOOKVL 4, G1 view, size 8.0 SACETT passed easily over bougie…However notable air leak and obvious cuff failure identified via pilot balloon deflation and when air leak felt/heard via left submandibular wound Wound covered with adhesive defib padAttempted exchange over GEB however unable to pass ?obstruction distal to ETT. Decision made to switch out ETT under direct visualisation Second ETT passed successfully with nominal cuff inflation ETCO2 confirmed with bilateral chest wall movement.
7. Transfer to RIE: Left scene 1915 (DSI started approx. 1850)Uneventful Enhanced trauma call pre-alert made to RIELast obs prior to hospital arrival: HR120, NIBP 140/90, SpO2 99% on FiO2 0.4Progress: CT – see next slide!Theatre for repair of 15cm neck wound (down to mandible but not communicating with mouth or involving neck structures) and complex facial wound Prolonged delirium (no HIE on repeat CTBs) and 18-day ICU stayTF SJH – OMFS/ENT/oculoplastic inputDischarged last week back to Glenochil Prison
8. CT
9. DiscussionChallenging situation Complex decision making – difficult airway and non-PHEM personnel Ambulance vs. elsewhere Crowd control Complex airway decision making Wider context – Medic 1/kit familiarity