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• W1988208051 abstract "Although the surgical cricothyrotomy procedure is used on combat casualties in the most challenging environments, we are unaware of any published report in the United States of surgical cricothyrotomy performed in a wilderness recreational setting. We describe a 31-year-old male rock climber who fell 24.4 m (80 feet), sustaining serious injuries and requiring rescue from the base of the cliff by a cave/cliff rescue team. Ultimately, a surgical cricothyrotomy proved necessary because of ongoing oropharyngeal bleeding, facial fractures creating an unstable airway, and the need to place the patient in the litter. The patient survived a prolonged and arduous evacuation. This report presents the management of the patient during the rescue and the challenges faced by the rescue team physician and others that led to the decision to perform an improvised surgical cricothyrotomy. Although the surgical cricothyrotomy procedure is used on combat casualties in the most challenging environments, we are unaware of any published report in the United States of surgical cricothyrotomy performed in a wilderness recreational setting. We describe a 31-year-old male rock climber who fell 24.4 m (80 feet), sustaining serious injuries and requiring rescue from the base of the cliff by a cave/cliff rescue team. Ultimately, a surgical cricothyrotomy proved necessary because of ongoing oropharyngeal bleeding, facial fractures creating an unstable airway, and the need to place the patient in the litter. The patient survived a prolonged and arduous evacuation. This report presents the management of the patient during the rescue and the challenges faced by the rescue team physician and others that led to the decision to perform an improvised surgical cricothyrotomy. Surgical cricothyrotomy is a necessary and life-saving emergent procedure by prehospital and emergency personnel to oxygenate and ventilate patients in a situation in which they cannot be intubated or otherwise ventilated.1McIntosh S.E. Swanson E.R. Barton E.D. Cricothyrotomy in air medical transport.J Trauma. 2008; 64: 1543-1547Crossref PubMed Scopus (21) Google Scholar, 2Robinson K.J. Katz R. Jacobs L.M. A 12-year experience with prehospital cricothyrotomies.Air Med J. 2001; 20: 27-30Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 3Fortune J.B. Judkins D.G. Scanzaroli D. McLeod K.B. Johnson S.B. Efficacy of prehospital surgical cricothyrotomy in trauma patients.J Trauma. 1997; 42: 832-838Crossref PubMed Scopus (84) Google Scholar Although there are reports of surgical cricothyrotomy procedures used for combat injuries in the most challenging environments,4Adams B.D. Cuniowski P.A. Muck A. De Lorenzo R.A. Registry of emergency airways arriving at combat hospitals.J Trauma. 2008; 64: 1548-1554Crossref PubMed Scopus (45) Google Scholar, 5Mabry R.L. Edens L. Pearse J.W. Kelly J.F. Harke H. Fatal airway injuries during Operation Enduring Freedom and Operation Iraqi Freedom.Prehosp Emerg Care. 2010; 14: 272-277Crossref PubMed Scopus (40) Google Scholar, 6Mabry R.L. Frankfurt A. An analysis of battlefield cricothyrotomy in Iraq and Afghanistan.J Spec Oper Med. 2012; 12: 17-23PubMed Google Scholar there are no published reports of a surgical cricothyrotomy performed in a recreational wilderness setting in the United States. This case report describes how the physician and others on a cave/cliff rescue team used a surgical cricothyrotomy airway successfully on a severely traumatized rock climber. At 2030 hours, after climbing with a safety rope up a rock wall, a 31-year-old male free-fell from the cliff edge 24.4 m (80 feet) to the rocky floor below. One member of the 3-man climbing group had already departed to go back to the trucks 1 to 2 miles away. The other climber witnessed the fall, ran to the truck, grabbed a sleeping bag, instructed the other climber to go get help, and then ran back to the injured patient. The fate of the patient at that time was unknown other than “he was hurt bad.” The fellow climber used the sleeping bag to keep the patient warm and helped him remain sitting up so he could breath (owing to his severe facial injuries). Phone service was unavailable at the scene. A local rescue cave/cliff unit was called out at about 2200 hours. They arrived at the incident command post at about 2300 hours. After an incident briefing, the initial rescue team, comprising 7 personnel including an emergency physician and a nurse anesthetist, drove several miles on a 4-wheel drive trail and then hiked up a creek bed with gear for 45 minutes to arrive at the scene. Because of the height of the fall the team was expecting a body recovery. About midnight with a light rain, the initial rescue team found the patient at the bottom of the cliff sitting with his back against a rock. His head was leaning forward and he was able to look around. His face appeared severely traumatized, with his jaw broken on both sides and hanging open onto his upper chest. As with any bleeding patient, gloves were used as a standard precaution. A rapid assessment revealed that the patient had multiple fractures to the face, both upper and lower extremities, and a suspected pelvis fracture. Heart rate (HR) and respiratory rate (RR) were normal (blood pressure not obtained because of the complex injuries under assessment at this time). The patient indicated he had no neck pain, and the team continued assessment cautiously in the position in which he was found without a cervical collar. Intravenous access proved difficult (because of prior intravenous drug abuse and blood loss), and ultimately a line was introduced into the left external jugular vein. The rescue team was careful to maintain the airway during this procedure, as the patient was only able to lean his head back for a few seconds at a time because of the open mandible fracture and the collapse of the airway. Oxygen and a suction device were already on their way to the scene. However, there was concern that any delay in evacuation could result in exsanguination. Ventilation was attempted via bag-valve mask although the facial injuries made it extremely difficult to achieve a good seal with the mask. With the extensive facial fractures, there was concern there may also be a cribriform plate fracture at the base of the brain. This would be a relative contraindication for nasal intubation. There was no suction available, and too much blood was present to risk intubating the conscious patient orally. A definitive airway was necessary because of ongoing oropharyngeal bleeding, facial fractures creating an unstable airway, and the need to place the patient supine in the litter to transport. Vecuronium was the only paralytic available. Owing to the inability to adequately ventilate on account of the facial injuries and concerns of paralyzing the patient and then having difficulty intubating a sitting patient, at night with a tenuous airway, the decision was made to use a small endotracheal (ET) tube nasally to protect the airway and oxygenate him, and then consider a surgical airway. First, the patient was sedated with 2 doses each of morphine 5 mg and diazepam 5 mg (10 mg total, administered intravenously 3 minutes apart. At 0030 hours, a 6.0-mm ET tube was carefully inserted into the left nares. The nasal ET tube was placed successfully, but there appeared to be a minor cuff leak preventing inflation and airway protection. The decision was made that the nasal ET tube could not be left in place during evacuation because, although the patient could be ventilated, it afforded inadequate airway protection for the litter evacuation (supine) because of the cuff leak and would aggravate the facial bleeding. Thus, a surgical cricothyrotomy was deemed necessary. With the patient still sitting in an upright position, ventilation was continued via the nasal ET tube. To induce paralysis before the procedure, a single 10-mg dose of vecuronium was administered intravenously, effective within 2 minutes. The skin was prepped with betadine, but no skin anesthetic was administered because of a lack of drug in the medical kit. A large blade from a multipurpose tool was then used to make a horizontal incision through the skin at the cricothyroid membrane landmark followed by a horizontal stab through the membrane into the trachea. Forceps were used to dilate the membrane space and a shortened 6.0-mm cuffed ET tube was inserted and inflated. When good air movement was verified and the tube taped in place, the nasal ET tube was removed. A trauma dressing was applied around the neck and a cervical collar placed, and he was then placed supine. Splints were applied to both lower extremities, and he was put into a whole-body vacuum splint. He was secured on an evacuation litter with nylon webbing. At this point, the patient had been given 2 L of intravenous fluid, cefazolin 1 g, and promethazine 25 mg. Because of open fractures and prolonged extraction time until arrival at the hospital, an antibiotic was administered to prevent infection. A second team delivered oxygen and a monitor to assess electrocardiogram and vital signs. Oxygen was started at 10 L/min. Blood pressure was 124/62 mm Hg, heart rate was 100 beats/min, and oxygen saturation was 99%. Before the start of the evacuation, the physician requested delivery of 4 units of type O-negative blood as well as additional vecuronium to maintain paralysis. Supported by intravenous fluid, transfusion of 2 units of blood, and pharmacologic management, the patient survived a prolonged and arduous evacuation. After arriving at the designated landing zone, the patient was transferred by emergency medical services helicopter, arriving at 0630 hours at a local trauma center. On admission, his hematocrit was 32 mg/dL with an estimated loss of 30% of blood volume. However, no major trauma to his head, chest cavity, abdominal cavity, or spinal cord was reported. The patient injuries included the following: open mandible fracture; LeForte 3 facial fracture; closed left elbow fracture; closed left wrist fracture; L5 lip fracture of the back; right ischium fracture of the pelvis; left tibia laceration with a portion of the bone cut but not broken; closed left calcaneus fracture; and open right calcaneus fracture as well as several other bones of the foot. After multiple surgeries, including above-the-ankle amputation on the right, the patient had a full recovery. He has had multiple different sized climbing prostheses made for him and continues to climb. The use of emergent cricothyrotomy procedures in austere environments has been reviewed recently.7Hessert M.J. Bennett B.L. Optimizing emergent surgical cricothyrotomy for use in austere environments.Wilderness Environ Med. 2013; 24: 53-56Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 8Bennett B.L. Cailteux-Zevallos B. Kotora J. Cricothyroidotomy bottom-up training review: battlefield lessons learned.Mil Med. 2011; 176: 1311-1319Crossref PubMed Scopus (24) Google Scholar This case report reveals the major challenges of performing a surgical cricothyrotomy in the austere setting in a trauma patient who fell 24.4 m (80 feet) at night. Medical personnel on the initial rescue team felt strongly the patient would not survive the evacuation to the hospital without a definitive airway. Even though it took approximately 10 hours total time from point of injury to arrival at the hospital the next day, the rescue was successful at many levels. First, the emergency wilderness services were well prepared, which included a large number of rescuers and cave/cliff instructors who frequently train and respond to technical rescue situations. The cave/cliff rescue team responded to the callout, and arrival at the incident command post occurred in a relatively short time frame. The quick assembly of the 7-person initial rescue team included a local ranger. Usually either the nurse/paramedic or the physician goes forward to the scene, but in this rescue both experienced medical personnel went forward. The 2 other climbers had clear thinking and not only rapidly went for help, but used a sleeping bag to treat for hypothermia, helped to maintain an open airway, and provided other supportive care. It was noted that the patient seemed to rapidly use the medications administered. The patient was still awake after morphine and diazepam given in a 5-minute period. It became apparent later that this was probably because of his prior and ongoing drug use. At the time there was uncertainty that there would be enough medications to treat the patient the entire way out of the wilderness, and the team had to use clinical judgment about how much to administer based on these logistical constraints. This was also part of the reason a nasal airway was established first. The physician had some experience with surgical cricothyrotomy previously. He had used surgical cricothyrotomy airway procedures on live-tissue models, assisted in a dozen or so similar procedures, and taught these surgical cricothyrotomy procedures to emergency medicine residents, but he had never actually done one on his own in the emergency department or during a previous wilderness rescue. Just as in this case, a wilderness medical provider is unlikely to have a “cric kit” and more likely will need to improvise his or her own equipment. Because preparation and training for an emergent surgical cricothyrotomy in the front or backcountry environments is such an important feature in the success of airway management, it is essential that each provider become intimately familiar with the various tools and procedures. An overview of many surgical cricothyrotomy devices and procedures including improvised tools was recently reviewed.7Hessert M.J. Bennett B.L. Optimizing emergent surgical cricothyrotomy for use in austere environments.Wilderness Environ Med. 2013; 24: 53-56Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar The most rigorous austere environment in which to manage a difficult airway is found on the battlefield. Recent reports on recent combat casualty care reveal a significant amount of compromised airways that have an indication for a surgical cricothyrotomy, and identification of correct airway landmarks in a traumatized head and neck has been a challenge at times for successful surgical cricothyrotomy placement.5Mabry R.L. Edens L. Pearse J.W. Kelly J.F. Harke H. Fatal airway injuries during Operation Enduring Freedom and Operation Iraqi Freedom.Prehosp Emerg Care. 2010; 14: 272-277Crossref PubMed Scopus (40) Google Scholar, 6Mabry R.L. Frankfurt A. An analysis of battlefield cricothyrotomy in Iraq and Afghanistan.J Spec Oper Med. 2012; 12: 17-23PubMed Google Scholar Based on more than a decade of combat casualty care in Iraq and Afghanistan, many new innovations have come forth with crossover application to civilian emergency medical services. There are now small and lightweight surgical cricothyrotomy kits that contain all needed items to perform a surgical cricothyrotomy in any austere environment. These kits can be easily implemented into the list of recent recommendation for successful application of surgical cricothyrotomy procedure in austere environments.7Hessert M.J. Bennett B.L. Optimizing emergent surgical cricothyrotomy for use in austere environments.Wilderness Environ Med. 2013; 24: 53-56Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 8Bennett B.L. Cailteux-Zevallos B. Kotora J. Cricothyroidotomy bottom-up training review: battlefield lessons learned.Mil Med. 2011; 176: 1311-1319Crossref PubMed Scopus (24) Google Scholar This case presentation clearly reveals the challenges of backcountry patient rescue. A surgical airway procedure is demanding and stressful in the best of cases, but when done in the wilderness trauma setting many things need to be done well. The authors recommend that wilderness medicine clinicians perform frequent training with many surgical cricothyrotomy airway models conducted in a medical simulation center and during medical scenarios in austere settings to be successful with this rare and emergent procedure." @default.
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• W1988208051 title "Surgical Cricothyrotomy in the Wilderness: A Case Report" @default.
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