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CASE PRESENTATION

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A 30-year-old male arrives by Emergency Medical Services (EMS) helicopter with a tree branch impaled in his neck (see Figure 24–1). It is apparent that substantial force was involved in this impaling injury.

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FIGURE 24–1.

A patient is admitted to the emergency department with a tree branch impaled in his neck.

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He is a healthy lumber-worker in a surrounding mountain area. The injury occurred 4 hours ago, the patient was extricated from the scene and the medics received report that there was a moderate amount of blood at the scene. Shockingly, he is intact neurologically with normal movement and sensation. His airway was intact in-flight but the medics are now reporting some increased hoarseness and confusion. They were with him for 2 hours and administered 4 mg of midazolam and 200 mcg of fentanyl. He kept pulling off his oxygen so they left it off even though his oxygen saturation was 94% with the oxygen by non-rebreather face mask. They are concerned that he seems to be getting more agitated. The patient denied past medical history, medications, or allergies.

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The patient is sitting semi-upright in restraints, slightly agitated and appearing very anxious. His vitals are: BP, 150/110; HR, 130 bpm; RR, 32 breaths per minute, and a pulse oximetry of 90% on room air. He is moderately cooperative for the examination but seems anxious and his voice is definitely hoarse. The neck wound is not pulsatile but there is oozing blood.

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INITIAL PATIENT ASSESSMENT AND MANAGEMENT

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What Are the Important Considerations in Evaluating This Patient?

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This patient has a suspected penetrating tracheal/esophageal injury as evidenced by his hoarse voice. He is also at significant risk for a cervical spine injury and has the potential for rapid deterioration to his airway and cardiovascular stability. The most important first step is to get control of the patient. Aggressive initial management is necessary in order to safely care for the patient, for both the team and the patient's sake. Immediate chemical restraint is necessary.

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The presence of this large impaling foreign body in his neck signals that intubation in the supine position is highly unlikely. Therefore, it is imperative to better evaluate this airway in order to strategize how to proceed with intubation. His hypertension is most likely due to anxiety from the injury. His tachycardia could be due to anxiety as well or blood loss and impending shock. He is a young patient who should have adequate cardiorespiratory reserves. His initial oxygen saturation is concerning but since he is thrashing around it is unknown how he might respond to supplemental oxygen. He has no other signs of trauma and associated injuries. Therefore, besides his wound, you should have no further complications.

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