Case of the Month
May 2005

52-year-old male — headache

At 1130 hours your three-person aid car is dispatched to a 52-year-old male who is complaining of a headache. While en route dispatch relays information that the patient has had a headache all morning and pain relievers have been ineffective in relieving the headache.

On arrival you find the front door to the house ajar and, upon entering, you find the patient alone, face down, holding the phone and moaning. You attempt to get him to respond but he does not. Your team rolls him on to his back and becomes apnec for about ten seconds. You direct a team member to bag the patient while another checks for a pulse. As you are requesting a medic unit the patient starts breathing again.

You further evaluate the patient while one partner assists respirations with a bag-valve-mask and the other obtains a blood pressure. The patient's arms are held tight to his chest and he has a grimace on his face. He appears flush. He has a blood pressure of 280/palpation and a rate of 70.

The EMT who is breathing for the patient is using the head tilt, chin lift with the One EMT technique, but the patient's respirations are noisy as his airway is not adequately controlled. An oral airway is placed but the patient does not tolerate it so it is immediately removed.

To remedy the airway problem, one EMT holds the patient with a modified jaw thrust while the other EMT ventilates. This alleviates the noisy breathing. A few moments later the patient becomes flaccid and the airway is suddenly easier to manage. His pupils are very small at about 2mm even though the room is not brightly lit. The team takes a blood sugar reading.

The medic unit then requests a short report, which you give. You begin preparing to package the patient for transport.

LOC	—	Unconscious, not responding to noxious stimuli
RR	—	40/min
HR	—	70 full and regular
BP	—	280/palp
Skin	—	Flush and warm skin, mildly diaphoretic
Eyes	—	Equal eyes that are 2mm and do not react to light
Chest	—	Clear lung sounds, stable chest with palpation
Abd	—	Soft and unremarkable
Ext	—	Patient is flaccid and does not react to pain.
Pulse Ox	—	98% with high flow oxygen/BVM
Glucose	—	175 mg/dl

The patient starts to vomit violently. The team quickly turns the patient on his side and waits for the vomiting to stop. As soon as he finishes you suction out the remaining emesis and roll him back on to his back. Your partner continues ventilations.

S	—	Initially reported as headache, but patient is now unconscious
A	—	Unknown
M	—	Unknown
P	—	Unknown
L	—	Unknown
E	—	Patient had told dispatch that he had a headache all morning.

Your team rolls the patient onto a backboard and quickly straps him down (a c-collar is not needed). While moving the patient to the apparatus the medics arrive. You move the patient to the back of the medic unit where he is reassessed.

His pressure is now 216/P and the heart rate is the same. The medics obtain permission for IV and intubation. Prior to attempting intubation one of the medics give the patient 100 mg of lidocaine and 100 mg of succinylcholine. As the patient goes flaccid from the succinylcholine, his airway becomes difficult again, however the jaw thrust is immediately used and the airway is corrected.

The medic intubates the patient utilizing breath sounds, end tidal CO2 monitoring and oxygen saturation to confirm the effectiveness of the tube. The patient is then transported to the hospital with an EMT driving and a second EMT in the back with the medics.

At the hospital the patient is quickly evaluated in the emergency department and then is sent to CAT scan for an image of the head. It is found that he has a sub-arachnoid hemorrhage and the bleeding in his head is severe. By the time he arrives in surgery he has "blown a pupil" and his prognosis is deemed to be very poor.

Head Bleeds
Head bleeds can take several forms and range in scope from minor (even unnoticed) to catastrophic. Some of the symptoms of a serious head bleed includes headache, decreased level of consciousness, forceful vomiting, seizure, and partial paralysis. Signs may include hypertension, changes in respiratory pattern (usually after unconsciousness), and bradycardia. Often the EMT will watch these signs and symptoms progress during the care of the patient. As part of your treatment note these changes and anticipate what will be needed as your patient's condition deteriorates. The complaint of headache must always be taken seriously and fully investigated as even young people can fall victim to a cerebral aneurysm.

The lesson learned from this case: Airway management is one of the most important things an EMT does. Know how to do it well and how to adapt to changing patient needs.

We most often execute airway management through the head tilt, chin lift method - and we are frequently very successful with this method. However every patient is a little different anatomically, so we need to be well versed in several methods of airway control. Below is a review of important airway management techniques used in this case.

One EMT Technique (BVM)
With this technique the EMT positions him or herself at the top of the patient's head and opens the airway by pulling back on the chin. The EMT then braces the patient's head between the thighs to keep the head tilted. Bagging can now be accomplished easily and the EMT can easily view for adequate chest rise. See page 92 of Patient Care Guidelines.

Oral Airways (oropharyngeal airway or OPA)
OPAs are shaped plastic devices that hold the tongue out of the airway. These devices should be considered when you are bagging an unconscious patient who does not have a gag reflex. Any indication of a gag should result in the immediate removal of an oral airway to avoid vomiting. See page 87 of Patient Care Guidelines.

Modified Jaw Thrust
This method of airway control is the best choice when a cervical spine injury is possible. It is also useful when the head tilt/chin lift maneuver does not offer an adequate airway. This method requires two EMTs in order to be effective. One EMT holds the airway open by gently extending the jaw forward. This position is maintained by one EMT while the other performs the ventilations with a BVM. It is a very effective technique.

Emesis Control and Suctioning
Vomit can cause serious damage to lung tissue and often leads to aspiration pneumonia when as little as two tablespoons of emesis reach the lower airways. This is why the proper control of the vomiting patient is so crucial. Vomiting in the unconscious patient can be greatly reduced with proper airway control. But if it does occur, act quickly! Roll the patient on his side, allow for the vomiting to finish, and suction well before rolling the patient back on his back.

Vomiting is often subtle in the unconscious patient, so the individual who is bagging needs to be constantly alert to the signs of vomiting. Gurgling respirations, the presence of vomit in the upper airway or just a change in the way it feels to bag the patient can all indicate that the patient has thrown up. Act quickly so that the rest of your efforts are not in vain.