Alright I was watching a Documentary on World War I And it was talking about the Various new Weapons systems that were used at the Time, Airplane, Flame Throwers, Posine Gas, And Submarines and such. They eventually showed some pictures of the causlties of these weapons and one picture showed a man that had His entire lower Jaw shot off. You know he lived throught it because his Eyes were open and his face had scare tissue. This photo struck me with this thought... "How in the Hell would I treat that!!??"

Okay I have recently Completed both an EMT Course and National Registry so I am not a complete stranger to the Medical field. During my EMT Class they told us what to do about Eyeballs being outside the eyesocket, *****es(I guess even the Anatomically correct term for the Male genital are consider offsive to the Military.com Net Nanny) getting cut off, what to do after a woman is sexual assulted, hell they even showed us some pictures of a guy that was impaled on a telephone pole and lived. and they told us how they saved him. But in all the class they never told us what to do if there is a Amputated Jaw or Avulsion of a Jaw.

In all honesty if I found someone Missing their Jaw I would be in almost complete shock It would take Me a Minute to Even think about the ABC's
I mean you would Have to Control the Bleeding first in order for you to actually Control the Airway because all the blood would flow into the Airway. You would have to be very careful on how you Bandage so it would not obstruact the airway.

How do you perform Rescue Breathing on some one like this?

Also are the Any consideration I have to make in reguards to C-Spineing the Patient? Because I am goning to assume that if someone is missing their Jaw there is a pretty good chance they might have a neck injury. This is kind of linked to the above question because the whole "JAW THRUST MANEUVER" just went out the window.

Are there any tricks to bandaging an Amputated Jaw?

If I knew how and also had the correct equipment could I or should I intubate?

If the back of the Tougue is still attach is there any way to reduce the chance of it sliping back into the airway? Or am I going to have to keep my finger on it all the way to the Hospital?

This post can be sum in this question, "What can someone with BLS knowledge do to Keep this patient alive until ALS shows up or until a M.D. can take over?

I was trained in the Civilian world and I am assuming that this is more of a military Situation. I was hoping the Army may have trained you 68w's and 18D's in the situaion and that you are willing to pass on your knowledge to a curious Devil Dog. Thank You.

I believe since the jaw is gone there would be also bones dislarged and that is why you would likely not be able to go that route to establish airway. Further, when there is any facial trauma you would not intubate, because of bones that can wander upwards into the brain etc.

I am guessing if you are out there without much equipement that you would likely use a cricoid incision to establish airway. Also, using this method would alleviate you from the problem about the worry with the tongue. That is my guess anyway.

You still would go through the ABC's, since without an airway nothing else would matter. I certainly would stablize his spine by the use of another person, or the best available method you can find out there; guessing that a C collar at this time would not work so well .

This message has been edited. Last edited by: SusanneCollins,

quote:

Originally posted by SusanneCollins:
I believe since the jaw is gone there would be also bones dislarged and that is why you would likely not be able to go that route to establish airway. Further, when there is any facial trauma you would not intubate, because of bones that can wander upwards into the brain etc. So it is simular rules as a NPA?

I am guessing if you are out there without much equipement that you would likely use a cricoid incision to establish airway. Also, using this method would alleviate you from the problem about the worry with the tongue. That is my guess anyway.

You still would go through the ABC's, since without an airway nothing else would matter. I certainly would stablize his spine by the use of another person, or the best available method you can find out there; guessing that a C collar at this time would not work so well .

Thanks for the Response. the Whole C-spine question was in reguard to the Jaw thrust Maneuver becuase it allowed for simltainious control of the airway and C-Spine. and Seeing if there is know jaw there is no Jaw thrust maneuver. But I would try to do something to stabilize his head. Lets take me for example. I don't know the First thing to do...excuse me I don't know the Second thing about performing a Cricoid Incision. I am taking the wild guess the frist step in making a cricoid incision is to steralize the scalpal and incision area. but but beyond that I wouldn't know Exactly where to cut, how Deep to cut and in what direction to cut, to cut up to down, down to up, left to right, right to left.

I am only trained in Basic Lifesaving Skills. So I am wondering is the only way I can save his life is learn how to do a Crioid incision?
Or is there something else I can do that is withing my scope of Practice? Any Insights Appreciated. thank you.

I am trying to figure out if you speak about being in a war zone and how you would react. My thought is, but I am not positive, that even if you are an EMT in civi life that you at this time could do the cricoid incision.

The reason for this: in a war situation if you do nothing he will die, at least by you performing this he has a chance to live. It is not a difficult procedure. Would you use sterile equipement ding ding ding "Of course" Would you still perform it without having much stuff available? Hell yeah, he will be dead either way otherwise.

I was trying to think what else you could do. I am assuming if you had suction equipment available you could suction the blood out of his throat. However, obviously you can not ventialte this way, because how are you going to get a seal to ensure that ventilation is adequate? I would not mess around in the face at all for the prior reasons mentioned in the other post. I would just cut and pray that I knew what I was doing lol.

Cricoid incision is described on many powerpoints and its fairly easy to do. You feel where your adams apple is. You can tell where the cartilidge is when you press on that area and between the cartilige you slice from right to left with a scapel. Then you insert a straw if you have too and ventilate in that manner.

Now if someone is in a car accident and you are a civi EMT you have scope of practice issues that you must adhere too, I doubt you can do a cricoid: In that instant all you really can do is suction or clear the airway maybe use the ambu bag and try to push some air down that thoat, but I do not think that this truly would be helpful

However, I think in a war situation out there in nowhere land with not much available and the knowledge that no 911 amublance is going to get to you quick; you are expected regardless if you are EMT or not to do something to save his life.

Hope someone reads this post who is more versed in terms of the legal issues can answer this point.

I go with cricoid though.

No clue how it was treated, but a guy from my hometown was shot in the face in Iraq and lost his lower jaw.
The three shots that hit him, came through the driver's window of the truck he was in, missed the driver and hit him in the head. In addition to his jaw, he lost his right eye and almost everything forward of his ear on the right side of his head. He lived.

Wow, its amazing that someone can live through such an ordeal. Alot of rehab for him I am sure and surgeries that followed.

On top of all that, he was Army Reserve, when he deployed, he'd stored all his stuff at his ex wife's house. It burned when he was still at Walter Reed. Even lost his Purple Heart.

THEN, the Army rated him at 30% disability. No jaw, no right eye, no right ear and all the auditory system with it. 30%!!!

You got to be kidding me. That is just...outrages!

That poor man, so much bad luck and then you get kicked into the butt after going through so much difficulties and life changing events. That is just so horrid and then you have other soldiers who melinger...and they get served front to back. Just sad.

That is an outright slap in the face Gumby. That is what peaces me off the worst. The way VA is. With no fix on the horizon.

I know he appealed it, but I've never heard the outcome.

Getting back to the original situation, assuming you are a BLS provider only:

1. Either log-roll or - if you can ascertain no neck injury - position on the side to allow drainage of blood, saliva, etc.

2. Forget a mask, AMBU, etc. - nothing will make a seal. If O2 is available, position near mouth and nose and increase the % delivered.

3. IF you have the training and IF respirations are compromised, a cricoid incision makes sense. You don't need a scalpel. In these sorts of situations, a penknife or K-BAR will do, and the barrell of a pen has been used to keep the opening patent.

4. You can do mouth-to-straw/pen/whatever respirations; inhaling oxygen yourself is another way of at least marginally increasing the O2 being delivered to a patient you're resuscitating if you are not using mechanical means of delivery.

5. If you can sweep out loose teeth, bone fragments and the like, do so - but not by digging. Just what you can easily see and reach.

If you have more advanced training - ATLS for example - and more equipment:

1. Intubate or insert an oral airway, provided you can visualize adequately. Otherwise the cricothyroidotomy is the better way to go.

2. Once the airway is established, you can try to control bleeding by elevating the head. There aren't a lot of pressure points you can access readily! Unfortunately, if a major vessel is compromised (jugular veins, carotid arteries), the game is pretty much up without rapid access to surgical repair; fortunately, if they are NOT involved, bleeding from the face and neck LOOKS a lot worse than it often is.

I don't know if this makes much sense - and it's certainly not laid out in order of priority - but it's a start. Interesting scenario ... that I hope I never come across.

quote:

Intubate or insert an oral airway, provided you can visualize adequately

Ty for that response Cider; now I have another question about the quoted area up there.

I am not certain but I thought i recalled from my nursing school the intubation would not be an option, because if there is facial trauma likely there are bone factures that might travel to the brain? Maybe I was confused about that part. So I could still intubate?

I agree about the topic. I wish more people would post incidents like that it would be a great learning tool to see what other people would do in some rare instances. Great post.

Since we can all have different concepts of a particular thing, here's mine regarding "facial trauma": it primarily involves the zygomatic processes, eye orbits, nose, temporal bones and front part of the skull. In other words, mostly from the nose up.

I think of "jaw amputation" (an awkward but not entirely inaccurate phrasing) as involving primarily the mandible with some involvement of the maxilla. And obviously dental fractures/avulsions and extensive soft tissue damage. Again, in other words, mostly from the nose down.

That said, there is less danger from these bony fragments being pushed into the brain than from, say, an orbital or frontal fracture with bony fragments scattered about.

Again, adequate visualization of a clear (or clearable) oropharynx and beyond the larynx is required to do a safe intubation. Inserting an oral airway is usually done blind, so that might not be the best way to go - second-thinking my own post.

Hope that clears it up a little - at least so you know how I got to the approaches I came up with.

It seems that with trauma, many answers lie at the feet of anatomy, anatomy and anatomy. With disease, the answers lie at the feet of physiology, physiology, physiology. Except when they intersect.

Yes, thank you that was very helpful indeed.

I like how you explained your thinking process and you obviously thought this out with a lot more detail then me lol.

Now here is another question. How does this all work with staying in the scope of practice.

Lets say, we are in a combat environment and we are somewhere out there in nowhere land and you as a Nurse, or Medic are the only medical people out there. Is scope of practice still then applied or could you under some severe circumstances apply something that might not be in your scope of practice?

I am asking this, because as a medic you appear to have more leeway in the Army then you would have as a civilian, but then as a civilian you more likely have a hospital and access to such available.

Thanks you Ladies for the Responses. Looks like if I want to truely be able to save someone life I am going to have to learn how to do a Cricoid incision.

I just have a couple of side questions

Cider33_Alpha what would you call an amputated jaw?
Amputated mandibal? I do admit it is kind of hard to think of the Jaw as something that can be cut off or ripped off, but it can happen and it is really unusual to hear something like that happening. so what would you call it?

Also about Susan's scope of practice question. I always assumed the Military is going to be a lot more forgiving in reguards to practicing outside your scope of practice if it is truely I life or death situation.
While I generally see the civilian side ready to crack the whip at any violation. Do you think this is acurate?

Rigger & Susanne - I agree about the military and the scope of practice. In the field (military), field expediency is a GOOD thing - and it's easier to ask forgiveness than request permission. Especially in the thick of things. That's not to say that someone won't try to bite your azz in hindsight (no pun intended), but in an emergency I'd do what I had to do with little thought to the Nurse Practice Act in my state! My state's laws were drafted with the US in mind ... not A-stan or Iraq.

As to what to call it ... hmmm. I've seen references to "bilaterally disarticulated mandible," descriptions of avulsions and blast injuries, but never truly an amputated mandible. I'd think it highly unsual to have complete amputation anyway - it's more common to have one side blown away or multiple fractures to the point that reconstruction using existing bone is not possible (hence prosthetic/titanium jaws), but not the whole lower jaw.

Thank you again that answered a lot of questions.

quote:

I am taking the wild guess the frist step in making a cricoid incision is to steralize the scalpal and incision area. but but beyond that I wouldn't know Exactly where to cut, how Deep to cut and in what direction to cut, to cut up to down, down to up, left to right, right to left

No, the guy cannot breath period and if he can't he dies STERILITY IN THIS CASE GOES OUT THE WINDOW!!!! Any infection can be dealt with with antibiotics once in a stable hospital environment.

If you want you can make the incision, easiest way for a cric, cut the drip chamber on an IV line in half, find the cricoid arch in the neck use the spike on the IV drip chamber to puncture. The Ambu bag fits the cut drip chamber nicely (there is a reason for this).

As for Scope of practice no need to be all that concerned with it. Combat Lifesavers are now taught to perform a cricothyroidotomy, so if an infantryman can do it in an emergency a medic should be able to without scope of practice coming into play to much.

Bottom line is this, don't open the airway the guy dies screw up the cricothyroidotomy the guy dies. Try the cricothyroidotomy and everything go right the guy lives. So it boils down to no airway=death, screw up and say slice an artery during the cricothyroidotomy the guy dies. Was the outcome changed in either manner. But if you do it right the guy lives. So it is a crapshoot either way if the person doing the cricothyroidotomy gets lucky and is successful the outcome might be better than nothing at all.

If you have done a cricothyroidotomy correctly and the airway is good then you can move onto stopping the bleeding. Yeah that is going to be difficult. Elevate the head as stated. If you have the cric, you may be able to wrap the whole area maxillofacial area with combat gauze, hemcon bandages, kerlix, etc. But as stated it will be a crapshoot game either way, can't apply a tourniquet and IV might not do too well. I would suggest platelets to help with clotting but not like you carry those around with you. So that is about it for bleeding, you might be able to apply pressure to ONE carotid artery to slow it down but not BOTH.

C-Spine could stabilize with blocks on each side of the head and straps if you have the right type of spine board otherwise try duct tape to a sturdy surface applied across the forehead maybe sandbags or boots on each side of the head.

Suction as mentioned will be a must to keep any airway clear.

Well what to I do if I have to apply suction ? I do exactly that I can take a piece of tubing from my Stethascopes( If I have one ), and suck what ever kind of fluid or debry I can using my mouth.It's no different than an Oklamhoma Credit Card ( Garden Hose ),when you need gas.The trick is how not to suck to much gas in your mouth as with any other suction technic.Now as for me I carry a sanke bite kit which has a little suction cup in my first aid kit which was an old M-16 Ammo pouch which holds more on my pistol belt than the pouch issued with the first aid dressing alone. I also use the old bandolears to hold field dressings instead of rounds.In making a Cricoid inscission I just like the old Skilcraft government ball point pens as with a nip of my Swiss Army knife makes a nice tube for maintaining airways.since I carry my Swiss Army knife and some toe clippers on my Army of One key chain strap( I got from the army recruiter when I tried to sign up after 9/11). which goes around my neck I can check feet and toes as well as open a can of beans without ever having to stop suction or maintain an airway.Ok so I don't have all the latest technology but it sure beats Latrine Duty !