Just in case I invented this technique, I’m calling it the Happy Inverted Trendelenburg Leveling Airway Stabilization Technique or HIT LAST. Hence the late Dr Trendelenburg inverted here.
We are always taught to deal with supine patients, but how many of them present differently? Most often when we find them we manipulate them into our treatment position. But that isn’t always best.
We responded to a female who had not been seen for days and was found prone on the bedroom floor, emesis of varying type and time drying on the floor near her face, which was slightly turned to one side, likely saving her life.
She is unconscious, responding to loud verbal and pain only with mumbles clogged with emesis. The textbook says to roll her over and manage her airway. I figured since her body has been dealing with this for sometime, I’ll trust it has an idea how to solve it. As she’s breathing I can hear the stridor and the aspirated emesis is still pouring out slowly. Some may argue it was spilling from the esophogus, but I have to assume at this point it is coming out of the airway.
Her O2 sat is in the 80′s and her pressure is in the 60s, but I’m still hesitant to roll her over and create a natural blockage for all that junk to roll right back down into her lungs.
Then I got an idea.
All we had were a bunch of police officers at the scene who broke down the door for the well being check, so I put them to work. We ruled out trauma, so the unfamiliar movements we were about to perform could be handled by unfamiliar hands.
I fired up my suction with my airway kit open and ready. I instructed the legs to be lifted slightly first, just about a foot off the ground. When they were set, I had the next two officers, positioned at her waist, lift her mid section about 8 inches off the ground. When the wave came, I was ready. We gathered close to 200 cc of emesis from that movement and the stridor cleared. Since gravity was doing all the work, I was able to get fluid a supine patient would have choked on. She coughed a few times, understandable, then her sats started to climb after replacing the O2 we had on during set up.
Now supine and onto a board for removal and her lung sounds were far better. Not perfect, but better than the globs of fluid I heard earlier. Not even rhales, ronchi or bubbles, but sludge like. Like when your foot sinks deep into a mud puddle. Now I hear ronchi.
Code 3 to the ER she’s satting 99% on high flow, color is improving and she’s opening her eyes from time to time while taking 10 good solid breaths per minute.
At the ER, after RSI meds were administered,(gag intact pre-hospital) the Doc’s have that fancy slide scope, the one with the camera on the blade. They see all sorts of chunky goodness my mighty suction couldn’t clear that she was breathing around. Stuff so old it didn’t wiggle when she breathed. Her pressure was over 100 and a nice narrow complex rhythm was beating along as they intubated and “stabilized” her.
When I described my actions to the Docs, they smiled and said, “Yeah, that works alright.”
It’s not an A list intervention, but in this case I think allowing the junk a natural escape assisted with suction was the way to go. Many may argue that immediate full supine access and intubation would have been the way to go, but she still had a gag reflex in place and I have no access to alternate intubation methods. Yet.
So the HIT LAST is born. Keep it in mind the next time you hear that voice in your head say, “Oh crap, this airway sucks.”