Kenny Bramwell

A 50-year-old woman presenting after a motor vehicle collision

Dr. Daniel McGillicuddy: The patient is a 50-year-oldwoman who was involved in a single car, high-speed motorvehicle collision. The patient was an unrestrained driver ina car without air bags who sustained severe blunt forcefacial trauma secondary to the steering wheel, and wasbrought in as a non-trauma to this community hospital. Shewas also intoxicated and agitated. The patient was unableto provide a past medical history, social history or anyinformation with respect to the accident. The pre-hospitalfingerstick glucose level was normal. The patient’s vitalsigns were a heart rate of 88 beats/min, a blood pressure of160/palpation mmHg, a respiratory rate of 24 breaths/minand an oxygen saturation of 96% on room air. The patientdid not have a temperature recorded. The physical exami-nation revealed a patient who was awake, but agitated. Shewas in cervical spine immobilization as well as immobi-lized on a spine board. The head examination revealedblunt trauma to the left orbit and mid face. She had peri-orbital edema on the left, bilateral massive epistaxis, andshe was actively vomiting blood. The midface was stable,the trachea was midline, and she had normal bilateralbreath sounds. The heart sounds were regular, there was nojugular venous distention, and the pulses were fullthroughout. The abdomen was obese, soft and non-tender.The FAST examination was without free fluid. The pelviswas stable. The Glasgow Coma Score was 12 due toaltered speech. The back and extremity examinations werenormal.Dr. Peter Rosen: Dr. Ban, what is your assessment ofthis patient?Dr. Kevin Ban: The intoxicated, combative traumapatient presents unique challenges for the EmergencyPhysician (EP). The combative behavior may be secondaryto any number of underlying causes, including intoxication(drug or alcohol), head injury, hypoxemia, hypovolemicshock or underlying medical conditions (diabetes withhypoglycemia). The most important priority for the EP is toobtain immediate and definitive control of the patient’sairway to facilitate treatment and diagnosis of the severelyinjured patient. There is controversy as to whether or not toparalyze these patients or to sedate them without additionalneuromuscular blockade as is usually done in a rapidsequence intubation (RSI).Dr. Rosen: Dr. Davis, what is your opinion regardingintubation with sedation alone versus a RSI with neuro-muscular blockade?Dr. Daniel Davis: This is going to be a tough airway,and I’m a bit reluctant to paralyze someone like this. Shehas multiple features that raise concerns about being able tointubate her successfully: obesity, c-collar, facial trauma,blood in the airway. It is reasonable to consider ketamine inthis patient, which might allow an attempt to inspect the

An intoxicated man with facial trauma

Dr. Colleen Birmingham: The chief complaint is statuspost battery. The patient was a 51-year-old man who wasbrought in by Emergency Medical Services (EMS). EMSwas called because bystanders found the patient intoxicatedwith obvious facial trauma. The patient was combativewith EMS. He told them he had been beaten, but wouldn’tprovide a further history. By the time he arrived at triage,he was yelling and combative. Past medical history, med-ications, and allergies were all unknown. On physicalexamination, the vital signs were: temperature 37 C(98 F), blood pressure 196/130 mmHg, heart rate 96 beats/min, respiratory rate 24 breaths/min, and oxygen saturation100% on a 100% O

A 67-year-old man with anterior neck swelling.

Dr. Carlo Rosen: The patient was a 67-year-old manwho just got off an airplane from Florida complaining ofanterior neck swelling that developed either late the nightprior or early that morning. He was concerned enough inFlorida that he wanted to come to Boston, where all hisdoctors were, so he obtained a flight to Boston with hiswife. He said over the past few hours, the swelling hadgotten worse, and that he had developed a little bit of ahoarse voice. Initially he got put into one of our resusci-tation rooms, and a quick history revealed that he was oncoumadin for atrial fibrillation. He also denied fevers,denied any history of anything like this happening in thepast, denied rash or any pain or discomfort anywhere else,and was able to give a full history by himself. Other pastmedical history was significant for a previous carotid stentand asthma. He did say he had allergies to shellfish,associated with a rash, and took no other medications butthe coumadin. Are there any questions?Dr. Richard Wolfe: How many hours passed from theonset of his symptoms to the point he presented?Dr. C. Rosen: He was vague about the exact timing. Heprobably had symptoms the night before starting with theswelling, and the voice change happened over the past fewhours.Dr. Wolfe: You saw him roughly at what time?Dr. C. Rosen: Probably early afternoon. He took a taxifrom the airport to the Emergency Department (ED).Dr. C. Rosen: Tomethereweretwoworrisomepartsto the history. One was the swelling which had gone onfor probably 18 h. The second, and more concerning,was the voice change, which hesaidhadoccurredover2–3 h.Dr. Wolfe: I am not clear why he was taking coumadin.There was absolutely no history of any trauma, correct?Dr. C. Rosen: There was no history of trauma. He wason coumadin for atrial fibrillation, and said he had beentaking his usual dose. On physical examination the vitalswere: temperature of 36.5 C (97.7 F,) pulse 117 beats perminute, blood pressure 156/88 torr., respirations 25 breathsper minute, and oxygen saturation 99% on room air. Helooked very comfortable. The only alarming thing aboutthe examination was he had a slightly hoarse voice. I thinkwe picked up the voice changes more than he himself or hiswife did. He clearly had anterior submandibular neckswelling from the whole anterior mid to upper part of theneck. He had some tongue elevation and some sublingualecchymosis; it was not woody, but it was definitely feelingfull. The rest of the examination was normal. He wastotally appropriate and wide awake and not in a whole lotof distress.

Acute shortness of breath 10 years post laryngectomy

The patient stated that she had become progressively short of breath over the past month, but it was gradual so she didn’t seek help sooner. The morning of the ED visit, she noticed that she couldn’t walk up a flight of stairs in her home. The patient complained of increasing cough, shortness of breath on exertion, but today she noted shortness of breath while sitting eating breakfast. She has had no chest pain, no edema, and no wheezing. She has no cardiac history. Her most significant past history is that she was a heavy smoker for years: two packs/day starting during her teen years. She stopped smoking ten years prior at the time that she had a laryngectomy for laryngeal carcinoma. She also was treated with neck radiation at that time. Since then she has used esophageal speech, and a writing tablet, and has had annual negative chest xray studies. Her tracheal stoma is usually covered with a handkerchief. She has noticed some superficial bleeding around the stoma. She takes no medications other than an occasional Ibuprofin for some knee arthritis.

A 46-year-old man with difficulty breathing and the sensation of choking

Dr. Peter Rosen: Today’s patient is a 46-year-old man seen in the emergency department (ED) of a small rural hospital complaining of difficulty breathing and the sensation that he is choking. He says his symptoms started approximately a month earlier with throat irritation and a burning pain in his neck. The patient reports he had pneumonia in the past year, that he has a chronic cough and is always short of breath. Over the past month he has gotten progressively worse with notable difficulty breathing, a heavy cough productive of gray sputum, and over the last 48 h he has developed the sensation that he is being strangled with each inhalation. He denies fever or cold symptoms, and is tolerating food and liquids without difficulty. The patient is a bartender who is himself a heavy drinker. He reports consuming a pint of whiskey and several beers daily. He has been a cigarette smoker for 30 years, smokes 2 packs daily as well as several cigars. He chews tobacco. He says he was treated for syphilis while he was in the Army 5 years ago. Upon presentation to the ED the vital signs are as follows: blood pressure 140/90 mmHg; pulse 100 beats/min; respirations 24 breaths/min; temperature 37.4°C; and pulse oximetry 90% on room air. Physical examination is as follows: general: a heavy man with a dusky plethoric appearance. He is breathing shallowly, and appears anxious; HEENT: the patient has a palpable mass at the level of the larynx. There are numerous firm posterior cervical lymph nodes. The oral mucosa has multiple areas of leukoplakia, and there appears to be an area of ulceration just below the right tonsil. His voice is gravelly, and the patient appears to have difficulty obtaining enough breath to speak; chest: there are diffuse ronchi throughout both lung fields, and occasional rales at both bases; cardiac: The heart is enlarged to the anterior axillary line. There are no murmurs or rubs. The rhythm is regular; abdomen: normal; extremities: both ankles have three plus pitting edema up to the knees; neurologic: the patient is alert and oriented to time place and person. There are no focal findings; skin: the skin is dusky and appears cyanotic around the lips and fingernails. The emergency physician’s (EP) impression: this is an alcohol abusing patient with chronic bronchitis, and a probable laryngeal carcinoma. He was concerned about the patient’s compromised airway, and decided he would need transfer to a higher level of care. The resources in this rural hospital were extremely limited as fiberoptic intubation and immediate otolaryngology consultation were not available. A nurse anesthetist with only minimal airway skills provided anesthesia backup. He wanted to manage the patient’s tenuous airway definitively prior to transfer, but was reluctant to embark upon a rapid sequence intubation (RSI). Dr. Sakles, how would you proceed with the management of the patient’s airway prior to his transfer?

A 2.5-year-old child with a history of a foreign body aspiration

Dr. Peter Rosen: Today’s case is a 2.5-year-old child who had a sore throat; she was seen by a nurse practitioner and started on chewable erythromycin tablets. That evening, her mother gave her a tablet, and about five minutes later noted the child was having a choking spell, during which she gagged, sputtered, turned blue and coughed. She vomited once. The mother comforted her, and the child calmed down, and pinked up as she stopped crying. The mother took her by private car to the local emergency department (ED). Vitals at the ED: blood pressure not taken; pulse 120 b/min; respirations not measured as the child was crying; temperature 37°C orally; oxygen saturation 95%. The emergency physician (EP) examined the child and found her to be alert, and quiet in the mother’s arms. She had stopped crying when the mother took her back from the nurse. Head, eyes, ears, nose and throat (HEENT): the tonsils were somewhat enlarged, reddened but with no exudate. There was some jugular-digastric lymphadenopathy. The neck was supple. Back: normal; chest: clear to percussion and auscultation, there was no stridor, nor other adventitial sound; abdomen: normal; extremities: normal; neurologic: normal. The EP thought the child had coughed up the tablet, but to be sure, he ordered a chest X-ray study, and called for the general surgeon to come and examine the patient. There was no ear, nose and throat (ENT) specialist available in this community, nor a thoracic surgeon. Before the chest film could be obtained, the child suddenly choked again, turned blue and lost consciousness. Dr. Ban, obviously we have an acute airway problem to deal with, but before we address the airway problem, it is common to see children with potential airway or esophageal foreign bodies, and we might profitably spend some time discussing whether there is something that could be done at the point when the child looks good to prevent needing airway management.