Glass Ingestion

[RocketMedic]

A hypothetical...a 15 y/o male has decided to do something silly and eat glass. He managed to chew some and swallow at least two mouthfuls in five minutes before he alerted his family, who called EMS. Upon arrival, you encounter your patient in emotional distress, crying, complaining of 'heartburn' and abdominal pain 10/10, with obvious lacerations and bleeding to the mouth, tongue, and gums. Pulse is 110, strong, and regular, BP is 130/80, R16/regular, lung sounds clear and equal, BGL 100, patient denies any recreational substances and takes antidepressants for depression.

Here's my thoughts- we're worried about shards, and peristalsis is going to push those, but we really don't want our patient moving himself and digging them in more. Thus, I would reckon that full immobilization would be a good idea. Pain management is important, and if possible, I would like to dose our patient with fentanyl or morphine (with respect to his hemodynamic status). GI bleeding is a massive concern, so we're going to need IV access and potentially conservative fluid boluses. Suction for the airway, potential intubation in the event that the patient can't maintain his airway, and rapid transport. Huge, huge concerns for esophageal laceration and potential rupture, as well as tracheal ruptures. However, we really, really need to remember that the ET tube is our only real option- Combitubes and the like would be really bad.

Anything else? This is a bad situation, I reckon...

 

[usafmedic45]

I wouldn't restrain him unless he was combative. It's just likely to make things worse.

 

[RocketMedic]

True- would sitting be a better place? I don't really think it matters how he sits, but I really, really wouldn't want him moving from that spot once he finds it.

 

[Sasha]

Why would you immobilize? We really need to get away from the whole "TRAUMA!!!!!!!!! backboard." mentality.

I am sensing a baker act in this guy's future.

 

[DesertMedic66]

Why would you immobilize? We really need to get away from the whole "TRAUMA!!!!!!!!! backboard." mentality.

I am sensing a baker act in this guy's future.

I don't believe has was under the impression of "OMG its a trauma we have to backboard". I think it was more of a Glass is in the kids stomach so we don't want him moving around alot because that would cause his stomach to move. so if we backboard him he wont have to move at all.

 

[Sasha]

Backboarding is uncomfortable, I'd think they'd move a lot more, considering it's not true immobilization, trying to get comfortable as oppose to being allowed to rest in a position of comfort.

You can move a patient without backboarding them.

 

[DesertMedic66]

It is easier to move a patient from point A to point B using a backboard. So that would cause for less movement. But on the opposite side as Sasha said the backboard is uncomfortable so the patient would more then likely be fighting the straps which would cause for the abdominal to contract possibly causing more damage.

The draw sheet method isnt exactly the "smoothest" method. The sliding board is possibly a little "smoother". As for me personally, as far as moving the patient, i would use the break-away flat.

 

[Sasha]

With patients who can't ambulate I honestly find using a draw sheet to be the easiest method. Even some of our patients who can ambulate, it's easier to pull them over or do an extremity lift than to take ten minutes for them to stand and then an additional ten for them to pivot.

 

[medicdan]

Agreed. Why not put the patient in a position they are most comfortable in-- have them sit up on the stretcher, and secure them as usual, asking to move as little as possible, then draw-sheet over when you get to the hospital.
Wise-members-- what other treatments are prudent in this case? Should medics be proactively giving a fluid bolus?

 

[RocketMedic]

My concern isn't anything that a backboard would fix, but I am worried about the glass in the GI tract moving. Our patient writhing on the gurney would do that quite well, and although he can writhe on the board, that's what padding, restraints, and pain management are for. As long as I could immobilize this patient, I'm ok with it. My fear is that he moves and causes a shard to rip something it ordinarily would not have.

Long-term, he'd get endoscoped, and an almost-guaranteed ICU trip. Glass is a horrible thing to try and find in the body, and even removing it is a huge, huge struggle.

 

[Handsome Robb]

I don't see a need for a bolus right this second, I do agree with gaining access so you have it in a pinch.

Good BP, HR is slightly tachy but I'm guessing this is more from the pain than the patient actually compensating. The fact that he isn't vomiting leads me to believe that he hasn't actually lost that much blood into his stomach yet. Now with the potential vomiting from blood in the stomach I'm wondering if a prophylactic dose of Zofran or Phenergan would be appropriate? I know he isn't complaining of N/V but if he is bleeding in his GI tract he very well could start vomiting and with all that glass he swallowed I feel like that would be terribly painful and traumatic on the way back up. What say yee?

 

[Sasha]

My concern isn't anything that a backboard would fix, but I am worried about the glass in the GI tract moving. Our patient writhing on the gurney would do that quite well, and although he can writhe on the board, that's what padding, restraints, and pain management are for. As long as I could immobilize this patient, I'm ok with it. My fear is that he moves and causes a shard to rip something it ordinarily would not have.

Long-term, he'd get endoscoped, and an almost-guaranteed ICU trip. Glass is a horrible thing to try and find in the body, and even removing it is a huge, huge struggle.

You do understand though, that backboards aren't true immobilization? Your patient can still move? Have you never seen a drunk fight the backboard and manage to fanagle himself into a position where he could freely sit up?

 

[Nerd13]

I don't see a need for a bolus right this second, I do agree with gaining access so you have it in a pinch.

Good BP, HR is slightly tachy but I'm guessing this is more from the pain than the patient actually compensating. The fact that he isn't vomiting leads me to believe that he hasn't actually lost that much blood into his stomach yet. Now with the potential vomiting from blood in the stomach I'm wondering if a prophylactic dose of Zofran or Phenergan would be appropriate? I know he isn't complaining of N/V but if he is bleeding in his GI tract he very well could start vomiting and with all that glass he swallowed I feel like that would be terribly painful and traumatic on the way back up. What say yee?

Zofran or Phenergan would be one of my first moves I suspect. I am concerned about the traumatic effects of the glass going down but I'm twice as concerned about it coming back up...

 

[DesertMedic66]

You do understand though, that backboards aren't true immobilization? Your patient can still move? Have you never seen a drunk fight the backboard and manage to fanagle himself into a position where he could freely sit up?

Ive had patients fight on the backboard but i have never seen anyone get to the point where they could freely sit up on the backboard. We have the D-ring straps that cross over in the center of the chest and then the straps from the gurney itself that adds more straps over the chest (2 shoulder and then 1 lateral strap that goes all the way across the chest.

 

[Handsome Robb]

You do understand though, that backboards aren't true immobilization? Your patient can still move? Have you never seen a drunk fight the backboard and manage to fanagle himself into a position where he could freely sit up?

No offense but that sounds like a terrible strap-job. We deal with intoxicated patients on a daily basis and I've never heard of this or seen this happen.

In this instance, if the patient is writhing around as much as it seems is being implied he needs a hefty dose of fentanyl and if that doesn't make him comfortable I'd be giving him some versed to sedate him as well. Then use a backboard or scoop to move him. Heck at that point you might even be able to get a tube in him, although not the best way to go about it, if his airway truly is compromised.

 

[Sasha]

No offense but that sounds like a terrible strap-job. We deal with intoxicated patients on a daily basis and I've never heard of this or seen this happen.

In this instance, if the patient is writhing around as much as it seems is being implied he needs a hefty dose of fentanyl and if that doesn't make him comfortable I'd be giving him some versed to sedate him as well. Then use a backboard or scoop to move him. Heck at that point you might even be able to get a tube in him, although not the best way to go about it, if his airway truly is compromised.

I'm not sure about the strap jobs, I'm talking about patients I've seen in the ER while dropping off/picking up. I haven't backboarded in probably over a year. Aaah IFT.

But I have seen patients who are uncomfortable, who work themselves into different positions on the backboard, including someone who's sat up.

 

[DesertMedic66]

I'm not sure about the strap jobs, I'm talking about patients I've seen in the ER while dropping off/picking up. I haven't backboarded in probably over a year. Aaah IFT.

But I have seen patients who are uncomfortable, who work themselves into different positions on the backboard, including someone who's sat up.

In the ER that might be possible. When we drop off patients who are backboarded the first thing the ER does is remove all the straps and tell the patient to not sit up.

IFT is weird lol. Im on a BLS unit. We do about 95% IFTs and then other "well i called my doctor because i think i broke my leg and he gave me this phone number to call". So we do get to backboard often.

 

[icefog]

I would try to steer away from morphine - while it may reduce propulsive peristalsis, it considerably increases the intestinal tonus. You'd have to bring in atropine (or something else) to decrease the hypertonicity produced by morphine, but personally I'm not much of a cocktail guy.

I'd go with ketamine for the pain and butylscopolamine for relaxing the smooth muscles and killing the peristalsis.

Large bore IV access is a must, yup, but I'd just keep it open and, in case he's going into schock, just treat it as any other internal bleeding - permissive hypotension, no fluid bolus.

 

[Sasha]

In the ER that might be possible. When we drop off patients who are backboarded the first thing the ER does is remove all the straps and tell the patient to not sit up.

IFT is weird lol. Im on a BLS unit. We do about 95% IFTs and then other "well i called my doctor because i think i broke my leg and he gave me this phone number to call". So we do get to backboard often.

Oh no, they're definitely still strapped.

We do a lot of injuries from falls but I have yet to backboard one. I don't see a point when they've been up and ambulating for 30 minutes after the injury.

I'd still opt for a sheet pull or extremity lift and a "dont move."

Anti emetics are a good call.

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[usafmedic45]

Zofran or Phenergan would be one of my first moves I suspect. I am concerned about the traumatic effects of the glass going down but I'm twice as concerned about it coming back up...

Got any evidence to back up that stance or are you just assuming that all nausea is equal?

I'd go with ketamine for the pain and butylscopolamine for relaxing the smooth muscles and killing the peristalsis.

Personally, I wouldn't given any anti-emetics or try to screw with gastric motility. This is one of those "the less you do, probably the better" sorts of cases. The actual risk from eating glass is pretty low as evidence by most circus freakshows, etc. The human body's ability to ingest even rather freakish objects with minimal complication is rather amazing. I had a patient who once ingested a fork. I'm still trying to figure out how but her claim was confirmed by X-ray.