A 16-year old male arrives in the E.D. by private car 
after sustaining a gunshot wound to the face.  The 
details of the incident are not clear.  He is alleged to 
have shot himself in the mouth with a hand gun.  
However, several of his friends were handling the gun 
around the time of the incident which took place inside 
their car.  Foul play cannot be ruled out.  He is brought 
into the E.D. by his friends.  He is in a standing position 
being held up by his friends.  He is able to weakly 
ambulate to a gurney with assistance from his friends.  
He is now supine on a gurney in the E.D.
     VS Temp not obtained, P 90, R 20, BP 125/80.  He 
is poorly responsive, but is breathing spontaneously.  
He is not able to speak.  Oxygen saturation on 
supplemental oxygen is 99%.  Two IV's are established.  
Normal saline is infused.  Breath sounds are coarse 
and somewhat shallow bilaterally.  There is extensive 
bleeding from the face and mouth.  O negative packed 
cells are requested until crossmatched blood is 
available.  A lateral neck radiograph is obtained.

View lateral neck film.

     There are no abnormalities of the cervical spine 
noted.  No foreign bodies are seen.  A surgeon in 
attendance discovers an exit wound in the right 
posterior neck.  His oxygen saturation begins to decline 
and his respiratory effort declines.  He is mask 
ventilated, and oral intubation is attempted, but upon 
insertion of the laryngoscope, he gags and coughs out 
blood, splattering it over several nurses and the 
physician intubating him.  He is noted to have extensive 
intra-oral injuries making visualization of the airway 
difficult.  After a second unsuccessful intubation 
attempt, a rapid sequence intubation is performed using 
vecuronium and a low dose sedative while a surgeon is 
standing by with a surgical airway set.  Intubation is still 
not successful after several attempts, and mask 
ventilation with high flow oxygen is required to maintain 
ventilation and oxygenation in the 93% range.  A 
surgeon initiates an emergency surgical airway.  
Bleeding is encountered during the procedure and the 
surgeon requests an electrocautery unit.  The 
electrocautery unit is able to minimize the bleeding and 
the tracheostomy procedure continues until a 
complication arises.

Can you predict what the complication is ?
View the complication below:

Below:

Below:


Below:



Below:




Below:





     If you were able to anticipate this complication as 
the patient's resuscitation proceeded, then you 
successfully avoided this complication.  This is a 
hypothetical case; however, its occurrence has been 
reported in the literature.  Other non-reported cases are 
likely.
     High-flow oxygen, necessary during the 
resuscitation of severely ill patients, is capable of rapid 
combustion in the presence of any sparks.  In this case, 
electrocautery in the neck region is in close proximity to 
the high flow oxygen used for mask ventilation.  The 
oxygen leaking from the mask and during exhalation 
through the ventilation device is sufficient to result in 
combustion when electrocautery sparks are produced.  
Electrocautery and heat cautery should not be used for 
an emergency tracheostomy or cricothyrotomy in the 
presence of supplemental oxygen.
     Preparing for an emergency airway in a patient for 
whom oral tracheal intubation is not possible requires 
periodic familiarization with the emergency airway kits 
available in the E.D.  Periodic case simulations should 
be used to train the entire emergency team to prepare 
for this emergency.  Nurses who understand the 
consequence of using electrocautery in the presence of 
high flow oxygen will not allow electrocautery to be 
used if it is ever requested.
     Case 16 in Volume 2 (Sweeping the Airway for a 
Foreign Object) discusses one approach for 
transtracheal ventilation through a cricothyrotomy 
catheter.

View transtracheal ventilation set-up.

     While this diagram describes one approach for 
ventilating a patient temporarily until the establishment 
of a more definitive airway, proprietary emergency 
airway kits using dilators and/or Seldinger technique 
wires are available.  Regardless of which method is 
preferred, the emergency team must familiarize 
themselves with an approach to an airway emergency 
where oral tracheal intubation is not possible.

References
     Supplemental oxygen:  Ensuring its safe delivery 
during facial surgery.  Plastic and Reconstructive 
Surgery 1995;95(5):924-928.
     Le Clair J, Gartner S, Halma G.  Endotracheal tube 
cuff ignited by electrocautery during tracheostomy.  
AANA J 1990;58(4):259-261.
     Yamamoto LG.  Emergency anesthesia and airway 
management.  In:  Fleisher GR, Ludwig S (eds).  
Textbook of Pediatric Emergency Medicine, 3rd edition.  
Baltimore, Williams & Wilkins, 1993, p. 70.