A Hole New Airway Challenge by Vickie Sandy

A Hole New Airway Challenge
by Vickie Sandy, EMT-B

About the Author: Vickie Sandy is an EMT-B, soon to be paramedic, from Elkins West Virginia.

see also on this site 'Body Piercing R Us'

If you’ve walked down the street or looked at a ski slope recently, you’ve noticed that piercings are in. And not just all those rings and studs in the ears. Nose, lips, tongue, eyebrows, belly buttons, nipples and other unusual locations are regularly pierced today and not just by the young. There is nothing wrong with these unique personal expressions as long as the piercee has acknowledged the possible long-term physiological risks of their piercings. These modern body modifications present some challenges and complications to rescuers and we must accept and cope with them rather than judge our patient’s lifestyles. With that in mind, several questions arise when dealing with the pierced patient who has potential airway problems. How do these piercings affect airway adjunct usage? And how problematic are they to deal with especially when the airway is involved? These are just a few of the questions that come to mind when dealing with the pierced patient. First I’ll provide a bit of background on piercings in general, and then take a short look at a few of them and the problems they may present to the EMT or paramedic who stumbles upon them in the field setting.Body modification in the form of piercing has been practiced by almost every society or culture at some time or another. And as previously mentioned, piercing is not restricted to the young, a survey by Body Art found that 79% of respondents were 29 years old or older. Facial piercings, in general, historically have been used to denote status, courage and for spiritual rituals and events. Today, they are used as personal expressions, for the sheer shock value they cause others, as self-indicators of a hurdle passed or a life change accomplished, a private physical challenge, and upon occasion for no reason other than to boost personal sensation during intimate encounters.

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Facial and oral piercings use a wide variety of jewelry and jewelry materials but new piercings are generally restricted to a narrow band of types and materials. These are also the ones most commonly encountered in piercings of all ages. I will restrict this discussion to those jewelry types because the others are generally variations of them and can be approached in the manner of that which they most resemble. Jewelry types most frequently encountered are various styles of captive bead/ball rings, barbells, labrets and L-shaped fishtail labrets. Jewelry materials most frequently used are surgical steel, niobium, and titanium. Other natural materials are also used and will be briefly discussed.
Captive bead/ball rings (CBR’s) are widely used in most piercings. The basic design of a CBR is an open closure ring, in which a dimpled bead or ball is fitted between the ring ends which are tightened into the dimples. This variation is generally easy to remove with the application of simple tension to release the bead. As the gauge thickens or ring diameter decreases, higher amounts of tension are needed to open the ring and in some cases ring expanding pliers may be needed. Common variations of the standard CBR include: ball and socket rings (thick gauge rings) which are very similar to the standard CBR; attached bead/ball rings, in which the bead is soldered to one end of the ring; screw-on-ball rings; and "seamless" or beadless rings. Other shapes and variations may be seen.Barbells are often used in nasal, large-bore ear piercings, eyebrows, and tongue piercings. Barbells are straight or curved, some into half-moons or nearly circular. Straight barbells are straight rods with balls threaded onto each end. Curved barbells, also called banana barbells, L-barbells and half-moon barbells are curved and their end balls are also threaded. A circular barbell is a heavier barbell curved into approximately a three-quarter circle. A fourth variation is called a slave, banger or captive barbell and has a CBR attached to one or both ends of the barbell. Barbells in complex shapes and with charms instead of balls are also common.

Labret studs and L-shaped fishtail labrets are used in cheek, lip and labret piercings. Labret studs are barbells that have a small thin disc soldered in place of the ball on one end. Fishtail labrets are L-shaped and do not have either a disc or ball on one end; the visible end is capped with a ball just like the standard labret stud. Fishtail labrets are intended to fit into the indentation below the gum line and are usually slightly flexible to permit adjustment of the mouth bar. Nostril screws are shorter versions of labrets used for non-septum nasal piercings.
Jewelry material varies a lot. Those materials most frequently encountered are those that are safe for new piercings. Surgical stainless steel (SSS) is appropriate for all piercings and all stages of healing. SSS does contain small quantities of nickel (to which some people are sensitive) but the specific composition and melting procedure generally concentrates it in the non-surface areas of the jewelry reducing the risk of reaction by the nickel sensitive. 14kt and 18kt yellow and nickel-free white gold are also used but most piercers do not use 14kt in new piercings. Niobium and titanium are growing in popularity because both metals are chemically non-reactive and can be colorized by anodizing. Palladium and platinum (both very expensive) are also preferred because like the aforementioned materials, they have zero or little reactivity to the body and no porosity to their surfaces to harbor dirt or infection. Other materials seen in well-healed piercings can include silver, sterling silver, exotic hardwoods, nylon/Teflon, bamboo, ivory and horn. Gold-plated or gold-filled jewelry is discouraged as well as colored gold. The former because repeated bending will cause the coating to flake and penetrate the wound and the later due to the risk of copper or zinc poisoning.
Nasal piercings generally consist of three species: nostril, septum and bridge. Nostril piercing placement is usually somewhere along the groove of the nostril where the cartilage is often thinner. Most commonly CBR’s are used due to ease of cleaning but nostril screws are also common. Septum piercings are made through the layer of tissue between the alar (outer) and quadrangular (separating the nostrils) cartilages. This is most commonly towards the tip of the nose. Usually CBR’s or barbells are used for this piercing but a U-shaped septum retainer can also be used when confidentiality is desired because it can be flipped up comfortably snug into the nasopharynx and not be visible to the public. Bridge piercings are made through the tissue over the bridge of the nose. Straight and curved barbells and CBR’s are the most frequently used jewelry.The biggest problem with nasal piercings during emergency interventions is snagging the jewelry. Nasopharyngeal airway insertion and nasotracheal intubation with in place nostril and septum jewelry pose two challenges. The first is you may not get the adjunct past the jewelry. The second is if you do, you may still cause trauma to the airway by ripping the piercing or by displacing or compressing the jewelry into the tissue. The jewelry can also compress tubular adjuncts. The best means of management here is to remove the jewelry. If the patient is conscious and you are concerned about airway patency, ask them to remove the jewelry and proceed with care. If unconscious and patency is at risk, carefully remove the jewelry and proceed with treatment. Bridge piercings do not present airway hazards except in two cases. If the piercing is too deep, it can damage nerves and large blood vessels with the resultant bleeding draining into the sinuses and nasal cavity. Bridge piercings also present a high risk of sinus involvement if they become infected, again with drainage into the nasal cavity possible.
Oral piercings, which include lip, labret, tongue and cheek present the piercee with risks of chipped or cracked teeth, damage to oral tissues, gum line tissue erosion and possible bone loss in the eroded areas, along with blood vessel damage and possibility of swallowing their jewelry. Labret piercings are usually made centrally, approximately three quarters of an inch below the colored part of the lower lip, through or just above the chin cleft. Lip piercings are made anywhere along the outside of the lips. Cheek piercings are very close to several large facial arteries and veins and nerves. Because of the high risk of profuse bleeding due to improper placement or trauma to these piercings, many reputable piercers refuse to perform cheek piercings. Tongue piercings are most commonly placed in the center of the tongue to minimize the risk to nerves and blood vessels, which usually run to either side of the tongue’s center. Tongue frenulum piercings are piercings through the webbing under the tongue. Dependant upon position, CBR’s, barbells, labrets or L-shaped fishtail labrets can be used.
Generally, oral piercings present the same problems to rescuers as nasal piercings. Lip and labret piercings can become snagged on equipment and care must be taken to avoid pinching or tearing the lip by applying pressure in the wrong place. Tongue piercings can be difficult to navigate around because they are especially subject to snagging. Tongue piercings are also prone to infection that includes in some patients bleeding and edema. The presence of one or the other can severely complicate airway management. Again, just like in nasal piercings, the best method of handling is removal of the jewelry, preferably by the patient, or as a last resort by the rescuer.
Eyebrow piercings, belly button and nipple piercings, genital piercings and all manner of ear piercings may also be encountered. Other than the usual risk of infection, the only other risk they present are traumatic removal causing tissue damage, profuse bleeding and in the long run potential scarring. Management of these injuries includes normal bleeding control and wound care.
All piercings regardless of location and jewelry used have certain inherent risks. The first is edema, which occurs with all new piercings. Bleeding is dependent upon site selection and if done properly is light, localized and usually short-lived. Improper site selection (especially in the cheek) can result in copious amounts of bleeding. Infection is a problem if the site is not cleaned properly before piercing or is not cleaned properly during the healing process. Improper jewelry materials, especially porous or non-high polished surfaces, also can predispose a new or partially healed piercing to infection.
In closing, piercings are a form of individual body modification that can present challenges to rescuers while providing care, especially if the airway is involved. This basic information on piercing jewelry and materials will help to provide a rescuer with information on how to remove jewelry in the event that the patient is unable to do so. The information provided on general piercing anatomy will help guide the care provider during injury management involving piercings. Again I must reiterate, no matter what our personal opinions are on the inconvenience of these body modifications to our delivery of care, or our own reactions to seeing the facially or orally pierced patient, it is not the place of emergency medical care providers to judge these individuals. There is nothing intrinsically wrong with their choice of personal expression. One cannot assume today that the pierced patient is a punk, a junkie, or some other frowned upon social group; he or she may very well be a doctor, a banker or even a fellow EMT. They have accepted the risks of their piercings and it is our duty to provide them the same level of care we provide to the non-pierced patient.

see also on this site
'Body Piercing R Us'

Bibliography
Gray’s Anatomy, Henry Gray, FRS, copyright 1974 Running Press Different Loving: The World of Sexual Dominance & Submission, Gloria Braeme, William D. Braeme, Jon Jacob, copyright 1993 Gloria Braeme, Villard Books

"A Hole New Set of Problems", Emergency Medical Services, the Journal of Emergency Care, Rescue and Transportation, Volume 30, Number 1, page 81

Piercing FAQ, rec.arts.bodyart, Anne Greenblatt, copyright 2000 Anne Greenblatt, http://www.faqs.org/faqs/bodyart/piercing-faq

"Oral Piercing Dangers", http://www.geocities.com/HotSprings/Spa/7563/trans5.html

"Everything You’ve Always Wanted to Know about Body Piercing", http://www.healthcentral.com? "Body Piercing Can Pose Problems in ER", http://www.healthcentral.com