Tag Archives: intubation

EMS: Scoop and Run or Stay and Play for Trauma Care? Part 3

Scoop and run or stay and play. Is one better that the other? Over my last two posts, I reviewed a couple of papers that were older (6-7 years) and had smaller patient groups. Now let’s look at a more recent one with a larger experience using a state trauma registry.

This one is from the Universities of Pittsburgh and Rochester, and used the Pennsylvania state trauma registry for study material. The authors wanted to really slice and dice the data, postulating that previous studies were not granular enough, such that significant trends could not be seen due to lumping all prehospital time together. They divided prehospital time into three components: response time, scene time, and transport time. To some degree, the first and third components are outside of the prehospital providers’ control.

The records for over 164,000 patients were analyzed. These only included those for patients transported from the scene by EMS, and excluded burns. The prehospital time (PH time) was divided into the three components above. A component was determined to be prolonged if it contributed > 50% of the total PH time.

Here are the factoids:

  • Half of the patients had a prolonged PH time interval (52%)
  • Response time was prolonged in only 2%, scene time was prolonged in 19%, and transport time was longer in 31%
  • Mortality was 21% higher in those with a prolonged scene time component
  • There was no mortality difference in patients with no prolonged time components, or those with prolonged response or transport times
  • These patterns held for both blunt and penetrating injury
  • Extrication and intubation were common reasons for prolonged scene time. Extrication added an average of 4.5 minutes, and intubation 6.5 minutes.
  • Mortality was increased with prehospital intubation, but this effect lessened in severe TBI
  • Increasing experience with extrication and intubation appeared to decrease the mortality from the increased scene time they caused

Bottom line: This paper suggests that the dichotomy of “scoop and run” vs “stay and play” may be too crude, and that a more nuanced approach should be considered. In plain English, the optimal management lies somewhere in between these polar opposites. Actual on scene time appears to be the key interval. EMS providers need to be aware of scene time relative to response and transport times. Patients with specific injury patterns that benefit from short scene times (hypotension, flail, penetrating injury) can quickly be identified and care expedited. Increased scene time due extrication cannot be avoided, but prehospital intubation needs to be considered carefully due to the potential to increase mortality in select patients. 

Reference: Not all prehospital time is equal: Influence of scene time on mortality. J Trauma 81(1):93-100, 2016.

Tongue Piercings And Emergency Intubation

Urgent and emergent intubation is challenging enough, but what if your patient is sporting some type of tongue piercing? Does it make a difference? Do you need to do anything differently?

Obviously, the jewelry may physically impede the process of intubating the patient, impairing visualization of structures or getting in the way of inserting the tube. It can also cause complications later down the road, such as pressure necrosis from the tube coming into contact with it.

The anesthesia literature recommends removing all oral jewelry prior to elective intubation, or declining to do the case if the patient refuses. Unfortunately, trauma professionals do not have that option when the patient needs an emergency airway.

Here are some pointers for dealing with oral jewlry:

  • Is the item going to impede insertion of the airway? Is it large, or obstructing the usual tube pathway? If so, remove it quickly (see below).
  • Sweep the tongue well to the side during tube insertion to avoid the jewelry. You may need an assistant to grasp it with gauze to keep it out of the way.
  • Once the airway is secured, remove the item. This takes two people! The ET tube should be moved to the side, and one person will grasp the tongue with a gauze pad and extend it. The other person can then grasp the jewelry with gloved fingers, and unscrew the ball on one side. It can then be removed and saved in an envelope.

Note: both hands must always be in contact with the jewelry at all times! It is slippery, and if the pieces are not controlled, this can happen!

Sharp stud foreign body in the bowel from tongue piercing that came apart and was swallowed (arrow). Images courtesy of Intermountain Medical Imaging, Boise, Idaho.

 

Submental Intubation – The Video!

Yesterday, I described a technique for providing a secure yet short-term airway tailored to patients who can’t have a tube in their mouth or nose. Patients undergoing multiple facial fracture repair are probably the best candidates for this procedure.

A picture may be worth a thousand words, but a video is even better. Please note that it is explicit and shows the blow by blow surgical procedure. Of note, it is a quick and relatively simple advanced airway technique.

Related post:

How To: Secure An Endotracheal Tube To… Nothing!

Several decades ago I took care of a patient who posed an interesting challenge. He had been involved in an industrial explosion and had sustained severe trauma to his face. Although he was able to speak and breathe, he had a moderate amount of bleeding and was having some trouble keeping his airway clear.

Everyone frets about getting an airway in patients who have severe facial trauma. However, I find it’s usually easier because the bones and soft tissue move out of your way. Or are already gone. As long as you can keep ahead of the bleeding to see your landmarks, things will go fine.

In this case, the intubation was easy. The epiglottis was visible while standing above the patient’s head, so a laryngoscope was practically unnecessary! But now, how do we secure the tube so it won’t fall out? Sure, there are tube-tamer type securing devices available, but what if they are not available to you? Or this happened in the field? Or their face was missing or falling off? Or it was in the 1980’s and it hadn’t been invented, like this case?

The answer is, create your own “skin” to secure the tube. Take a Kerlix-type stretchable gauze roll and wrap it tightly around their face, and their head if needed. Remember, they are sedated already and they can breathe through the tube. This also serves to further slow any bleeding from soft tissue. Once you have “mummified” the head with the gauze roll, tape the tube in place like you normally would, using the surface of the gauze as the “skin.”

Be generous with the tape, because the tube is your patient’s life-line. Now it’s time for the surgeons to surgically stabilize this airway, usually by converting to a tracheostomy.

“Pull The Tube Back 2 Centimeters”

How often do trauma professionals hear that? Patients intubated in the ED (or before) almost universally have a chest x-ray taken to check endotracheal tube position. And due to variations in body habitus (and sometimes number of teeth), the tube may not end up just where we want it. So look at how deep or shallow it is and adjust it by the number of centimeters out of the correct position it should be, right?

Not so fast! A small, prospective study from Yale looked at endotracheal tube adjustment in ICU patients using tube markings and the patients incisors. Their “ideal” tube position has the tip between 2 and 4 cm from the carina. Any patients with an ET tube outside these parameters was included in the study. Here are the interesting tidbits:

  • There were only 55 patients who met criteria for the study. No denominator information was give, so we can’t tell how good or bad the intubators were initially.
  • Most tubes that needed adjustment were too far out. The median starting position was at 7cm above the carina (!),
  • A smaller number were too deep (median position 0.7cm). These were mostly in women.
  • The usual intended adjustment was 2cm. The actual distance moved after manipulation was half that (1.1cm).

Bottom line: Endotracheal tube repositioning based on tube markings at the incisors is not as accurate as you may think. Patient body habitus and reluctance to pull a tube out too far probably are factors here. So be prepared to readjust a second time unless you intentionally add an extra centimeter to your intended tube movement.

Related post:

Reference: Repositioning endotracheal tubes in the intensive care unit: Depth changes poorly correlate with postrepositioning radiographic location. J Trauma 75(1):146-149, 2013.