“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.

Why We’re Still Losing The Motorcycle Helmet Battle

Fewer and fewer states have good helmet laws any more. Part of the problem is political. But the other part, may be… the end user. Here’s a piece written by a doctor and published in the St. Paul Pioneer Press in 1994 about a case he saw in medical school:

“I was working in a rural emergency room one day when the ambulance brought in a 17-year-old who had been in a motorcycle accident. It had just started raining, and the road was slick; he’d tried to take a corner too fast and had laid the bike down and skidded quite a long way.

“Fortunately, all he had were crapes and bruises. he had no head injury.

“Just as I was finishing up with him, a policeman came in and brought the young man his helmet, which they had taken off him at the scene. it was obviously a fancy and expensive helmet. It was a full-face unit – shiny, multicolored, metal-flake.

“One entire side of the helmet was ruined. It was deeply gouged and had obviously scraped along the asphalt with considerable impact for quite a distance. In some places, it appeared that the entire thickness of the hard shell had been penetrated, and you could see the soft inner lining.

“The young man was obviously very lucky.

“He looked at the helmet, groaned and said: ‘Oh, man! I just bought that a week ago! What a waste of $150!’”

SMACC Chicago – What A Meeting!

This is my first SMACC. And what a SMACC it is! Holey moley! This is a celebration of the FOAMed community, and it’s almost a festival atmosphere. Check out this photo of the opening ceremony:


The audience is an enthusiastic mix of disciplines and backgrounds, and covers a wide range of topics most appropriate to emergency medicine. But there is information of interest to any resuscitationist, and this includes trauma and critical care professionals. The reception at the end of day 1 as fun, and I’m sure the gala dinner tonight will be something to behold. 

One observation: It’s interesting that a group of people that are so into online learning have the need to physically meet from time to time. I think it points out our very human social nature, and demonstrates that online social media/networks will never replace actual face to face contact!

Check out the links below to see if next year’s meeting might be for you!

Info on SMACC: click here

View or download the program here

Heading to SMACC Chicago!

This meeting starts tomorrow at McCormick Place in Chicago! I’ll be speaking tomorrow in Concurrent Session 6: Trauma at 2:55pm. I’ll also be participating in Concurrent Session 16: It’s A Knockdown, a fun panel at 2:30pm on Thursday with the likes of Cliff Reid, Karel Habig, John Hinds, Karim Brohi, Deb Stein, Bill Knight and Andrew Dixon.

Look me up at the meeting or at the opening reception! I look forward to seeing you!

Info on SMACC: click here

View or download the program here


Incidental Pulmonary Embolus

In my last post, I described a case where a fresh trauma patient was found to have an incidental finding of small, distal pulmonary embolus (PE) on her initial trauma evaluation. What should you do when you see this? Reflexively anticoagulate for months?

There are only a few papers dealing with this topic. One is from the MGH, which looked at their experience in screening for deep venous thrombosis (DVT) with duplex ultrasound and diagnosing PE with chest CT. They found that quite a few PEs were found that had no associated DVT in the legs or with clot in the pelvic veins. They also noted an interesting distribution: PEs with no DVT tended to be more distally located, and vice versa for those with DVT. This suggested that some PEs may not be emboli at all, but clot that forms spontaneously in the distal lung circulation.

Scripps Hospital in San Diego did some similar work. Only 31 of some 12,000 patients developed PE, and 19 of these had no identifiable DVT as a source. They also noted that these “de novo” PEs tended to be single and peripherally located. PE associated with DVT tended to be multiple and more central. They also noted an association with chest trauma (pulmonary contusion, rib fractures), blood transfusion, and pneumonia.

Bottom line: As usual, the literature is of little help in this relatively recently identified phenomenon. So what’s the trauma professional to do? Here’s my take. If a PE is found incidentally on the initial trauma evaluation, take a good history to see if there are any family members with clotting problems. Failing that, search for DVT using duplex ultrasound. If the PE is central or multiple, or there is a positive history or duplex screen, anticoagulate as you would any other patient with this problem. If not, carry out the usual prophylaxis and screening as laid out in your usual protocol (you have one, don’t you?), but don’t consider it a “real” PE. At least until we know more about this phenomenon.

Related posts: