I’ve had a number of recent requests regarding this technique, so I’m updating and reposting today and tomorrow.
Here’s one of the weirder procedures I’ve seen in some time. Imagine that you need a definitive airway, but you can’t use the face for some reason (mouth or nose). The usual choice would be a tracheostomy, right? But what if you only need it for a few days? Typically, once placed, trachs must be kept for a few weeks before decannulation is safe.
Enter submental intubation. This technique involves passing an endotracheal tube through the anterior floor of the mouth, and then down the airway. This leaves the facial bones, mandible, and skull base untouched.
The technique is straightforward:
After initially intubating the patient orotracheally, a 1.5cm incision is created just off the midline in the submental area under the chin.
Using a hemostat, all layers are penetrated, entering the oropharynx just lateral to the tongue.
A 1.5cm incision is then made at the puncture site, parallel to the gum line of the lower teeth.
The ET tube is removed from the ventilator circuit, and the connector at the proximal end of the tube is removed.
The hemostat is placed through the chin incision again. The proximal end of the ET tube is curled into the oropharynx and grasped with the hemostat, then pulled out through the skin under the chin, leaving the distal (balloon) end in the trachea.
The connector is reinserted, and the tube is then hooked up to the anesthesia circuit again.
The tube is then secured using a stitch under the chin.
After a final position check, the surgical procedure can commence. Cool!
There are a number of variations on this technique, so you may encounter slightly different descriptions. The tube can be pulled at the end of the procedure, or left for a few days to ensure safe extubation, if needed.
A small series of 10 patients undergoing this technique was reviewed, and there were no short or long term problems. Scarring under the chin was acceptable, and was probably less noticeable than a trach scar.
Bottom line: This is a unique and creative method for intubating patients with very short-term airway needs while their facial fractures are being fixed. Brilliant idea!
Tomorrow: Submental intubation – the video!
Reference: Submental intubation in patients with panfacial fractures: a prospective study. Indian J Anaesth 55(3):299-304, 2011.
Consultants provide very important services to trauma patients in the ED and inpatient settings. The trauma professionals managing those patients can’t know everything (although we sometimes think we do). But occasionally our patients present issues that require evaluation by other experts in order to guarantee excellent care.
Sometimes our consultants want to do too much, or make recommendations that are not really in their area of expertise (e.g. a cardiologist evaluating a cardiac contusion). See the related post link below for tips on this situation.
But sometimes you know what the patient needs, but the consultant doesn’t agree or doesn’t do what you expect. Or they don’t want to come in when called. What to do?
Here are some tips:
The patient is in the ED and the consultant won’t come in to see the patient.
Are they right? Does that problem really need to be dealt with in the ED in the middle of the night? Many simple fractures and wounds do not need immediate attention. They can be dressed/splinted, the patient reassured, and instructed to see the consultant in the clinic the next day.
Is your knowledge of current management of the condition correct? Perhaps it has evolved, and it is now commonplace to temporize and deal with the problem as an outpatient during business hours. Make sure you are up on the current literature.
The patient is in the ED and the consultant won’t come in to see the patient, and you are sure that they should! Now what?
Call them personally(not a resident, midlevel provider, or any other intermediary) and clearly and concisely explain the situation, and your assessment of why the problem needs their immediate attention.
Listen to or elicit their rationale for not seeing the patient. If legitimate, this may help educate you and modify your future management of similar patients. If the rationale is not legitimate, inform them (tactfully) that this is at odds with your education/training/experience with other providers. Ask them to further explain, if they can.
If they still won’t come in despite what you think is a legitimate need, then you must calculate a quick risk:benefit ratio. Will any patient harm occur if the consultant does not see the patient? And what is the professional damage that you will incur if you move on to the next steps. If you believe that harm will occur, here are your options, from least to most damaging to your professional status at the hospital:
Contact another consultant in the same or overlapping specialty (if there is one). Apologize for the fact that you know they are not on call, and explain the situation.
Appeal to a higher authority. Contact the trauma medical director, service chief, or hospital administrator and see if they can intervene.
Explain to the consultant that you truly believe that harm will occur, and you will have to document that fact in the medical record as well as their failure to respond. In some cases, this will shake them loose, but they will certainly be pissed.
If all else fails, see if you can find a service that will help you by accepting the patient as an admission so they can be managed appropriately the next day. But then follow through by reporting the event to appropriate people including chief of staff, chief medical officer, VPMA, hospital quality department, and risk management. This is the nuclear option, so be prepared for the fallout.
Bottom line: This is not a fun situation to find yourself in. Good luck!
A Chinese man was in the news a few years back after having a four inch knife blade removed from his head. It had been there for four years! The knife blade broke off after he had been stabbed under the chin. Unfortunately, he was unaware that any part of the knife had been retained. It remained partly within the nasopharynx and the tip came to rest behind his left eye. His symptoms included headaches, stuffy nose and bad breath. The picture below shows the badly corroded blade in front of some of his radiographic images.
See the video at the bottom of this post for more details and images.
What is the best way to deal with a problem like this? Here are some practical tips:
First, get in the habit of imaging any body part with a penetrating injury. Retained objects can be as simple as gravel or as complicated as the knife blade above. And remember, some patients who have been stabbed present with a simple laceration but don’t want to tell you how they got it. Image before you close it!
Next, don’t remove it. This is common knowledge, but innocent looking objects (pencils, nails) can penetrate arteries and keep them from bleeding while embedded. Unpleasant and sometimes fatal bleeding can ensue if pulled out.
If you do not have specialists versed in the body regions involved in the injury, transfer immediately with the object secured in place. For objects penetrating minimally complex areas like the extremities, surgeons may opt to carefully remove it in the emergency department, or may elect to do so in the operating room.
Injuries to complex areas should undergo high resolution CT scanning so that 3D reconstruction can be performed if needed. The surgical specialists can then plan the operative approach. This is dictated by the anatomy of the area(s) involved and the architecture of the object (think about hooks and barbs). For objects located near critical areas, an operative exposure must be selected that provides access to all portions of it, and allows for rapid vascular control if needed.
A few months ago, I started to notice a new piece of information coming across on my trauma activation pages: point of care lactate level. I had heard nothing about this prior to these pages, and was curious to know whether this was a new policy/practice, or some study that was in progress. So, of course, I had to do a little bit of reading to find out what was up with that. I’ll share that with you today.
Serum lactate has been used since forever in the inpatient setting, especially in the ICU. It is used as a surrogate for tissue hypoxia and/or metabolic acidosis. A number of studies have found that hypoperfusion is frequently underappreciated, since we tend to use crude vital signs (BP and pulse) which may look normal in early hypovolemia. Serum lactate guided therapy has been shown to improve survival in some studies, and can indicate that resuscitation is proceeding appropriately. Patients who do not show early improvement in their lactate levels are more likely to be refractory to resuscitation, and have higher mortality.
So it would make sense that if prehospital trauma professionals could identify occult tissue hypoperfusion in the field, appropriate resuscitation could start earlier. And nowadays, one can find a point of care device to measure just about anything. Thus, the extra tidbit of information on my trauma pages.
But remember, just because something makes sense doesn’t mean that it actually works. Thus, a group at the University of Birmingham (in the UK) did a systematic review of the literature through 2015, looking specifically at lactate levels obtained in the prehospital setting.
Here are the factoids:
Of the 2,415 articles screened, only 7 were suitable for analysis
These studies were judged to be of “low” or “very low” quality
The methods by which the lactate level were obtained (venous vs capillary), timing, and documentation were highly variable
The authors concluded that there is not yet enough data to support point of care lactate in the field
Bottom line: Point of care lactate drawn in the field would seem to be a good idea. Unfortunately, there aren’t any studies yet that are good enough to make this a standard practice. As with any new technique, if there’s no data then you MUST participate in a well designed study so it can be shown, yea or nay, that the practice is a good one. So join up!
Reference: Prehospital point-of-care lactate following trauma: a systematic review. J Trauma 81(4):748-755, 2016.
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