All posts by TheTraumaPro

“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.

Pop Quiz: Final Answer

The quiz presented a single slice from a pelvic CT, asking for mechanism, age and diagnosis.

So here’s how to do it. First, what’s wrong in the picture? A number of you picked this one out. The right buttock area has a large hematoma present, and there is a contrast blush posteriorly. This is an injury to the gluteal artery with active extravasation.

Next, look at the rest of the image. Not a whole lot to see, but there is significant calcification of pelvic arteries. So this patient is elderly.

Finally, what happened? Elderly people who have gluteal artery injuries are typically pedestrians struck by a car. Most other blunt mechanisms don’t have enough energy to do this.

And what about treatment? Sometimes in younger patients, the bleeding will stop, but don’t count on it. And in the elderly, it almost never does. Angioembolization is the best way to treat this problem, because surgical exploration is generally a bloody mess.

Piece of cake! Congrats to the readers who got this one right!

I’m writing a novel and one of my characters gets stabbed in the lower region of the abdomen. I don’t want him to die or be incapacitated for a long time, so the wound can’t be too deep. The novel is set in a post-apocalyptic world so going to a hospital is not an option. What I want to know is: 1) How deep can the knife go without hitting anything vital?; 2) What do his friends need to do to help him (stop the bleeding, patch the wound…)?; 3) Would he be able to move/walk? Thanks in advance.

Great questions, and I’d love to answer in detail. Please contact me by email (see my profile at the side of the page) so we can chat!

Pop Quiz! Hints

So far, no correct answers to all three questions from yesterday’s pop quiz! Given the scan below, I want to see if you can figure out:

  • Mechanism of injury
  • Age range
  • Diagnosis

And bonus points for the correct answer on how to treat the problem!

Hint: You can tell the age by the appearance of the blood vessels in the pelvis. And the bright areas outside the pelvis may not be calcium. This should give you enough information to figure out the rest.

Tweet or comment your results!