Category Archives: General

WTF? Submental Intubation?

October 28, 2013 The Trauma Pro Leave a comment

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 several 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. Using a hemostat, all layers are penetrated, entering the oropharynx just lateral to the tongue. A 1.5cm incision is then made parallel to the gum line of the lower teeth. The connector at the proximal end of the endotracheal tube is removed, and a hemostat is placed through the chin incision again. The proximal end of the ET tube is grasped from within the pharynx and pulled out through the skin, 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 secured using a stitch under the chin. After a final position check, the surgical procedure can commence.

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!

Reference: Submental intubation in patients with panfacial fractures: a prospective study. Indian J Anaesth 55(3):299-304, 2011.

Photo source: internet

General

Hard Time Discharging Your Trauma Patient?

October 23, 2013 The Trauma Pro Leave a comment

Trauma services tend to have fairly rapid patient turnover. Many of the patients that are seen have injuries that are easily managed, leading to discharge within one to two days. On the flip side, some have such severe injuries that they may be in the hospital for weeks or even months. But regardless of injury, there are always a few who we just can’t seem to discharge at all. Why does this happen?

The trauma program at the Massachusetts General Hospital looked at 5 years worth of admission data on adult patients. They looked at the usual hospital demographics, billing information, hospital financial information, and discharge disposition. The ultimate goal was to identify patients who had an excessively prolonged hospitalization (defined as 2 standard deviations above the average length of stay for the associated Diagnosis Related Group) and why.

Here are the factoids:

155 of 3237 admitted patients (5%) had an extended stay. The total number of admits seems weird, since this would average out to only 650 admissions per year to this busy hospital.
The usual injury severity demographics were similar.
Extended stay patients tended to be older, sustained blunt trauma, were Medicare or no-pay patients, and were discharged to facilities other than home.
Length of stay was 3 times longer than the usual patients
Hospital cost was 3 times higher, and the hospital lost a lot of money on them.
In-hospital mortality was lower for these patients (?!).
The biggest factors delaying discharge were transfer to a rehab or other post-acute care facility, and self-pay or Medicare pay status.

Bottom line: Extended stay in the hospital when not medically indicated is a bad thing, and it’s a system problem. The chance of complications is always present, including deep venous thrombosis, exposure to resistant organisms, UTI, pneumonia, and medication error, just to name a few. And it’s generally bad for the hospital’s financial health, as well. If you are experiencing this at your center, carefully analyze the reasons why it typically occurs. Then work proactively to address them.

Identify potential problem discharge patients on their first day in the hospital
Develop special arrangements with post-discharge facilities.
Hire skilled (and aggressive) social workers
Don’t give up!

Related post:

Discharged to soon?

Reference: Excessively long hospital stays after trauma are not related to the severity of illness. JAMA Surg 148(10):956-961, 2013.

General

What’s The Optimal Method For Inline Stabilization Of The C-Spine?

October 22, 2013 The Trauma Pro Leave a comment

We’ve been pondering this question for nearly 30 years. In 1983, trauma surgeons at UCLA looked at a number of devices available at that time and tested them on normal volunteers. They measured neck motion to see which was “best."

Here’s what they found:

Soft collar – In general, this decreased rotation by 8 degrees but insignificantly protected against flexion and extension. Basically, this keeps your neck warm and little else.
Hard collars – A variety of collars available in that era were tested. They all allowed about 8% flexion, 18% lateral movement, and 2% rotation. The Philadelphia collar allowed the least extension.
Sandbags and tape – Surprisingly, this was the best. It allowed no flexion and only a few percent movement in any other direction.

The Mayo clinic compared four specific hard collars in 2007 (Miami J, Miami J with Occian back, Aspen, Philadelphia). They found that the Miami J and Philadelphia collars reduced neck movement the best. The Miami J with or without the Occian back provided the best relief from pressure. The Aspen allowed more movement in all axes.

And finally, the halo vest is the gold standard. These tend to be used rarely and in very special circumstances.

Bottom line:

For EMS: Rigid collar per your protocol is the standard. In a pinch you can use good old tape and sandbags with excellent results.
For physicians: The Miami J provides the most limitation of movement. If the collar will be needed for more than a short time, consider the well-padded Occian back Miami J (see below).

Miami J with Occian back

Related post:

Inline stabilization vs traction

References:

Efficacy of cervical spine immobilization methods. J Trauma 23(6):461-465, 1983.
Range-of-motion restriction and craniofacial tissue-interface pressure from four cervical collars. J Trauma 63(5):1120, 1126, 2007.

General

Distracted Driving In Police Officers

October 21, 2013 The Trauma Pro Leave a comment

A lot has been written about the hazards of distracted driving. Now, there is new information about the impact of distraction on police officers! A public safety administration class at St. Mary’s University here in Minnesota analyzed 378 crashes involving police cars from 2006 to 2010. The results are intriguing!

Key findings included:

Most crashes occurred during non-emergency responses
Crashes occurring during emergency responses were the most expensive
Distracted driving caused 14% of all crashes
Half of distracted driving crashes were due to the use of squad car computers
Average insurance claim was $3,000 per crash. However, if the crash was due to distracted driving it doubled to $6,000. If the crash was due to squad car computer distraction the average cost was $10,000!

This study is interesting, but it’s only a partial snapshot of this type of crash in one state. It did not include some of the larger police departments, such as St. Paul and Minneapolis.

Bottom line: It’s safe to assume that distracted driving is just as dangerous to police (and prehospital providers, too). And with growing dependence on advanced technology for law enforcement, this problem is just going to get worse. It is imperative that everything be done to improve safety for our law enforcement colleagues. Potential solutions include training to increase awareness of distractions within the car, simulator testing of driving while using cockpit technology, and ergonomic studies to maximize field of view from within the car.

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