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.

Photo source: internet

One of the tenets of trauma surgery, handed down for generations, is that we should pack the abdomen to help manage major abdominal hemorrhage. “All four quadrants were packed” reads the typical operative note. But how exactly do you do that? Sounds easy, right?

Well, there are nuances not found in the surgery textbooks. Here are some practical tips for the trauma surgeon:

• Prepare. Have your scrub nurse fluff up about 20 laparotomy pads in advance. The point of packing is two-fold: soak up blood, and stop bleeding. Fluffed up pads work better than the flat, rolled up pads shown above. And you will need them fast, so have a supply ready.
• Do you really need to pack? Your patient is hypotensive, and you are convinced the abdomen is the source. You run to the OR, open it and… no blood. So don’t pack. It won’t slow down the (lack of) bleeding, but it is possible to cause serosal tears or worse. Just figure out where the bleeding is really coming from.
• Be careful. Don’t just jam them in there. Carefully place pads over and under the liver. Carefully place a hand on the spleen and push toward the hilum so you can place pads between spleen and body wall. Try not to cause more damage than is already there.
• Penetrating trauma: Pack where you know (or think) the penetrations are first. Basically, if it’s not bleeding there, don’t pack there.
• Blunt trauma: Pack the upper quadrants first. This is where the money is, because the liver and spleen are the top culprits. Then pack the lower quadrants to soak up shed blood.
• Once packed, check for successful control. If bleeding has stopped (or at least decreased significantly) stop and wait for anesthesia to catch up and continue your massive transfusion protocol. If bleeding continues, remove packs from the offending area and try to obtain definitive control. This is now the patient’s only chance, since you have now determined that you can’t stop the bleeding with packing.
• Remove packs in the proper order. In blunt trauma, remove the lower quadrant packs first. They’re not doing anything and just take up valuable space. In penetrating trauma remove the packs in the area of the injury first.
• Get an xray to confirm that all packs are out at the end of the case. Self explanatory. It’s easy to lose a few in the heat of the moment. I’ve seen two bundles (10 pads) left over the liver in one case decades ago!

On Monday, I’ll write about the importance of the final x-ray when the abdomen is closed.

Related post:

• The ABThera damage control dressing (video)

Your patient is at their healthiest as they roll in through the emergency department door

Yes, major trauma patients are sick, but they are going to get sicker over the next few hours to days. No matter how bad they look now, they will tolerate more at the time you first see them than they will tomorrow.

Too often, we look at them and delay because “they are too sick to operate.” This is usually not the case.

Bottom line: Move quickly, get surgical clearances done promptly, and perform all interventions (especially major surgery) early before your trauma patient gets really sick!

Other Laws of Trauma:

• The first law
• The second law
• The third law
• The fourth law
• The fifth law
• The sixth law
• The seventh law