Several decades ago I took care of a patient who posed an interesting challenge. He had been involved in an industrial explosion and had sustained severe trauma to his face. Although he was able to speak and breathe, he had a moderate amount of bleeding and was having some trouble keeping his airway clear.
Everyone frets about getting an airway in patients who have severe facial trauma. However, I find it’s usually easier because the bones and soft tissue move out of your way. That is, as long as you can keep ahead of the bleeding to see your landmarks.
In this case, the intubation was easy. The epiglottis was visible while standing above the patient’s head, so a laryngoscope was practically unnecessary! But now, how do we secure the tube so it won’t fall out? Sure, there are tube-tamer type securing devices available, but what if they are not available to you? Or this happened in the field? Or it was in the 1980’s and it hadn’t been invented, like this case?
The answer is, create your own “skin” to secure the tube to. Take a Kerlix-type stretchable gauze roll and wrap it tightly around their head. Remember, they are sedated already and they can breathe through the tube. This also serves to further slow any bleeding from soft tissue. Once you have “mummified” the head with the gauze roll, tape the tube in place like you normally would, using the surface of the gauze as the “skin.”
Be generous with the tape, because the tube is your patient’s life-line. Now it’s time for the surgeons to surgically stabilize this airway, usually by converting to a tracheostomy.
Rapid airway control is key in critically injured trauma patients. But too many times, I’ve seen trauma professionals take far too much time to establish one. Here’s a good rule of thumb to use in these situations.
After pre-oxygenating the patient, your first pro gets a crack at it. They generally have the most time available, often 3-5 minutes before sats begin to drop.
In the unlikely situation that they are not successful, strike 1. Stop trying and resume bagging the patient. At this point, someone (trauma surgeon, lead medic) must get the crich set out. Then the next most experienced intubator gets a shot.
If they are not successful, strike 2. Resume bagging and open the crich set.
The most experienced intubator now gets their chance, using any advanced technology available. No success even now? Strike 3, use the crich set!
Bottom line: We should never allow more than 3 airway attempts, and sometimes clinical conditions will dictate fewer tries. Examples that come to mind are severe brain injury patients (hypoxia is bad) and patients who do not recover from oxygen desaturation when they are bagged. Don’t lose track of time and the number of attempts!
Cricothyroidotomy Using The Scalpel-Bougie Technique
Here’s a video from our colleagues in Australia that shows a slick way of performing a surgical cricothyroidotomy. The number of required instruments is the bare minimum: a scalpel and a bougie. I have not tried this technique, but it looks like it would be very handy when dealing with obese patients with a deep neck. It would also be useful to prehospital providers who are credentialed for crichs and are faced with a difficult airway.
If any of you have used this technique, please leave a comment for us!
Intubation is the one procedure that provokes the most anxiety for trauma professionals. What about those facial fractures? What if you can’t get it? Video-assisted intubation is now readily available and at a reasonable cost. And it seems like a great idea, but does it make intubation easier?
A paper to be presented at the AAST next week looked at intubation success among relatively inexperienced users, junior residents. They compared success rates of video assisted (VA) intubation in an ICU (74 patients) with direct laryngoscopic (DL) intubation performed in an ED (54 patients).
All patients were successfully intubated by the junior resident, or by a more senior backup if they were unsuccessful (fellow or attending). The junior residents were successful in 96% of the VA intubations, but in only 76% of DL intubations. Less experienced residents (<20 intubations) were successful in all 96% of the VA intubations but in only 40% of the DL. And the least experienced, those who had done less than 5 intubations, obtained an airway with VA 37% of the time vs 7% for DL. The number of desaturations to less than 80% and hospital mortality was the same for the two groups.
Bottom line: Video assisted intubation is superior to the old-fashioned direct laryngoscopic technique. Even inexperienced providers have a better success rate with the video assisted technique. Over the next few years, it will become the standard for intubating patients, both in the field by medics and in the hospital.
Reference: The emergent airway: video-assisted intubation is superior to direct laryngoscopy for teaching junior residents. AAST 2011 Paper #65.
Oral endotracheal intubation is the gold standard when a field airway is needed. However, they are not always possible due to protocol, training, patient anatomy or specific injuries. To allow airway support in these situations, a number of techniques and devices have been developed. The problem is, do we really know which one(s) are best?
To try to answer this question, a huge meta-analysis of all the English literature with information on success rates for these techniques was carried out. Over 2000 papers were identified, and they were narrowed down to 35 studies involving over 10,000 patients.
The success rates that they identified were as follows:
- King LT airway – 96.5%
- Esophageal Obturator / Esophageal Gastric Tube Airway – 92.6%
- Surgical cricothyroidotomy – 90.5%
- Laryngeal mask airway (LMA) 87.4%
- Combitube – 85.4%
- Pharyngeotrachael laryngeal airway (PTLA) – 82.1%
- Needle cricothyroidotomy – 65.8%
The Bottom Line: The King airway has the highest success rate of the alternative airway devices, although there was less data available and the effectiveness of ventilation has not been worked out yet. The best percutaneous rescue airway was the surgical crich.
Reference: A Meta-Analysis of Prehospital Airway Control Techniques Part II: Alternative Airway Devices and Cricothyrotomy Success Rates. Prehospital Emergency Care 14(4):515-530, Oct-Dec 2010.