Tag Archives: intubation

Best Of EAST 2023 #6: The Best Place To Intubate Bleeding Patients

Forty years ago, the presumption was that the best way to intubate a trauma patient was to take them to a fully equipped operating room and have an anesthesiologist perform it. Then, a few years later, we finally figured out it could be done in the emergency department. The key to doing it safely was that the trauma bay needed to look like an OR, with appropriate airway equipment, lights, and drugs. And you had to ensure that your intubator had sufficient skills.

But we are all too familiar with one subset of trauma patients much more sensitive to the intubation process: those who are bleeding and in shock. They are desperately compensating to attempt to maintain their vital signs as much as they can with their sympathetic tone. Unfortunately, the intubation process and the drugs we use can eliminate this reflex and lead to immediate hemodynamic collapse.

The trauma group at Johns Hopkins postulated that intubation in the ED could lead to worse outcomes in this particular group of patients. They analyzed three years of data from the National Trauma Data Bank dataset, isolating patients at Level I and Level II trauma centers who underwent immediate hemorrhage control surgery after arrival. Patients who were dead on arrival, intubated for airway concerns, or underwent resuscitative thoracotomy were excluded.

The authors used a regression model to determine any association between intubation and mortality. They also analyzed the usual secondary outcomes (complications [cardiac arrest, ARDS, AKI, sepsis], transfusions, and time in the ED).

Here are the factoids:

  • Nearly ten thousand patients at 253 trauma centers met inclusion criteria
  • Most patients were men with penetrating injury
  • One in five underwent intubation in the ED before their hemorrhage control operation and suffered a 17% mortality rate vs. 7% in the OR intubation group, which was a significant difference
  • Median dwell time in the ED was 31 minutes vs. 22 minutes in the OR group
  • Transfusion amount was significantly higher in the ED vs. OR group (6 vs. 4 units RBC)
  • Rates of all complications were significantly higher in the ED vs. OR groups (except sepsis)
  • Overall, cardiac arrest with CPR occurred in 10% of ED vs. 4% OR intubations
  • Centers that had low ED intubation rates generally had significantly lower post-intubation cardiac arrest events than those with higher ED intubation rates.

The authors concluded that ED intubation of patients requiring hemorrhage control was associated with multiple adverse events. They recommended that these patients be taken to the OR, where both intubation and rapid bleeding control can be achieved.

Bottom line: This nice, clean abstract addresses a simple question. Although it uses a large database, the authors focused on a limited number of variables, keeping the analysis uncomplicated.

The abstract paints a clear picture that agrees with the subjective observations of many trauma professionals that intubation in these patients can be dangerous. They found significant increases in mortality and complications in patients intubated in the ED.

Does this mean that the procedure is not being done as well there? Absolutely not! I believe the key is in the ED dwell time data, which shows an average of 9 more minutes spent there for intubation. Previous research has shown how even a few minutes count when it comes to hemorrhage control. This abstract provides some hard numbers that show how important it really is to get to the OR.

Here are my questions and comments for the presenter/authors:

  • First, a minor point: how can the “median” GCS be 15? Fifteen is the highest it can go. The median is the number where half the results are higher and half are lower. So if no results can be higher, none can be lower. Does this mean that every one of your 10K patients was wide awake?
  • Please explain the figure a little better. Does it just show the mix of low vs. average vs. high ED intubation rates? Or does it go along with the statement that high intubation rate centers have a higher likelihood of cardiac arrest in these patients?

I really enjoyed this abstract and am looking forward to any additional details provided at the presentation.

Reference: EMERGENCY DEPARTMENT VERSUS OPERATING ROOM INTUBATION OF PATIENTS UNDERGOING IMMEDIATE HEMORRHAGE CONTROL SURGERY, EAST 2023 Podium paper #13.

By Request: Submental Intubation – The Video!

In my last post, I dusted off an old post that described a novel technique for providing a secure yet short-term airway tailored to patients who can’t have a tube in their mouth or nose. Patients undergoing multiple facial fracture repair are probably the best candidates for this procedure.

A picture may be worth a thousand words, but a video is even better. Please note that it is explicit and shows the blow by blow surgical procedure. Of note, it is a quick and relatively simple advanced airway technique. Note the cool music!

Related post:

By Request Again!: Submental Intubation

I keep getting requests regarding this technique, so I’m reposting  this updated article today, and a video of the technique next week.

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.

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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.

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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

The April 2021 Trauma MedEd Newsletter Is Live! Potpourri

This issue is devoted to an uncommon yet potentially devastating problem, blunt carotid and vertebral artery injury.

In this issue, learn about:

  • Who’s Better At Invasive Procedures? Advanced care providers or residents?
  • How Many Salt Tabs In A Liter Of Saline?
  • Mainstem Intubation In Pediatric Patients
  •    And How To Avoid It!
  • Giving TXA Via An Intraosseous Line?

To download the current issue, just click here!

Or copy this link into your browser: https://bit.ly/TME202104

This newsletter was released to subscribers over a week ago. If you would like to be the first to get your hands on future newsletters, just click here to subscribe!

Is Intubation For Low GCS Necessary? Dangerous?

More dogma? I was taught that as the Glasgow Coma Scale (GCS) score drops toward 8, the higher the consideration of intubating the patient. And that a GCS 8 was pretty much an absolute indication for inserting the endotracheal tube. The rationale was that the more obtunded the patient was, the less able they were to protect their airway.

Even ATLS, our trauma textbooks, and practice guidelines from the likes of EAST recommend intubation for GCS 8 and less.

Having said that, I know many of you have been in a situation where you have a patient with GCS 8 or so, and they are lying there breathing peacefully with good oxygenation and ventilation. Do you really need to put in that tube? And we also tend to be very forgiving with obtunded children, avoiding premature intubation there as well.

Intubation is not a benign procedure. There is the potential for mayhem during the process, ICU admission will be required, and a host of ventilator and sedation-related complications are possible once the patient arrives there.

The trauma group at LAC + USC decided to look into this. They performed a five-year retrospective study of data from the TQIP database. A subset of patients was selected with isolated blunt head injury and GCS 7-8 who did not require immediate operation upon arrival. They were divided into intubation and non-intubation groups, and these were further subdivided into intubation within an hour of arrival, intubation after an hour, and never intubated groups.

Here are the factoids:

  • A total of 2,727 patients were studied; about two thirds were intubated within an hour, a quarter were never intubated, and the remaining 9% were intubated after the first hour
  • Immediately intubated patients were significantly younger and had fewer comorbidities
  • Mortality was 19% in the immediate intubation group vs 27% in the delayed group vs 11% in the never intubated group
  • Complications were significantly higher after immediate intubation, particularly DVT and ventilator associated pneumonia (VAP)
  • Regression analysis indicated that immediate intubation was independently associated with mortality compared to late or never intubated patients
  • Using additional regression testing, the authors concluded that the following two subsets of patients would benefit most from early intubation:
    • Younger patients (age < 45) with head AIS 5
    • Patients age <65 with head AIS 5

The authors recommend that “future research focus on more adequate parameters to identify patients requiring immediate intubation and should avoid an isolated fixed GCS threshold.”

Bottom line: This is a difficult paper to understand (at least for me). It looks like the authors are saying we should avoid immediate intubation of severe TBI patients with depressed GCS to reduce mortality and complications.

But you need to read the whole paper closely to really get it. First, let’s look at those mortality figures. The mortality in the three groups was:

  • intubated < 1 hour after arrival – 18.7% (from n = 1,866)
  • intubated > 1 hour after arrival – 27.4% (from n = 223)
  • never intubated – 11.4% (from n = 638)
  • If you combine the last two lines you get the mortality in the non-immediate intubations = 15.5% (from n = 861)

The authors then claim that the mortality for immediate intubation is greater than non-immediate intubation (the other two groups). This may be somewhat misleading, because the delayed intubation group actually has a higher mortality than the immediate group (27%)! This fact is covered up by combining delayed intubation with the never intubated group, bringing the number down to 15.5%!! Why shouldn’t you say that intubating the patient at any time is bad, immediate or delayed??

They suggest some criteria to try to focus in on the patients who really need intubation: younger patients (age < 45 or < 65) with head AIS 5 and GCS 7. Unfortunately, you can’t determine which patients have an AIS 5 in their head without a head CT, which may push them into the higher mortality delayed intubation group.

Remember, this type of study can only show an association, not cause and effect. The authors suggest that early intubation results in more deaths and complications. My suspicion is that patients with severe TBI don’t do poorly because they were intubated. I believe that they were intubated because the clinicians feared that they would do poorly. Unfortunately, this is information that can only be gleaned from a prospective study, not a retrospective database review.  And no amount of statistical manipulation or regression analysis can make up for this shortcoming.

This is yet another one of those studies that ends by concluding that a better study should be done. That would be okay if this one actually provided a hint that the endeavor would be worthwhile. But it doesn’t. I didn’t really learn anything from it, unfortunately.

So I still heartily recommend using your existing training, guidelines, and judgement to intubate these patients early and safely!

Reference: Isolated traumatic brain injury: Routine intubation for GCS 7 or 8 may be harmful! J Trauma, publish ahead of print, DOI: 10.1097/TA.0000000000003123, Feb 16, 2021.