Tag Archives: weird

Technique

By Request: Submental Intubation

Leave a comment

I keep getting requests regarding this technique, so I’m reposting  this updated article 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.

tumblr_inline_mvds1c14ye1qa4rug1

 

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.

tumblr_inline_mvdsm0zd8b1qa4rug1

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

General

How Likely Am I To Die From…

Leave a comment

Some interesting facts on how likely you are to die from a given cause in the coming year:

  • choking on a non-food object – 1 in 96,300
  • drowning in a bathtub – 1 in 724,900
  • firearm discharge – 1 in 4,101,000
  • contact with a powered lawnmower – 1 in 4,606,000
  • strenuous movement – 1 in 23,030,000
  • handheld power tool accident – 1 in 24,950,000
  • contact with hot food – 1 in 74,850,000
  • escalator accident – 1 in 90,470,000
  • vending machine accident – 1 in 112,000,000
  • shark attack – 1 in 251,800,000
  • noise exposure – 1 in 281,400,000
  • fall from playground equipment – 1 in 299,400,000
  • scorpion sting – 1 in 299,400,000
General
Gallery Leave a comment

Explain This! The Answer

This patient was running from an assailant at top speed and fell, tumbling for several feet. Medics found him in this position and pondered how to secure him for transport. eventually they just used straps and belts to hold him on a backboard.

The injury is an interesting one. He has a femur fracture, but there is a twist (literally). If he was a contortionist and had found a way to bend his knee toward his head, his toes would point to his face. If you look at the thigh, twisted muscle bellies can be seen.

The diagnosis is a mid-shaft femur fracture with a 180 degree rotation of the distal portion.

General

Final Answer: What The Heck Is It #1

Leave a comment

Alright, here’s the final answer to the xray I posted last Friday. This patient was using a ThermaCare Menstrual HeatWrap by Pfizer. It was applied to her back, though, for relief from back pain. It was not apparent during the trauma activation exam, even with clothes off, until we logrolled her to examine her back.

Each pocket in the wrap contains a granular mixture of activated carbon, iron powder, salt and a few other ingredients. When the wrap is removed from its vacuum pouch it heats up to 104F (40C) and stays hot for up to 8 hours. The iron shows up on xrays. The regular pattern is a giveaway that this is not some other problem (stones, drug pouches in the colon).

Bottom line: Remember, conventional xrays collapse a 3D space onto a 2D image, so you can’t tell how deep objects are (anterior to posterior). This is another reminder to be thorough when examining your patient. They can hide things anywhere!

Disclaimer: I do not have any financial or other interest in Pfizer Inc.

What The Heck Final Answer