Airway Management in Head Trauma (Scenerio)

[DesertMedic66]

Well we hotload in situations like this but I see your point. This is just my opinion. Most of our helicopters fly low ( under 500 ft) with ICP. He was (1-1-3) GCS which is where I got the posturing from.

Ahh, I missed the 3 motor score.

Under 500 ft? I thought the FAA minimum was 500 ft in a non populated area and 1,000 feet in a populated area?

 

[VentMonkey]

Under 500 ft? I thought the FAA minimum was 500 ft in a non populated area and 1,000 feet in a populated area?

Most of our helicopters fly low ( under 500 ft) with ICP.

Remind me to never apply for a HEMS job in your area. We fly as low as reasonably possible while staying legal, and safe. This sounds like a CFIT catastrophe waiting to happen.

 

[VFlutter]

It is only FAA legal to fly 500ft if you have speakers capable of playing Ride of the Valkyries...

But really most patients, even with free air or increased ICP, do not have issues flying 1000ft.

 

[Colt45]

It is only FAA legal to fly 500ft if you have speakers capable of playing Ride of the Valkyries...

But really most patients, even with free air or increased ICP, do not have issues flying 1000ft.

Haha that's awesome. Yeah I had a flight nurse tell me that literally a few days ago that 500 was what they liked to stay around with ICP if possible. I don't know their exact number though.

 

[NPO]

Thank you everyone for your answers and input.

In the above scenerio RSI was not available as part of my scope of practice, and would have only been available by helicopter which would have prolonged definitive care. I didn't mention, but can completely eliminate rendezvous with helicopter because the helicopter was coming from the West and the trauma center was east.

So what ended up happening is I managed the airway BLS but took some extra hands with me in case things deteriorated. The patient was fairly active given his GCS; he would occasionally flex and move a bit, but none of it seemed purposeful. I wasn't confident in my ability to get a more advanced airway (without making things worse with a sympathetic response or aspiration) without PAI, which I didn't have. I aired on the side of caution.

This scenario was to see how people would treat airway with respect to ICP. I'm not sure what current literature teaches but I was taught to be more reserved on TBI. That said, this is a rather obtunded patient. My new agency DOES carry PAI medications, which is why I was looking to compare notes.

 

[TXmed]

@VentMonkey i think its less to do about elevation and more to do about stimulation (extreme noise, vibration etc.)

Also, i would go pressure control with this guy so i can control his mean airway pressure more accurately. But thats personal preference.

@Qulevrius some of my rationel, is that you have an anotomically difficult'ish airway with the spinal precations and face trauma. You potentially have a situationally difficult airway depending on provider experience. Its best to handle the airway prior to making it a physiollogicaly difficult airway by adding hypoxia,hypercapnea, and further herniation that would come down the road. (When all 3 of those meet thats when you get sentinel events).

What do the anesthesia people think ? @Remi @E tank

To the folks with neuro-critical care backgrounds how would your thought process be with mannitol/ hypertonic NS admin with this guy?

 

[VentMonkey]

@VentMonkey i think its less to do about elevation and more to do about stimulation (extreme noise, vibration etc.)

An impractical solution given the much safer alternatives, and the realistically minimal changes it would have on the patient’s outcome.

 

[RocketMedic]

Isn't altitude safety in case something goes wrong (like engine failure)? More energy for autorotation? Why not fly at a thousand meters and have some extra room for error?

 

[Brandon O]

@VentMonkey Also, i would go pressure control with this guy so i can control his mean airway pressure more accurately. But thats personal preference.

To the folks with neuro-critical care backgrounds how would your thought process be with mannitol/ hypertonic NS admin with this guy?

Hard to say as we pretty much always have the CT. If he were truly unresponsive with a blown pupil after the initial event I suppose I would consider an empiric slug of hyperosmolar therapy.

Not sure what you mean about using pressure control.

I would say to intubate in the field if you're confident you can do it successfully and without hypotension or hypoxia. Otherwise defer if you think you can maintain without. Would be very wary doing it without drugs.

 

[TXmed]

@Brandon O sorry bout that. I would preffer to use a pressure mode over a volume mode to better controll the mean airway pressure (MAP) as on most transport vents focusing on map gives you better control/understanding of how your ventilation is efficting hemodynamic status and cerebral drainage. Atleast in the out of hospital enviroment. So keep the patient oxygenated to Spo2 > 95%, ETCO2 35-40 (30 if needed for short spells) and decreasing the MAP (generally below 10) to assist in whats mentioned above are my ventilator goals during transport. Then adjusting rise time pressure support to keep patient comfortable and manage sedation so when i arrive the patient isnt snowed unless its needed.

This is all personal preference for me. Volume mode is just fine just thought i would throw that in to stimulate convo.

 

[VentMonkey]

The advent of PRVC in the transport ventilator setting is in, and of itself, quite the godsend.

 

[TXmed]

@VentMonkey i do not have any hands on experience with PRVC in the transport setting. But thats great if you got it.

@Brandon O i know your settimg is more icu but, would you salt bomb this patient without a foley or labs ?

 

[NPO]

The advent of PRVC in the transport ventilator setting is in, and of itself, quite the godsend.

Do the Hamiltons have PRVC? Our vent is pretty decent, but does lack any kind of pressure modes other than adjustable pmax.

 

[StCEMT]

If I am playing within my service area, I am probably going to BLS the airway and personally be the one doing it with all the necessary back up equipment handy. I don't have any meds to intubate with. Technically I have Fent and Versed, but not in protocol for this. If I got to choose my preferred way? Probably Ketamine followed by Roc.

 

[Akulahawk]

Here's a little bit of my own thought process as I initially read the scenario. I know the TC is 40 minutes, helicopter is 45 minutes away. I'm not flying this one because by the time the helicopter arrives on scene, I'm going to be about 5-10 minutes out from the hospital and that means the patient is being evaluated by a trauma team about 20 minutes sooner with ground transport vs air. This is a no-brainer thing.

You assess his GCS to be 5 (1-1-3). He has snoring respirations, and two swolen eyes with unequal and non-reactive pupils.

This instantly makes me think severe TBI.

Upon removal from the van a CCollar is applied, and an OPA resolves the snoring.

Given the patient is tolerating the OPA, that means his airway reflexes are likely gone or minimal at best, so this guy is getting an ETT. I'm probably not going to RSI unless I cannot open his jaw. The swollen eyes take NTI out of the picture. Why intubate so early? Well, we're not moving so I have a stable place to do it. I want control of his airway and breathing as I suspect he's going to stop breathing on his own. He's also likely to vomit at some point and I want to prevent him from aspirating.

HR: 140
BP: 180/100
RR: 14, regular, improved with OPA, occasional snoring
BGL: 96
SPO2: 96% on 10lpm

These vitals tell me he's not herniating yet, but again makes me think severe TBI and to minimize any delay in getting him to a surgeon. The occasional snoring even with the OPA in place tells me the OPA is incorrectly sized, incorrectly placed, or both. Either way this guy's getting an tube. I do not want to have to scramble to intubate when this guy vomits... or loses his respiratory drive.

For those of you that are considering maintaining a BLS airway with this guy, consider that while this guy is breathing on his own (for now), he's occasionally snoring even with an OPA in place. Eventually as his ICP rises he's going to vomit and will aspirate. He will eventually require you to use a BVM. At that point, you'd best have another person in the back with you or you're going to be 100% focused on that BLS airway until you can place an advanced airway and get him on a vent. That means your workload dramatically increases while you're moving and if you have to stop moving to intubate, that's increasing the time to get him to a trauma team.

 

[VentMonkey]

Do the Hamiltons have PRVC? Our vent is pretty decent, but does lack any kind of pressure modes other than adjustable pmax.

PRVC is actually a VC mode, as the name implies. It monitors and adjusts the airway pressures in the patients lungs based on their efforts then delivers a set Vt accordingly. It requires somewhat less effort from the clinician in monitoring their airway pressures than your standard VCV modes, so it’s more of a “nice to have” mode.

If your vent has AC VC, you could utilize that and monitor their Pip’s and Pplats to make sure you’re where you want them, which is for us, a fairly restricted range. And yeah, the manufacturer programmed PRVC in our vents for us since it’s pretty much the standard in almost every ICU patient we transport and it’s much more practical to try and match their vent settings and parameters to begin with.

 

[RocketMedic]

Do the Hamiltons have PRVC? Our vent is pretty decent, but does lack any kind of pressure modes other than adjustable pmax.

What do you use?

 

[FiremanMike]

Because per scenario, the pt has a traumatic head/neck injury and the last thing you want to do is to remove the c-collar. Also because with that neuro presentation, the pt stands a pretty good chance of hernia which, when happens, will kill him regardless. And lastly because once you drop a tube, you better be prepared to ventilate and monitor CO2 output very closely - which I’m entirely not sure you have the tools for, unless you’re on a ground CCT with an RT or intensivist as a partner. Not to mention that you’ll be glued to that tube 150% of the time.

Just a couple of thoughts here..
1. Current literature shows that c-spine injuries have either already occurred prior to arrival or are stable. On top of that, removing a c-collar and holding manual c-spine during intubation has been common practice for many years now (even before we dispelled the "full c-spine precautions" myth).

2. Waveform capnography is the standard of care and standard equipment on ALS trucks around here, is that a regional thing? It doesn't take a CCT/RT/Intensivist to bag at 8/min and watch the numbers/waveform..

3. While I don't THINK this is what you meant, you kind of imply that this person is going to die of a herniation, so why bother? That's not really the mentality I like to see promoted in our field. If we have a chance to potentially impact or improve morbidity/mortality, we should jump on those opportunities.

As for my management, I'm going to ask my partner to go draw up our crash airway drugs (rocketamine) and RSI as soon as we get into the truck.

 

[Qulevrius]

Just a couple of thoughts here..
1. Current literature shows that c-spine injuries have either already occurred prior to arrival or are stable. On top of that, removing a c-collar and holding manual c-spine during intubation has been common practice for many years now (even before we dispelled the "full c-spine precautions" myth).

2. Waveform capnography is the standard of care and standard equipment on ALS trucks around here, is that a regional thing? It doesn't take a CCT/RT/Intensivist to bag at 8/min and watch the numbers/waveform..

3. While I don't THINK this is what you meant, you kind of imply that this person is going to die of a herniation, so why bother? That's not really the mentality I like to see promoted in our field. If we have a chance to potentially impact or improve morbidity/mortality, we should jump on those opportunities.

1) I’ve been indoctrinated with the ‘once the c-collar is on, it stays on’ approach.

2) I can watch the capno morphology and bag just fine. What I, unfortunately, cannot do, is grow an extra pair of hands for doing anything else. Only CCT trucks carry ventilators.

3) What I was saying is that, IMO, the risk of him herniating is significantly greater than the risk of him hypoxiating and, therefore, should be addressed immediately and aggressively with sedatives, osmotic procedures and body temp control. Because whilst there’s something you can do about his airway if things start getting worse, there’s absolutely nothing you can do if/when the pt herniates.

 

[VentMonkey]

As for my management, I'm going to ask my partner to go draw up our crash airway drugs (rocketamine) and RSI as soon as we get into the truck.

What does your service define as crash airway vs. full on RSI? This sounds more like the latter and not the former. They’re not exactly the same.

Also, @Qulevrius is the kind of EMT I wish I had worked with: extremely well-versed. Unfortunately, he has to keep his lemonade stand open in his county.