Airway - Trauma Scenario

[Handsome Robb]

Ran this call this morning. Wondering what people's decision would have been.

35 year old male was crossing the street when he was struck by a sedan-type vehicle traveling approximately 20 mph.

Arrive on scene to find ALS fire on scene with an NPA in place and assisting ventilations.

GCS 3, pupils are fixed at 2mm, laceration noted to the occipital region with moderate bleeding. Face is autraumatic, jaw is trismussed, cheyne-stokes respiratory pattern. His chest is atraumatic, lung sounds are clear to auscultation bilaterally, abdomen is soft and his pelvis is stable. Upper and lower extremities are atraumatic, strong peripheral pulses x4.

Vitals:
HR 46, sinus, without ectopy.
RR 0-28, cheyne-stokes pattern
136/70
100% with ventilations assisted with 15lpm via BVM.

You're approximately 6-7 minutes from the level 2 trauma center, 30 minutes from the level 1.

You're a dual medic, RSI capable ground unit with an ALS engine crew on scene.

Do you intubate? Why or why not? Do you have any other questions as far as the scenario or assessment findings?



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[VentMonkey]

Ran this call this morning. Wondering what people's decision would have been.

35 year old male was crossing the street when he was struck by a sedan-type vehicle traveling approximately 20 mph.

Arrive on scene to find ALS fire on scene with an NPA in place and assisting ventilations.

GCS 3, pupils are fixed at 2mm, laceration noted to the occipital region with moderate bleeding. Face is autraumatic, jaw is trismussed, cheyne-stokes respiratory pattern. His chest is atraumatic, lung sounds are clear to auscultation bilaterally, abdomen is soft and his pelvis is stable. Upper and lower extremities are atraumatic, strong peripheral pulses x4.

Vitals:
HR 46, sinus, without ectopy.
RR 0-28, cheyne-stokes pattern
136/70
100% with ventilations assisted with 15lpm via BVM.

You're approximately 6-7 minutes from the level 2 trauma center, 30 minutes from the level 1.

You're a dual medic, RSI capable ground unit with an ALS engine crew on scene.

Do you intubate? Why or why not? Do you have any other questions as far as the scenario or assessment findings?



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Probably wouldn't RSI with that ETA. O2 sats are good as is, closest trauma center probably has neuro capabilities, so go there, if not the Level 1 that does.

These things along with presentation are enough to scream TBI/ ICH, with a good chance said patient needs or may need a crani...rapidly.

Only thing I would be aggressive with is seeing his is (safely) taken to the right place to perform said surgery, and if CT is clear then meh better safe than sorry, just me though.

 

[VentMonkey]

To add to this, if the Level 1 has neurosurgery and the Level 2 doesn't (highly doubt it?), ground it the extra ~25 minutes to the Level 1 with plenty of time to RSI if need be, assuming his GCS doesn't begin to improve en route; don't forget to place them on the vent though.

All I got for now, Robb.

 

[DesertMedic66]

I would go with the same treatment route that @VentMonkey stated.

 

[Handsome Robb]

Level 2 has all the same capabilities as the level 1 minus being a teaching facility. That was my little test of all y'all's knowledge of level 2 va level 1 trauma centers

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[VentMonkey]

Level 2 has all the same capabilities as the level 1 minus being a teaching facility.

We only have one trauma center in our county, a level 2, which is also a teaching hospital.

 

[StCEMT]

I wouldn't based on the info you gave. If it ain't broke, don't fix it.

 

[zzyzx]

Yes, I would intubate. This guy needs an airway.
Once he's intubated, you can control his oxygenation and ventilation very nicely, which is also going to be important for someone with a head injury like this.
If I didn't have RSI, I would see if he could maintain perfect sats with only a mask and not the BVM. I would be worried about gastric insufflation in this scenario.
Level II trauma center is fine.

 

[SpecialK]

RSI with fentanyl, ketamine and rocuronium. Would love to be able to mechanically ventilate him, but as not, ventilate to ETCO2 of 35-45 mmHg.

I would bind his pelvis (but absolutely not "spring" or firmly palpate it)

Take him to a major trauma hospital directly.

 

[TXmed]

With this guy displaying cushings i would use ron walls "crash airway algorithim".

Administer succs (or roc) alone for the airway procedure and attempt to intubate. with that kind of ETA im not too concerned about getting the intubation (although try) as i am just maintaining an airway and keeping the O2 sats up.

 

[EpiEMS]

Quick high level reference for trauma centers -- level 2 hospitals have 24 hour neuro coverage.

Robb, did you get an ETCO2 reading?

 

[RRTMedic]

Ran this call this morning. Wondering what people's decision would have been.

35 year old male was crossing the street when he was struck by a sedan-type vehicle traveling approximately 20 mph.

Arrive on scene to find ALS fire on scene with an NPA in place and assisting ventilations.

GCS 3, pupils are fixed at 2mm, laceration noted to the occipital region with moderate bleeding. Face is autraumatic, jaw is trismussed, cheyne-stokes respiratory pattern. His chest is atraumatic, lung sounds are clear to auscultation bilaterally, abdomen is soft and his pelvis is stable. Upper and lower extremities are atraumatic, strong peripheral pulses x4.

Vitals:
HR 46, sinus, without ectopy.
RR 0-28, cheyne-stokes pattern
136/70
100% with ventilations assisted with 15lpm via BVM.

You're approximately 6-7 minutes from the level 2 trauma center, 30 minutes from the level 1.

You're a dual medic, RSI capable ground unit with an ALS engine crew on scene.

Do you intubate? Why or why not? Do you have any other questions as far as the scenario or assessment findings?



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Okay, so without looking at anyone elses' posts and giving you my clear cut opinion... this is a grab and go case. Sounds like he has a clear case of cushing reflex and will have the potential for neurosurgical intervention. Airway of course is a definite, but also a priority, doesn't seem to be completely compromised. You're BVM'ing him well and his blood pressure is stable. So far, you have hit on two of the three keys to traumatic brain injury: Hypoxia (spo2 100%), hypotension (136/70) and hypoglycemia (???). Sounds to me that you cannot truly justify paralyzing him in the field and risk a failed airway when there is a capable hospital 6 minutes away. What he needs is intubation and Head CT.... and I don't think that hanging out and intubating would be the best idea. IF, you did not have the option to go to the Level 2 and then had a 30 min transport time... I'd reconsider.

 

[Carlos Danger]

Turn & burn to the level 2. I would intubate and hyperventilate only if I could do it enroute.

Someone mentioned intubating with only sux.....what is the advantage of driving ICP even higher than it is?

 

[Tigger]

With that ETA I think I would call an alert into the hospital as soon as we got on scene and tell them to expect to RSI him on our arrival. No reason to sit out there. Get a line or two enroute and ensure that the BVM is being used appropriately.

If he was entangled or something and I had time to set everything up while they're bringing him to me I'd be more inclined to do so.

Would you consider lidocaine?

 

[VentMonkey]

Would you consider lidocaine?

Only as a pre-RSI measure, but if there's no reason for an immediate advanced airway, there's no need for Lidocaine.

 

[VFlutter]

Lidocaine is no longer in my protocols for pre-RSI.

 

[Handsome Robb]

Quick high level reference for trauma centers -- level 2 hospitals have 24 hour neuro coverage.

Robb, did you get an ETCO2 reading?

32 mmHg. We ended up turning the O2 off and just BVMing him through his periods of apnea with room air. SpO2 stayed at 99-100%.

We discussed intubating him with ketamine and roc but deferred it due to proximity to the TC. We actually don't RSI, only DSI so even once you've got a line in place and give the ketamine it's still a 4.5 minute procedure and transport was about 6 minutes.

Found out he ended up herniating and as a donor. His ICP was in the 80s per the neurosurgeon when we checked in on him later.


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[Summit]

Load and go to the Level 2. You could think about RSI, but by the time you finish you'll be at the ED doors, so pass given the presentation.

 

[VentMonkey]

32 mmHg. We ended up turning the O2 off and just BVMing him through his periods of apnea with room air. SpO2 stayed at 99-100%.

Nice job with the ETCO2 threshold. I am unfamiliar with the second part of this quote though, what's the theory?

 

[TXmed]

Someone mentioned intubating with only sux.....what is the advantage of driving ICP even higher than it is?

with the crash airway algorithm its more about airway control rather than intubation. So if i was to administer succs and walk into the ER with an OPA, good BVM, Good o2 sats, and good ETCO2 thats more what this patient needs rather than a piece of plastic between his vocal cords (although i would try an intubation). We know laryngescopy increases ICP but it hasnt been proven that laryngescopy alone leads to poor patient outcomes (or atleast from the studies i have read) and fentanyl/lidocain are more thoughts rather than proven science, or atleast that is the view of my MD. If this patient was to seize, vomit, combative, and even their trismus is raising their ICP, atleast with a paralytic on board we can help this.


I fully support peoples affinity for short scene times. but me personally on this call i would slow everyone down, properly manage the airway, (good job on the NPA and ETCO2 by the way), administer a paralytic, suction, ensure proper o2 sats, etco2, and airway protection. all these things is what the ER facility is going to do in the first 10 minutes. But that is just my personal opinion. i dont think anyone who commented above is wrong in their thinking.