Airway - Trauma Scenario

[SpecialK]

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.

Sorry? Where on earth did you get the idea you could paralyse somebody with suxamethonium without a general anaesthetic first?

I cannot for the life of me think of why anybody would even try such a thing?

With a severe TBI and a 30 minute drive to a major trauma hospital I'd want to be underway as soon as possible however it's worth spending the extra 10 minutes to perform an RSI. That means he is asleep and intubated in 10 minutes, not the 30 it is going to take to drive to the major trauma hospital, plus the 10 minutes it is going to take to get the ambulance parked, get him inside and have everything handed over and set up until he can be intubated.

 

[VentMonkey]

Sorry? Where on earth did you get the idea you could paralyse somebody with suxamethonium without a general anaesthetic first?

I cannot for the life of me think of why anybody would even try such a thing?

With a severe TBI and a 30 minute drive to a major trauma hospital I'd want to be underway as soon as possible however it's worth spending the extra 10 minutes to perform an RSI. That means he is asleep and intubated in 10 minutes, not the 30 it is going to take to drive to the major trauma hospital, plus the 10 minutes it is going to take to get the ambulance parked, get him inside and have everything handed over and set up until he can be intubated.

I believe this is the algorithm @TXmed is referring to, but he's more than welcome to correct me if I am wrong.

 

[TXmed]

Sorry? Where on earth did you get the idea you could paralyse somebody with suxamethonium without a general anaesthetic first?

I cannot for the life of me think of why anybody would even try such a thing?

.

My medical director fully support ron walls and george kovacs veiws on this. THAT is where i got this crazy idea. This patient is very critical, he is also not alert enough to comprehend what is going on when you do this.

Scott weingart from emcrit talks about this in his LAMW podcast as we must treat the patients life threats and THEN pain, and THEN possible sedation in the critical patient.

 

[VentMonkey]

My medical director fully support ron walls and george kovacs veiws on this. THAT is where i got this crazy idea. This patient is very critical, he is also not alert enough to comprehend what is going on when you do this.

Scott weingart from emcrit talks about this in his LAMW podcast as we must treat the patients life threats and THEN pain, and THEN possible sedation in the critical patient.

I agree somewhat, but admittedly, I have yet to listen to this particular series by Doc Weingart, so I'll ask what the risk/ benefit ratio is in regards to time savings to definitive care?

Granted, I can respect how this can be spun (i.e., saving the ED the extra steps in performing ETI, and reducing arrival time to CT vs. them performing this procedure in-house). I'm merely trying to keep this thread alive for the sake of a nice healthy airway debate.

 

[Tigger]

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

Should have been more clear...if you're going to intubate would you give lidocaine. As far as I can tell lidocaine does prevent ICP spikes and suppressed the cough reflex but might not really matter anyway.

 

[StCEMT]

I agree somewhat, but admittedly, I have yet to listen to this particular series by Doc Weingart, so I'll ask what the risk/ benefit ratio is in regards to time savings to definitive care?

Granted, I can respect how this can be spun (i.e., saving the ED the extra steps in performing ETI, and reducing arrival time to CT vs. them performing this procedure in-house). I'm merely trying to keep this thread alive for the sake of a nice healthy airway debate.

While that podcast is one I will have to listen to a few times to let it fully sink in, I found it to be pretty informative. Worth a listen if you have 20 minutes to spare.

 

[VentMonkey]

Should have been more clear...if you're going to intubate would you give lidocaine. As far as I can tell lidocaine does prevent ICP spikes and suppressed the cough reflex but might not really matter anyway.

Lol, don't get @Remi started. Honestly though his view is not without reason.

The way I understand it is basically since any patient short of having bolts placed directly into theor skull for ICP monitoring to "study" any increase in ICP with vs. without Lidocaine, there are no hard, and fast studies, or proof, so it's still very much something people are hard pressed to prove with definitive studies.

With that said, it sounds discretionary, though I am sure people can very much argue for either or, but in grand scheme of "prehospital measures", I hardly doubt it matters that much so @Tigger it sounds as though we're on the same page.

 

[TXmed]

I agree somewhat, but admittedly, I have yet to listen to this particular series by Doc Weingart, so I'll ask what the risk/ benefit ratio is in regards to time savings to definitive care?

Granted, I can respect how this can be spun (i.e., saving the ED the extra steps in performing ETI, and reducing arrival time to CT vs. them performing this procedure in-house). I'm merely trying to keep this thread alive for the sake of a nice healthy airway debate.

yea his Laryngescope as a murder weapon series is great. he talks about the differences in RSI'ing hypoxic patients, hypotensive patients, using push-dose pressors, DSI ETC. really interesting.

admittingly this is tough thought process to get on board with. But after reading some books by some of the people i named previously ive become more open to it.

 

[VentMonkey]

I'll have to check it out, his energy and enthusiasm are second to none.

Great discussion, BTW everyone.

 

[TXmed]

haha glad i could offer something. Yea airway stuff on this site always offers a lengthy discussion. But their is alot of very knowledgeable people on here to offer up their opinions and advice.

 

[VentMonkey]

their is alot of very knowledgeable people on here to offer up their opinions and advice.

100% in agreement.

 

[SpecialK]

This patient has an SpO2 of 100% with an NPA and an ETCO2 of 32 mmHg. Looks pretty good. What doesn't look so good is their intermittent apnoea.

I don't see any point in giving them suxamethonium alone if the initial attempt at intubation is unsuccessful which is what the above picture talks about. Just because somebody has a GCS of 3 doesn't mean they should be paralysed without an anaesthetic first. A single bit slug of ketamine is pretty much the standard general anaesthesia for RSI in most places and it has a reasonably fast onset (at most 30 seconds) and if you give your neuromuscular blocker immediately after the anaesthetic the patient will be fast asleep about the same time as they are being physiologically paralysed.

If the patient is so obtunded and near death, they will accept a basic airway for the two minutes it is going to take to set up for an RSI. What is going to make a clinically significant difference is ensuring adequate oxygenation. You could even have an attempt without RSI, but I wouldn't really want to, indeed the CPGs state GCS of 3 and ineffective breathing as the only indication for doing so, with the point the risks of intubation generally outweigh the benefits without RSI, and I agree.

What saves lives (and brains) is good airway care done well; even if that is a nasoairway and a bag mask; what you use doesn't matter; it's the end-result of good oxygenation and normocarbia, and avoiding hyperventilation.

There are no studies I am aware of looking at this, but to me it's half measures, if you are going to do RSI, do it properly, and not half measures. I have seen some services around the world who seem to just give people enough sedation until they are unconscious enough to be intubated, and now somebody wants to paralyse people without a general anaesthetic when they'd just as easily accept an LMA in the interim. If you are going to do something, do it properly. And, how are we to know somebody who has a GCS of 3 hasn;t got, or will not develop, some awareness?

For this patient, with a 30 minute drive time to a major trauma hospital, if an RSI capable ICP was not available in a few minutes and could not meet us en-route, I would have one single attempt at intubating without RSI. If that didn't work I'd just stick with an LMA.

 

[Bullets]

With a 6 minute hit to a Level II, i would probably forgo intubation as long as an OPA and BVM are working to maintain oxygenation through the apenic period. Should i think i need to place something more advanced i would prefer doping an iGel in that short time period. And then a call to the ER to get ready to tube when we arrive. I also think i would go with Ketamine up front if he tolerates the OPA. If he starts gagging then a paralytic, maybe Vec

No reason to divert to a Level I with a Level II that close

 

[Carlos Danger]

Alright, here's my take on what's been discussed so far here:

First, what does the evidence tell us about how to manage these patients, airway wise? It's been looked at a lot, and while there are no conclusive prospective studies out there, I don't think there is any study anywhere that indicates that intubating a patient with an Sp02 of 100% who is only six minutes from a trauma center is anything but a bad idea. In fact, outcomes have repeatedly been shown to be worse in patients who we intubate in the field. Not better, not the same.....worse. So there's that. I'm not trying to convince anyone that we should throw away our laryngoscopes, but I think any time we talk about the best way to manage a given scenario, one of the first things we should do is consider what the research has to say about it

CNS trauma victims are very sensitive to hemodynamic changes. You can cause secondary injury by not blunting the sympathetic response to intubation properly, or by causing hypotension with your sedation. Hypotension is almost certainly worse than hypertension, but that doesn't mean it's OK to do things to them that cause their ICP to go even higher than it is.

@TXmed, you are absolutely correct that sometimes it is appropriate to forgo sedation. People have laughed at my "Sux --> tube --> apologize later" saying but it really is the best approach on occasion. I don't think it is in this case, though. Partly because of the issues I described in the last paragraph, and partly because I don't think any patient with an intact respiratory drive and an Sp02 of 100% meets any definition of "crash airway". This patient requires the exact opposite of a crash airway....a slow, methodical, gentle approach with as much attention paid to hemodynamics as possible.

@Tigger, it is true that lidocaine has not been shown to improve outcomes in TBI patients. It does blunt the sympathetic response to intubation which decreases the increase in ICP, but that hasn't translated into improved outcomes in this population. I still use it pretty routinely though. A healthy serum level of lido has all sorts of effects that, at least in theory, could be helpful. It potentiates opioids and anesthetic agents, it can reduce coughing if you are a little trigger happy with your laryngoscopy (as I tend to be), it reduces myalgia from succinylcholine, it reduces the incidence of chronic pain development, maybe delays the onset of ectopic activity if we start to get hypoxemic, etc. If I were by myself in the field and already task-saturated with dealing with a critical patient, I would definitely not worry about trying to give lido 5 minutes before I intubate. But if I'm preparing for a case in the OR, or if I get paged that an unintubated trauma is 10 minutes out from the ED and they are calling for help from anesthesia, then yeah, I'll take a few seconds to draw up lido with my other drugs, and it'll be the first thing I give, as I'm assessing the airway and getting my other stuff ready.

 

[VentMonkey]

@Remi for the win, excellent post.

 

[harold1981]

For the time being an airway is secured by the NPA, and the B is managed by proper ventilations with the BVM. The C is stable, despite a bradycardia.
Overall I have an ABC-stable patient, with a lifethreatening TBI. What will save his life is neurosurgery, which is available quickly with a pre-alert to the level 2 trauma center. I would not perform RSI up to this point.
Now if he vomits in those six minutes I have a big problem. I had an airway, now I don´t. I can´t properly suction, because of the trismus.
An open airway is not necessarily a safe airway. With TBI I can expect the patient to vomit anytime soon. An LMA or antiemetics is not going to stop that.
With that in mind, I prefer to perform the RSI before transporting.

 

[VentMonkey]

The C is stable because of a reflexive and protective mechanism such as a bradycardia.

So as long as we're both understanding this correctly. There's no need to treat or worry about the HR in this patient population. As others mentioned the two factors that kills any brain injured patient are hypoxia, and hypotension, so the reflexive HTN, and relative bradycardia seen in "classic" Cushing's is actually helping keep said patient afloat.

 

[harold1981]

I said: even though this patient is bradycardic, he has a stable circulation. I wasn´t intending to worry about it or treat it.

 

[VentMonkey]

I said: even though this patient is bradycardic, he has a stable circulation. I wasn´t intending to worry about it or treat it.

It was meant more in terms if a general statement towards us both, and everyone else.

I have seen some crazy rationalizing for treatment rendered way out of protocol or thought process, and often things get lost in translation in terms of what the individual thought of a specific procedure at the time.

I was mainly clarifying, it's more so directed at the masses as this is what an online forum is for...to help others get a better understanding of things missed elsewhere. I never said, indicated, nor assumed you specifically would treat it.

 

[harold1981]

okidokie VentMonkey, no problem sorry I misinterpreted.