Airway - Trauma Scenario

[VentMonkey]

okidokie VentMonkey, no problem sorry I misinterpreted.

 

[SpecialK]

So I've just read what a "Level II" is; and we do not have these.

We have a national network of five major trauma hospitals. We have a larger network of "secondary hospitals" which are fine for some trauma, for example somebody who needs a nail in their femur or has a flail chest or needs general medical intensive care but they do not handle major trauma. Our five major trauma hospitals are the only centres which have neurosurgery.

We do not transport major trauma to a non-major trauma hospital unless the patient has an immediately life-threatening problem with their airway, breathing or circulation which cannot be handled by ambulance personnel; for example, somebody who needs their chest opened to relieve a pericardial tamponade, or a formal chest drain inserted, or has had a cricothyrotomy for complete airway obstruction and needs a definitive airway. If we do this it is called "staging" and Control will activate a helicopter to transfer the patient to a major trauma hospital approximately 20-30 minutes after arriving a the staging hospital.

Much of the country is a long way away from a major trauma hospital (several hours by road and an hour or so by helicopter) so the network of "staging" hospitals is good in the rare instance you absolutely need something lifesaving done before the patient can be taken to a major trauma hospital.

 

[VentMonkey]

Very interesting @SpecialK, do you mind me asking where you work (country/ continent)?

 

[SpecialK]

Very interesting @SpecialK, do you mind me asking where you work (country/ continent)?

 

[Nova1300]

I waffle a lot on this question. On the whole, I'm not convinced prehospital intubation does much to save lives. Anecdotally, there are likely cases in which it helps. But to play it out statistically, it probably makes little mortality difference in the grand scheme.


That being said, I have always suspected that brain injured patients may be the one population in which there could be a benefit. I will tell you, a large number of these patients aspirate. You may not see it happen, but their bronchs consistently look awful on hospital day 1.

I have to wonder a couple things:
1. Does protecting the airway with a balloon, prior to strapping these patients supine and moving them around, decrease the incidence of these aspirations?
2. Does the sedation provided for intubation in the field provide a protective effect to the injured brain by decreasing the cerebral metabolic demand during a time of great stimulation( lifting, moving and transporting)?
3. Does early control of respiratory acid/base status improve outcomes? Specifically when instituted prior to moving and transporting the patient?

Perhaps these things would only have a benefit for longer transport times? Who knows. But this has always been a nagging question in the back of my mind. Because I have a hunch early intubation in these folks, specifically before transport, really could be of benefit.

 

[VentMonkey]

I waffle a lot on this question. On the whole, I'm not convinced prehospital intubation does much to save lives. Anecdotally, there are likely cases in which it helps. But to play it out statistically, it probably makes little mortality difference in the grand scheme.


That being said, I have always suspected that brain injured patients may be the one population in which there could be a benefit. I will tell you, a large number of these patients aspirate. You may not see it happen, but their bronchs consistently look awful on hospital day 1.

I have to wonder a couple things:
1. Does protecting the airway with a balloon, prior to strapping these patients supine and moving them around, decrease the incidence of these aspirations?
Would this be a patient population to benefit from early gastric tube placement in the prehospital setting?
2. Does the sedation provided for intubation in the field provide a protective effect to the injured brain by decreasing the cerebral metabolic demand during a time of great stimulation( lifting, moving and transporting)?
In my opinion said patients may benefit from a longer acting paralytic, or continued paralysis to furhter prolong any increases in metabolic demand/ ICP.
3. Does early control of respiratory acid/base status improve outcomes? Specifically when instituted prior to moving and transporting the patient?
Good question, and I don't have any definitive answers or proof, but will say that a fair amount of our "scene" patients are of the TBI variety, and furthermore, yet another reason PROPER prehospital ventilator management MUST be included when learning advanced airway management, and by advanced, I am referring to most of what is taught in the (United States') paramedic curriculum; again, simply "just getting the tube" does nothing for their recovery/ mortality ratio but prove our incompetence.
Perhaps these things would only have a benefit for longer transport times? Who knows. But this has always been a nagging question in the back of my mind. Because I have a hunch early intubation in these folks, specifically before transport, really could be of benefit.

These are just my thoughts, Nova. Feel free to chime in with yours.

 

[TXmed]

@VentMonkey i agree with you. Ive learned alot of applicable information when i learned about ventilator management and it has helped me become a better clinician even without the vent. Im also a big fan of resuscitate before you intubate and that placing that ET tube alone is not a treatment. i also feel that not all RSI is created equal. The patient mentioned above should have a different RSI then the septic patient, asthmatic, CHFer ETC. and thus the medications, dosage, pre and post treatment should differ and maybe prehospital intubation would have better outcomes.

 

[VentMonkey]

@VentMonkey i agree with you. Ive learned alot of applicable information when i learned about ventilator management and it has helped me become a better clinician even without the vent. Im also a big fan of resuscitate before you intubate and that placing that ET tube alone is not a treatment. i also feel that not all RSI is created equal. The patient mentioned above should have a different RSI then the septic patient, asthmatic, CHFer ETC. and thus the medications, dosage, pre and post treatment should differ and maybe prehospital intubation would have better outcomes.

early intubation in these folks, specifically before transport, really could be of benefit.

@TXmed, good point, and to further elaborate on the last part of @Nova1300's post, my personal opinion is that not all providers are created equal, and hence those properly trained for such specific situations should probably be the only ones coming near their airway with an advanced approach in the prehospital setting.

 

[Tigger]

Incidentally in the past I was taken to task for giving lidocaine to a bradycardic patient (completely different bigeminy scenario). Obviously if the patient happens to be in a bi/trifasicular block lidocaine is bad, but I don't really see sinus bradycardia as an issue for premedicating with lidocaine, am I wrong?

 

[VentMonkey]

am I in the wrong thread?

Yes, but I did this recently and caught all kinda of crap for it as well, sooo...

 

[VentMonkey]

Incidentally in the past I was taken to task for giving lidocaine to a bradycardic patient (completely different bigeminy scenario). Obviously if the patient happens to be in a bi/trifasicular block lidocaine is bad, but I don't really see sinus bradycardia as an issue for premedicating with lidocaine, am I wrong?

Unless you're referring to the earlier post re: treatment of the bradycardia, nonetheless, it sure is easy to ger things crossed.

And nah, I would equate it to the prophylactic treatment of bradycardia with Atropine, mainly in the pediatric RSI population, though, many places are moving away from that in their treatment tree as well TMK.

 

[Carlos Danger]

I don't really see sinus bradycardia as an issue for premedicating with lidocaine, am I wrong?

I don't really, either. I know bradycardia is listed as a side effect of lido, but I don't think I've ever noticed it decrease HR at all.

 

[Tigger]

Unless you're referring to the earlier post re: treatment of the bradycardia, nonetheless, it sure is easy to ger things crossed.

And nah, I would equate it to the prophylactic treatment of bradycardia with Atropine, mainly in the pediatric RSI population, though, many places are moving away from that in their treatment tree as well TMK.

Some people see bradycardia as a contraindication to lidocaine. I am not sure why.

 

[VentMonkey]

Some people see bradycardia as a contraindication to lidocaine. I am not sure why.

I can honestly say I don't recall learning this; guess it's time someone revisits this med, huh?

 

[VentMonkey]

@Tigger, so I did a brief dig, and it seems to be an outdated theory as most articles cited are from the 70's (like this one).

Maybe this is something just trickled down over the decades? Here's the most recent publication that came up on my first search.

http://www.sciencedirect.com/science/article/pii/S0022073674800129

It would also appear that it's more specific with heart disease patients, although I am not sure if it's a small amount of this patient demographic or not.

Either way, it seems like something to keep in the back of ones mind, but in an emergent situation (RSI) I don't know that it would be that high up on our list as providers.

Hopefully it dispels some questions for you, as it did for me. If you or anyone can find something more recent, please, share it with the forum.

 

[RocketMedic]

Barring some odd situation like a predicted difficult airway, I'd tend to go along with TXMed: This guy ought to be intubated fairly quickly, transported quickly to the trauma center, and so on. For me, the trismus is the deciding factor- vomiting and trismus do not mix well and we can expect vomiting to occur fairly quickly.

 

[FLMedic311]

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?

I believe he is referring to the idea of trying to avoid hyperoxia....?

 

[zzyzx]

What's harder to do, ET intubation or properly using a BVM?
Considering how ****ty nearly all medics are at using a BVM, I'd say BVM use is at least as hard as intubation.
Sometimes paramedics brag about their intubation skills. Ever hear anyone brag about how great their are at using a BVM? Usually the task of BVM ventilations isn't done by the medic anyway. It's passed on to a single firefighter or EMT.
Consider how much damage you can do to a head-injured patient by improperly bagging him--even if it's only for a few minutes before you get to "definitive care."

 

[Akulahawk]

I guess I'm going to be an outlier on this then. Given the 6 minute transport time to a L2 TC, I'm going to forego the intubation and simply BVM this patient. While I am a Paramedic and still remember how to intubate, I'm not above using my basic skills when they're quite appropriate to use and this is one such case. I'd just call ahead, give the radio report, and request that they be ready to do an RSI asap upon arrival due to trismus/Cushing's response. They need time to get a room ready for this and time to clear out a CT scanner for this patient.

Taking the time to RSI this patient on scene just eats up time that can be used getting him to definitive Neuro care and have them be ready to mange this guy's airway.

This is just one of those times when an ALS assessment results in BLS care getting the patient to definitive care in an expedient manner, but wouldn't change the outcome much.

 

[NomadicMedic]

I guess I'm going to be an outlier on this then. Given the 6 minute transport time to a L2 TC, I'm going to forego the intubation and simply BVM this patient. While I am a Paramedic and still remember how to intubate, I'm not above using my basic skills when they're quite appropriate to use and this is one such case. I'd just call ahead, give the radio report, and request that they be ready to do an RSI asap upon arrival due to trismus/Cushing's response. They need time to get a room ready for this and time to clear out a CT scanner for this patient.

Taking the time to RSI this patient on scene just eats up time that can be used getting him to definitive Neuro care and have them be ready to mange this guy's airway.

This is just one of those times when an ALS assessment results in BLS care getting the patient to definitive care in an expedient manner, but wouldn't change the outcome much.

This. 1000x this.