Placing Two ET Tubes?

[EMSrush]

Question about intubation:

I knew of a medic who, if he tubed the goose, would leave the ET tube in, and place a second ET tube, which (he claimed) would always go into the trachea. He would leave both tubes in, even as he rolled up into the ED, but would plug up the first tube. I haven't tried this yet, and I'm not sure how the ED would look at it. It sounds like it could cause trauma.

Has anyone tried this before? I would love thoughts and feedback, positive or negative.

Thanks!

 

[Shishkabob]

Yes, you could do it, yes people do do it, and it's not necessarily bad because it when you go for the second tube you just have to tell yourself "Dont go where a tube already is"

You could then place a gastric tube down the ET placed in the coprophagous.



Make sure if you DO leave both in, you clearly mark which one is NOT to be used. Tape the crap out of it, tell the receiving doc, whatever.... just make sure it doesn't get used.

 

[usafmedic45]

For massive hemoptysis, one of the standard procedures is "lung isolation" (also called "selective intubation" and several other things) which can be done with two ETTs or a specialized tube (which most hospitals don't stock in readily accessible places...). It's a very interesting technique.

 

[EMSrush]

Other than the obviously pre-existing tube, I am wondering how the insertion process of the second ET tube differs from an initial insertion. Is it normally done blind...?

 

[medicstudent101]

Can't say I've ever heard of something like this being done before. Although it makes tons of sense. Another interesting thing I've seen done in the ICU, is pts with ARDS and a few other Resp. conditions with two ETT's placed in each mainstem of the right and left, respectivly. Pretty awesome stuff

 

[MediMike]

I work with a fella who swears by this technique, unfortunately when you consider the amount of time the pt. is going without ventilation its a rather poor choice in my opinion. Last ditch effort? Maybe. I'd rather rely on good bagging technique if I was unable to get the tube.

 

[firetender]

Help me out here...

You're talking if you mis-place the first tube, just leave it in, right?

...because that makes it "easier" to place the next tube in because the esophagus is all blocked up?

What happened to the part where you visualize the vocal cords and get it right the first time? And I don't recall it being easier to visualize the vocal cords while working around another tube.

 

[Smash]

I'm with firetender. Just don't suck the first time. If it looks like a tough tube consider adjuncts like a bougie or video laryngoscopy. If it looks really bad, consider whether you really want to intubate at all.

 

[Handsome Robb]

I'm with smash. They invented BIADs for a reason. Always have a backup plan for a failed attempt is what I was always taught. Also, with the failed tube still in place I don't see how you could visualize with a laryngoscope for the second attempt. A blind insertion with an ETT sounds like a high risk for trauma to the cords and other parts of the airway which can make your life even harder, introducing bleeding into an already compromised airway, unless your talking a digital intubation?

 

[truetiger]

The mechanics behind this sound good but how long is it going to take to miss with one tube and then correctly place another? You should take no longer than 30 seconds to intubate your patient, seems it might be kinda hard to reoxygenate a pt with an et tube sticking out of their mouth.

 

[reaper]

This is an old school thought. The thought process was one hole was blocked, so you will only go in the other. Problem is, You can fit more then one tube in the esophagus and it has been done before. This is why it is not taught any more.

 

[Melbourne MICA]

On the money

This is an old school thought. The thought process was one hole was blocked, so you will only go in the other. Problem is, You can fit more then one tube in the esophagus and it has been done before. This is why it is not taught any more.

Spot on reaper. There should be no reason for any Para to be doing this in this day and age. How many aids do you need to find the right hole for goodness sake.

Ambulance mythology stuff - someone thought he was being clever then everyone thinks the same thing because why? The funny thing is you can never find out who started it all.

Bad practice.

MM

 

[volparamedic]

I have used this technique before but it's few and far between. Depending on this every time isn't advisable. If you have to do this then you need retrained. I know on anterior patients or patients with a lot of bodily fluids that would cause you to miss easily it works great. I truly miss the salem sump tubes we use to carry. I always remove the missed tube. Once the airway is secured there is no reason to leave the other tube...it just complicates matters. It gives you an additional land line and let me tell you...if you've never intubated an anterior patient before....your time is coming.

 

[usalsfyre]

...if you've never intubated an anterior patient before....your time is coming.

Never tubed an anterior patient, but I've had a few who had thyromental distances that weren't conducive to direct laryngoscopy...

 

[8jimi8]

Never tubed an anterior patient, but I've had a few who had thyromental distances that weren't conducive to direct laryngoscopy...

Lol...

 

[TomB]

This is an old school thought. The thought process was one hole was blocked, so you will only go in the other. Problem is, You can fit more then one tube in the esophagus and it has been done before. This is why it is not taught any more.

True that. Not to mention that when the patient vomits the additional pressure created by the relatively small diameter and orifice of the tube extends the reach of the vomit which can come out with astonishing speed and force. Or, sometimes it just falls nicely into the patient's orbits. Not cool when the patient is dead and staring at you with vomit in his/her eyes. A tube in the esophagus also reduces the effectiveness of cricoid pressure. Just not a good idea.

 

[usalsfyre]

True that. Not to mention that when the patient vomits the additional pressure created by the relatively small diameter and orifice of the tube extends the reach of the vomit which can come out with astonishing speed and force. Or, sometimes it just falls nicely into the patient's orbits. Not cool when the patient is dead and staring at you with vomit in his/her eyes. A tube in the esophagus also reduces the effectiveness of cricoid pressure. Just not a good idea.

I've also seen it cascade off the ceiling through an esophogeal ETT, especially if it was ventilated a few times before the wrong placement was realized. Vomit in the eyes is one thing, vomit on every surface in the truck is a new level of suckage.

As for cric pressure, it's effectiveness period is pretty well in question from what I understand.

 

[WTEngel]

I'm with most on here. This is an old school technique and not generally taught anymore AFAIK.

Also, it opens you up to liability in my opinion, as there isn't any clinical research I have seen to back up this technique.

Also, as had been mentioned, it is very easy to fit two, maybe even three ET tubes into the esophagus. All it really accomplishes is making your field of view smaller, gives you false sense of security that your next attempt will be easier, and makes you look like a joker when you walk into an ER.

Leave dual ET tubes for the patient that needs dual intubation and the professionals who know how to do it...

 

[EMSrush]

I work with a fella who swears by this technique, unfortunately when you consider the amount of time the pt. is going without ventilation its a rather poor choice in my opinion. Last ditch effort? Maybe. I'd rather rely on good bagging technique if I was unable to get the tube.

I hope it's a back up technique that he swears by, and not an initial technique.

 

[MediMike]

let me tell you...if you've never intubated an anterior patient before....your time is coming.

(flips through AnP book)...Trachea is anterior on everybody...right?!

It was a backup technique, still don't like it. Way too much downtime on the ventilation end of things.