Airway Management in Head Trauma (Scenerio)

[NPO]

You arrive on scene of a 2 vehicle MVA involving a car and a prison transport van. The car tboned the van which caused it to roll. You are first on scene arriving with the FD and 2 additional ambulances are en route.

For the purposes of the scenerio, you will only be responsible for one patient; the prisoner.

You approach the van which is on its side and upon opening the rear door you locate one approximately 50 year old male inmate. The patient is shackled at his hands and feet, but was obviously not restrained by a seatbelt. He is wedged against the bulkhead with his neck at a near 90* angle. You assess his GCS to be 5 (1-1-3). He has snoring respirations, and two swolen eyes with unequal and non-reactive pupils. Rapid trauma assessment reveals an otherwise unremarkable exam except a few superficial lacerations.

Your nearest Trauma Center is a Level 2, 40 minutes away by ground. The nearest transport helicopter has a 45 minute ETA to scene.

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

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

I'd like to hear how everyone would treat the patient, with particular attention to airway.

 

[Qulevrius]

I don’t see any particular indication for RSI, due to a <8 RR and unobstructed airway. The OPA should do the trick, keep him on high flow O2 (I would increase to at least 15LPM and monitor saturation), start for the trauma center & request airlift en route to minimize transport time. His neuro and BP are way more alarming, obviously increased ICP so sedate with benzos, give hypertonic bolus & induce hypothermia with icepacks.

 

[SpecialK]

If the major trauma hospital is 40 minutes away by road ambulance, and the patient can leave in said road ambulance without undue delay (less than say, 15 minutes from now) there is no benefit in calling the helicopter unless either the only way to get an RSI Officer is by helicopter (which is not unlikely) or the major trauma hospital is not a major trauma hospital with neurosurgical facilities, and in either case they can meet us en-route.

My management? LMA, gain IV access in case we need it later, call for RSI Officer and start moving +/- meet helicopter en-route.

His very high blood pressure and unequal, unreactive pupils are quite worrying but about that I can do nothing.

 

[Qulevrius]

My management? LMA, gain IV access in case we need it later, call for RSI Officer and start moving +/- meet helicopter en-route.

You don’t want any tube near that crooked airway, unless the pt gets severely hypoxic.

 

[SpecialK]

You don’t want any tube near that crooked airway, unless the pt gets severely hypoxic.

.... because?

 

[TXmed]

As per your exam my primary concern is airway and less any catastrophic hemmorage. Im gonna choose to perform RSI while im still and not moving for transport that way i have all hands on to assist.

Place NC+NRB at flush rate to begin preoxygenation for atleast 2minutes while i prepare fully. Administer lido + fent. Prepare both suctions immediatly. Position patient in a ramping/HELLP position. I use a bougie on every airway. Ill have an airway assistant to my left prepared to help with guided crc pressure. Ill undo the c-collar and have an assistant hold stabilization. Im cool with using ketamine or etomidate as induction but will want rocuronium as my paralytic. Have ETCO2 on my bvm remove NRB and apply apnic CPAP to raise the spo2 to the highest i can. Remove OPA. Suction then attempt intubation with bougie. Aborting if spo2 drops to 93%-92% to reoxygenate or if SBP reduces below 110. Use high dose fentany and low to moderate dose versed as post intubation sedation.

 

[TXmed]

You don’t want any tube near that crooked airway, unless the pt gets severely hypoxic.

If you wait until the patient gets hypoxic to do something then youve already lost the battle

 

[Qulevrius]

.... because?

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.

 

[GMCmedic]

GCS of 5 and no gag reflex gets a tube while were sitting still.

 

[TXmed]

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.

Most airway experts suggest removing the collar and holding manual during the attempt. There has also been extremely very few instances of an intubation attempt further injuring a spinal patient. If he is going to herniate then he will do it with or without an ET/LMA in his mouth, that makes no difference. Present your LOC neuro assessment clearly to the recieving trauma staff. You can hyperventilate with bvm or vent to an etco2 of no less than 30 for short periods of time, but this patient is not presenting with cushings or uncontrolled seizures so i do not think that is necessary. In fact if you fail to be aggressive with this airway the patient could be hypercapnic for the entirety of the transport thus worsening his condition, if you wait for him to be hypoxic this will greatly worsen his conditon.

The OP had no mention of blood in the airway, broken teeth, obese, beard etc. The biggest thing making this a difficult airway is the one guy on scene freaking out yelling just load and go. Im all for BLS before ALS and yada yada but if you do not feel confident in your skills to manage this patients airways then you should spend time on a manniken and find some books by george kovacs and levitan. Thats what i did.

 

[Qulevrius]

Most airway experts suggest removing the collar and holding manual during the attempt. There has also been extremely very few instances of an intubation attempt further injuring a spinal patient. If he is going to herniate then he will do it with or without an ET/LMA in his mouth, that makes no difference. Present your LOC neuro assessment clearly to the recieving trauma staff. You can hyperventilate with bvm or vent to an etco2 of no less than 30 for short periods of time, but this patient is not presenting with cushings or uncontrolled seizures so i do not think that is necessary. In fact if you fail to be aggressive with this airway the patient could be hypercapnic for the entirety of the transport thus worsening his condition, if you wait for him to be hypoxic this will greatly worsen his conditon.

The OP had no mention of blood in the airway, broken teeth, obese, beard etc. The biggest thing making this a difficult airway is the one guy on scene freaking out yelling just load and go. Im all for BLS before ALS and yada yada but if you do not feel confident in your skills to manage this patients airways then you should spend time on a manniken and find some books by george kovacs and levitan. Thats what i did.

That’s exactly the rationale. His airway is patent and non obstructed with RR at 14. Monitor SpO2 & capno, but don’t tube ‘just in case’, because once you drop the tube, you won’t see the forest for the trees. And in this case the forest is the IC hypertension which, if left unaddressed, will kill him. You can’t trepanate and you can’t drain CSF, but you can try and address the issue with pharmaceuticals and hypothermia. Because at this particular point, his neck injury definitely is in the higher C’s (otherwise he wouldn’t be breathing at all) and his control centers aren’t affected; but if he herniates, the cerebrum will push the brain stem & it’s game over, tube or not.

Does that make sense ?

 

[TXmed]

Airway management is just one part of a treatment you should be able to see the forrest just fine. He requires an OPA to make his airway somewhat patent and the man still has occasional snoring. Everything you describe could happen either way. Hes not going to neuro icu, the OR or getting an emmergency drain without a more patent airway (atleast not in any trauma center in texas). Several studies on prehospital intubation report quicker times to CT or to OR.

 

[RocketMedic]

I'd RSI, much as TxMed has suggested.

 

[VentMonkey]

Etomidate—>Succs—>ETI*—>post ETI sedation/ analgesia—>VCV A/C (or ASV) FiO2- 1.0, peep-5, Vt- 6 to 8 ml/ kg IBW, f- 14 to 18 titrated to eucapnea.

*SGA at the ready with the rest falling in line as mentioned above.

 

[VFlutter]

RSI, aggressive analgesia/sedation, and maintain a good MAP. Mildly hyperventilate to an ETC02 of 30 and Mannitol if signs of herniation. At least once he is intubated you can more precisely ventilate and monitor ETC02. Hypoxia and Hypotension kills TBI patients, I am not going to sit there and wait for him to decompensate before attempting to intubate.


Technically they took Fentanyl out of pre-intubation medications for us but I would give a dose prior to induction. I would probably go with Ketamine for induction, Head Injury patient's usually don't have a sympathetic response so I wouldn't worry too much about hypertension.

 

[VentMonkey]

@NPO, @Qulevrius a rapidly deteriorating level of consciousness can often indicate a extremely valid justification for aggressive prehospital airway management. I don’t know too many EM physicians that would fault EMS for utilizing a “hands on” approach on this one.

 

[Qulevrius]

@VentMonkey you know that it’s purely academic for me. But at the same time, the scenario left me with an impression that the pt didn’t have a rapid deterioration but rather was unresponsive on scene, with a classic case of intracranial hypertension.

 

[Colt45]

There is going to be major variety in the answers to this. Initially whether or not your agency can do RSI, and the location of the incident. Is this in the country side with plenty of areas to land a bird- or are you in a very populated area and meeting a helicopter isn't really an option with nowhere to land? as far as the scenario goes, after dropping and OPA and seing my sats and RR REGULAR (key phrase for me in this situation) are within normal limits I would continue assisting ventilation and call for that helicopter to meet me halfway. Where I'm at we can't do RSI and his GCS is under 8. With obvious cerebral edema or hemmorhage and decorticateposturing. The more pressure builds up on the brain and Spinal cord the more likely this airway we are managing is going to go out the door. More than this guy needs me, he needs a hospital and a surgeon. I'm not wasting time on scene. I'll manage his airway and Spine and get some IV acess started so the flight crew have less to worry about.

An easier answer exists for this. He needs a tube based purely on the fact that this is a head injury and a higher spine injury. His GCS is low, and you potentially have a long transport time that gives that swelling a big opportunity to change his RR and work or breathing. Be proactive. Realize that when you get to where your going the first thing that doc is going to order is RSI to guarantee an airway with intracranial swelling and/or hemmorhage. If you do that this guy gets completely focused care on the injury that could kill him quickly.

 

[DesertMedic66]

There is going to be major variety in the answers to this. Initially whether or not your agency can do RSI, and the location of the incident. Is this in the country side with plenty of areas to land a bird- or are you in a very populated area and meeting a helicopter isn't really an option with nowhere to land? as far as the scenario goes, after dropping and OPA and seing my sats and RR REGULAR (key phrase for me in this situation) are within normal limits I would continue assisting ventilation and call for that helicopter to meet me halfway. Where I'm at we can't do RSI and his GCS is under 8. With obvious cerebral edema or hemmorhage and decorticateposturing. The more pressure builds up on the brain and Spinal cord the more likely this airway we are managing is going to go out the door. More than this guy needs me, he needs a hospital and a surgeon. I'm not wasting time on scene. I'll manage his airway and Spine and get some IV acess started so the flight crew have less to worry about.

An easier answer exists for this. He needs a tube based purely on the fact that this is a head injury and a higher spine injury. His GCS is low, and you potentially have a long transport time that gives that swelling a big opportunity to change his RR and work or breathing. Be proactive. Realize that when you get to where your going the first thing that doc is going to order is RSI to guarantee an airway with intracranial swelling and/or hemmorhage. If you do that this guy gets completely focused care on the injury that could kill him quickly.

The only information about the helicopter is that it is 45 minutes away and the level 2 is only 40 minutes away. Meeting the helicopter makes no sense to me. It’s going to take them 45 minutes just to get to your scene which doesn’t include landing time, crew egress, hand over, transferring patient to the airship, and then the take off time. That is if your area is comfortable doing hot loads.

By the time all of that is completed the patient could already be at the hospital being treated. You also have to include the time it takes for the airship to land at the hospital and then the elevator ride (at least in all the trauma centers I have been to) down to the ED. Also keep in mind that flying ICP patients may actually make the pressure increase in addition to possibly making them hypothermic.

I also didn’t read where the patient was posturing. Maybe I missed it in the OP.

 

[Colt45]

The only information about the helicopter is that it is 45 minutes away and the level 2 is only 40 minutes away. Meeting the helicopter makes no sense to me. It’s going to take them 45 minutes just to get to your scene which doesn’t include landing time, crew egress, hand over, transferring patient to the airship, and then the take off time. That is if your area is comfortable doing hot loads.

By the time all of that is completed the patient could already be at the hospital being treated. You also have to include the time it takes for the airship to land at the hospital and then the elevator ride (at least in all the trauma centers I have been to) down to the ED. Also keep in mind that flying ICP patients may actually make the pressure increase in addition to possibly making them hypothermic.

I also didn’t read where the patient was posturing. Maybe I missed it in the OP.

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.