Airway Management in Head Trauma (Scenerio)

[FiremanMike]

1) I’ve been indoctrinated with the ‘once the c-collar is on, it stays on’ approach.

You should rethink this approach, the standard of care has moved away from the importance of c-spine immobilization

2) I can watch the capno morphology and bag just fine. What I, unfortunately, cannot do, is grow an extra pair of hands for doing anything else. Only CCT trucks carry ventilators.

I did not notice the stipulation that you must be alone with this patient for the entirety of EMS care. If there is truly no way to get another person in the back of the truck, I'd probably wait the 45 minutes for the helicopter. Intubated or not, transporting this particular patient alone for 40 minutes is just a terrible idea.

3) What I was saying is that, IMO, the risk of him herniating is significantly greater than the risk of him hypoxiating and, therefore, should be addressed immediately and aggressively with sedatives, osmotic procedures and body temp control. Because whilst there’s something you can do about his airway if things start getting worse, there’s absolutely nothing you can do if/when the pt herniates.

I'm just not sure you're being realistic or fair about this scenario. Going back on the stipulation that I MUST be alone on this patient, aggressive pharmacologic therapy, osmotic treatments (of which I'd like to hear more about), and/or induction of hypothermia are all things that are just as risky (if not moreso) than induction of this patient and I am unlikely to initiate these treatments alone.

 

[FiremanMike]

What does your service define as crash airway vs. full on RSI? This sounds more like the latter and not the former. They’re not exactly the same.

Also, @Qulevrius is the kind of EMT I wish I had worked with: extremely well-versed. Unfortunately, he has to keep his lemonade stand open in his county.

It's the closest thing we're going to get to crash airway here. While we do technically have the ability to go straight to our paralytic, it doesn't take that much more time to draw out 100mg of ketamine into the syringe and push it all at once. Our actual RSI protocol includes a premedication phase of fent/versed, which I would absolutely skip in this case.

You're correct though, I mislabled that a crash airway. Lets go with "abbreviated RSI protocol"

 

[Qulevrius]

You should rethink this approach, the standard of care has moved away from the importance of c-spine immobilization



I did not notice the stipulation that you must be alone with this patient for the entirety of EMS care. If there is truly no way to get another person in the back of the truck, I'd probably wait the 45 minutes for the helicopter. Intubated or not, transporting this particular patient alone for 40 minutes is just a terrible idea.



I'm just not sure you're being realistic or fair about this scenario. Going back on the stipulation that I MUST be alone on this patient, aggressive pharmacologic therapy, osmotic treatments (of which I'd like to hear more about), and/or induction of hypothermia are all things that are just as risky (if not moreso) than induction of this patient and I am unlikely to initiate these treatments alone.

As I mentioned before, this is purely academic for me. I am a Basic who pretends to be a medic and, for all intent & purpose of this scenario, must stay within the confinements of his county’s scope & protocols. Working out of LACo & OC, most of the pharmacopoeia is N/A. There are no paralytics, the available sedatives are benzos and not barbiturates, RSI is out of the question etc. And yes, it’s just me & my partner in the truck.

As for osmotic procedures - no Mannitol for us, so I have to go with hypertonic saline. The effect is, essentially, the same - the fluid moves along the concentration gradient.

Same goes for hypothermia induction - icepacks to the head, simple yet effective. And I fully agree with you on the transport decision, that’s why my original post said ‘start for the trauma center & request airlift en route’.

 

[VentMonkey]

Personally, I’m not too comfortable with aggressively managing this patient with any form of osmotic diuretic, be it Mannitol or HNS in the prehospital setting.

Sure, there are key factors that may lead us down Cushing’s Triad, but even still I’m again, personally, more of a conservative here and think at least lower-end eucapnea is sufficient. At best, a careful titration of their blood pressure if at all needed with an anti-hypertensive to a reasonable SBP/ MAP absent any acute bradycardia.

With the prevalence of such late-stage game changers as DI, I vote leaving the diuresing to the hospital, moreover, neuro-ICU folks

As @Chase mentions- hypoxia and hypotension are our main combatants.

 

[EpiEMS]

I am a Basic who pretends to be a medic

FWIW...there is no "scope of practice" for assessment & critical thinking.

 

[Qulevrius]

FWIW...there is no "scope of practice" for assessment & critical thinking.

I’ve learned the hard way to keep all of it to myself. Because nearly every time I’ve stolen the fire medics’ thunder on scene, it ended up with either dirty looks (best case) or their BC calling in with a complaint.

 

[EpiEMS]

@Qulevrius Fair enough, I'm lucky (most of the time) because I have some medics who aren't averse to talking through patient presentations.

 

[Carlos Danger]

This has been a good discussion. I like the fact that some folks are advocating for a less interventional approach. Not that those who want to RSI are wrong - that's the standard approach that we've all had drilled into our heads - but there is a lot of evidence to support NOT necessarily intubating right away. Just because you have a hammer doesn't mean you need to whack every nail you come across.

@NPO how did the patient do? What was his diagnosis and disposition? Good job, BTW.

One thing to keep in mind is that when you intubate someone like this, it is pretty easy to hurt them. Even a brief episode of hypotension or hypoxemia (neither of which are uncommon) worsens their prognosis significantly. The sympathetic discharge that follows intubation probably isn't as bad, but probably isn't at all helpful to them, either. I flew for a little over 10 years and encountered patients like this (MVC —> TBI) routinely, and intubated them all with extreme prejudice. Knowing what I know now, I like to think I'd be a good bit less aggressive.

 

[NPO]

@NPO how did the patient do? What was his diagnosis and disposition? Good job, BTW.

He did well. He had virtually no change in condition for the entire transport and apart from a few times where I had to reposition the airway from his moving, the OPA did very well and he never had any periods of hypoxia.

That is until the med students RSI'd him at the hospital. They didn't remove the OPA before attempting intubation and effectively created a FBO until the attending realized something was wrong several minutes later.

I took a more reserved approach with this guy because he had enough reflexes that I wasn't confident that the intubation would be smooth without sedation (which I didn't have) and he was doing good, all things considered.

 

[zzyzx]

Coming to this late...

Why not intubate even if you don't have RSI since you were able to place an OPA with no gag? Bagging this guy w/o an ET tube is likely to cause all kinds of problems for such a long transport. Besides the fact that, as most of the previous posters agree, he needs to have his airway protected due to his GCS and the nature of his injuries, by bagging this guy for 40 minutes w/o a tube you are likely to 1) cause gastric insufflation 2) have no control over the minute ventilation.

This case is a great example of how EtCO2 can be important in managing a severe TBI patient pre hospital.

Most of use don't have vents, and usually the task of BVM ventilation is given to a BLS provider who will often bag at an incorrect rate. Studies have shown that improper BVM ventilation (usually too fast) likely causes poorer outcomes for severe TBI patients. In this case we can reasonable assume that the patient has an isolated head injury, and we can therefore also assume that the EtCO2 will be an accurate guide for BVM ventilations (with ET tube in place)

 

[Carlos Danger]

It is a myth that just because someone will accept an OPA, they will accept an ETT. Laryngeal reflexes are much more sensitive than pharyngeal ones. Laryngoscopy + placing a tube is MUCH more stimulating than placing an OPA. I don't know where that idea came from or how it keeps being perpetuated.

 

[VFlutter]

I assume you mean drug assisted intubation as opposed to RSI? I worked with a physician who loved Etomidate only intubations.....I cleaned up a lot of vomit and usually left in different scrubs then I came in with.

 

[zzyzx]

Remi, you are a nurse anesthetist, so I'll defer to your expertise.

If you have a patient who easily accepts an OPA, why not attempt to intubate? If they gag while you are making the attempt, you can abort the attempt.

Does this not seem reasonable? A guy like this really needs an airway if he's 40 minutes from a hospital, so making the attempt seems reasonable to me. But educate me if I'm wrong.

 

[TXmed]

@Qulevrius couldve fooled me i figured you were in intensive care somewhere.

@FiremanMike @VentMonkey I wouldnt advocate for a crash airway or a "modified RSI" for this patient, nothing tells me he will crash in the next 5 minutes so i would pull out all the stops. Premedicate if you are allowed, do your 7 P's of RSI, No rush necessarily with this patient, doing it right is more important than doing it fast with TBI patients.

@Remi @NPO Thats why i always try to follow the DASH-1A type of thinking. Just because you can get the intubation on first attempt doesnt mean you did not harm the patient or make things worse.

For everyone advocating for RSI, i would suggest listening to EMCRITS Laryngescope as a murder weapon series and reading the DASH-1A concepts. I firmly believe in being aggressive with airway but also not being a retard with a laryngescope either.

@Chase You are far from the first person and far from the last person to describe etomidate only intubation that way.

 

[VentMonkey]

I never advocated for any sort or crash airway, I’m not sure where you got that from.

 

[Carlos Danger]

Remi, you are a nurse anesthetist, so I'll defer to your expertise.

If you have a patient who easily accepts an OPA, why not attempt to intubate? If they gag while you are making the attempt, you can abort the attempt.

Does this not seem reasonable? A guy like this really needs an airway if he's 40 minutes from a hospital, so making the attempt seems reasonable to me. But educate me if I'm wrong.

I suppose making a gentle attempt is reasonable as long as you are quick to abort once they start wrenching or clenching. Bad things often follow that.

There's a reason why RSI has become so common in ED's and EMS over the past couple of decades: it makes intubating much easier and safer. Prior to RSI becoming commonplace, intubating across the board had much higher rates of complications and much lower rates of success. In a patient who is breathing and oxygenating well, I just don't see the reason to expose them to the substantial risks that come with literally wrestling an ETT into their trachea.

A guy like this really needs an airway if he's 40 minutes from a hospital, so making the attempt seems reasonable to me. But educate me if I'm wrong.

Does he really NEED an invasive airway? Right now? Why? Because he's asleep? He is breathing fine. Isn't gas exchange what matters? What does the research say on the topic of outcomes between TBI patients who are intubated in the field vs. those who are not? Did this very patient not do just fine with NPO's non-invasive management? Don't BLS crews all over the country transport patients just like this every day, and they do just fine?

Like I said before, I'm certainly not going to tell anyone they are wrong for wanting to RSI this guy. It's how I used to practice in the field. It's how we are all trained. It is (arguably) the standard of care. But WHY are we so set on it? WHY do we simply ignore the study upon study that tells us it isn't necessary? Just because it's what our paramedic instructors told us we should do? Because it's what we see the ED docs do? Again, what about all the TBI patients who aren't intubated in the field, and do just fine?

Wanting to intubate is perfectly reasonable, but so it taking a more conservative approach. Aside from dogma, I don't think there is any justification for the idea that an ETT is the only right way to manage a patient who is breathing and oxygenating well.

 

[Colt45]

I suppose making a gentle attempt is reasonable as long as you are quick to abort once they start wrenching or clenching. Bad things often follow that.

There's a reason why RSI has become so common in ED's and EMS over the past couple of decades: it makes intubating much easier and safer. Prior to RSI becoming commonplace, intubating across the board had much higher rates of complications and much lower rates of success. In a patient who is breathing and oxygenating well, I just don't see the reason to expose them to the substantial risks that come with literally wrestling an ETT into their trachea.



Does he really NEED an invasive airway? Right now? Why? Because he's asleep? He is breathing fine. Isn't gas exchange what matters? What does the research say on the topic of outcomes between TBI patients who are intubated in the field vs. those who are not? Did this very patient not do just fine with NPO's non-invasive management? Don't BLS crews all over the country transport patients just like this every day, and they do just fine?

Like I said before, I'm certainly not going to tell anyone they are wrong for wanting to RSI this guy. It's how I used to practice in the field. It's how we are all trained. It is (arguably) the standard of care. But WHY are we so set on it? WHY do we simply ignore the study upon study that tells us it isn't necessary? Just because it's what our paramedic instructors told us we should do? Because it's what we see the ED docs do? Again, what about all the TBI patients who aren't intubated in the field, and do just fine?

Wanting to intubate is perfectly reasonable, but so it taking a more conservative approach. Aside from dogma, I don't think there is any justification for the idea that an ETT is the only right way to manage a patient who is breathing and oxygenating well.

I like this explanation. I think there is multiple ways to handle this patient and there is also plenty of reasons you can back yourself up when explaining why this guy doesn't have a tube yet ( which the ER doc is going to ask right away while pointing at someone to get intubation equipment). I agree with all your points. I just feel that he is going to get a tube anyway, if you can RSI and speed up that process it's going to save you a lot of grief from E.R. staff. Now with all that being said am I a fan of maintaining a basic airway if it's possible and my patient isn't circling the drain? Sure. Just be sure I have good documentation.

 

[luke_31]

It is a myth that just because someone will accept an OPA, they will accept an ETT. Laryngeal reflexes are much more sensitive than pharyngeal ones. Laryngoscopy + placing a tube is MUCH more stimulating than placing an OPA. I don't know where that idea came from or how it keeps being perpetuated.

Very true, I've had a patient or two who has accepted an OPA but when starting to intubate would bite down on the blade I was using the second I hit the valecula.

 

[NPO]

It is a myth that just because someone will accept an OPA, they will accept an ETT. Laryngeal reflexes are much more sensitive than pharyngeal ones. Laryngoscopy + placing a tube is MUCH more stimulating than placing an OPA. I don't know where that idea came from or how it keeps being perpetuated.

I have met this scenerio face to face before, in a non-TBI patient. She accepted the opa with no problem but when I intubated she gagged and dislodged the tube. Not something I wanted to do in this TBI patient.

 

[Brandon O]

@Brandon O sorry bout that. I would preffer to use a pressure mode over a volume mode to better controll the mean airway pressure (MAP) as on most transport vents focusing on map gives you better control/understanding of how your ventilation is efficting hemodynamic status and cerebral drainage. Atleast in the out of hospital enviroment. So keep the patient oxygenated to Spo2 > 95%, ETCO2 35-40 (30 if needed for short spells) and decreasing the MAP (generally below 10) to assist in whats mentioned above are my ventilator goals during transport. Then adjusting rise time pressure support to keep patient comfortable and manage sedation so when i arrive the patient isnt snowed unless its needed.

This is an interesting thought! It does make sense that mean airway pressure should be the respiratory parameter most closely associated with intracranial pressure. Usually in the ICU we can directly follow the latter to see the effects of vent changes, but it's reasonable to do it empirically if you can't. I would just be careful to avoid getting so clever that you compromise oxygenation or ventilation (or cause dyssynchrony).

@VentMonkey@Brandon O i know your settimg is more icu but, would you salt bomb this patient without a foley or labs ?

It's all pretty academic since it's hard to imagine the situation. I have empirically used osmolar therapy prior to intracranial pressure monitoring (it can take some time to get in a bolt or EVD). Have not done it prior to imaging. It would probably be reasonable in an austere situation for at least a single bolus if you have very high suspicion (this scenario might qualify; even better if they blew a pupil in front of you).

I would avoid mannitol without a Foley. Hypertonic without a central line is not the best idea, but I know some places think it's reasonable with a good IV.

I suppose you could do an IO, although many places consider hypertonic fluids contraindicated via IO.

I have also bolused sedation for this purpose, although I would probably only use propofol which most prehospital services don't carry.

PRVC is actually a VC mode, as the name implies. It monitors and adjusts the airway pressures in the patients lungs based on their efforts then delivers a set Vt accordingly. It requires somewhat less effort from the clinician in monitoring their airway pressures than your standard VCV modes, so it’s more of a “nice to have” mode.

To be pedantic, I would describe PRVC as a pressure mode -- just one that tries to regulate its resulting volumes. If I showed you the scalars of a PRVC breath you would describe it as a pressure control breath. You wouldn't know it was PRVC unless you knew whether I was fiddling with the inspiratory pressure or the vent was doing it automatically.

Maybe they should have called it VRPC