GSW Intubation

[samiam]

I was recently shadowing at a hospital in downtown detroit and whenever we had a GSW come into the recess room the pt was intubated. Once the medics had gotten their paper work signed and left the room, the trauma surgeons and ED docs would complain that the patient was intubated and should not of been. What do you think? What are the protocols in your area for this?

 

[Shishkabob]

Too many variables, such as where they are shot etc etc.

 

[boingo]

I don't think Detroit has RSI or MDI capabilities, so if they came in via EMS intubated, they probably needed it. Is it possible the complaint wasn't about the tube, but more about the fact the pt was transported in arrest and should have been sheeted in the field?

 

[zmedic]

Often there is the concern that patients shot in the chest should have a chest tube before intubation. Otherwise if there is a lung injury and you are ventilating that lung you risk turning the pneumothorax into a tension pneumo. Some of the air could escape through the bullet hole, but if you've covered that with an occlusive dressing you could be in trouble quick.

 

[samiam]

Often there is the concern that patients shot in the chest should have a chest tube before intubation. Otherwise if there is a lung injury and you are ventilating that lung you risk turning the pneumothorax into a tension pneumo. Some of the air could escape through the bullet hole, but if you've covered that with an occlusive dressing you could be in trouble quick.

That was my guess too. The docs specifically complained about the tube and they complained for a gsw to the chest as well as to the head... the guy to the head was clearly not going to make it and they called it in the room and then proceeded to comment on how medics should not intubate gsw's

 

[Shishkabob]

If they need a tube, they get a tube. If the receiving doc doesn't like it, they are more than welcome to call up my med control and discuss the decision with them.

 

[MrBrown]

More and more we are moving away from intubation alone and towards rapid sequence intubation. Patients who will tolerate stand-alone intubation need to be deeply unconscious (typically GCS 3) with blunted airway reflexes and this is most often not the case.

While intubation remains the gold standard, in the short-time interval with which Ambulance Officers have the patient it is prudent to balance need for a protected airway and reduction in secondary brain injury with the need for transport to definite care.

Intubation is really non-mechanisim specific and is indicated for a particular patient presentation rather than how they got into that situation.

New Zealand has a very low (almost nonexistant) rate of penetrating trauma and Brown has never seen a stabbing or shooting and will safely say most Ambos will go thier entire career and encounter onr or two at the most.

 

[Flight-LP]

Often there is the concern that patients shot in the chest should have a chest tube before intubation. Otherwise if there is a lung injury and you are ventilating that lung you risk turning the pneumothorax into a tension pneumo.

Evidence please.............................

I have had a fair share of GSW's to the chest over the years, many of which received a tube thoracostomy. I have never personally placed, nor ever witnessed the chest tube be inserted before the endotracheal tube in the patient who needed both. I suppose it could be done concurrently if there is sufficient personnel, but I would question why one would change a logical approach to treatment (i.e. the simple ABC's) with one on whim of perception it is better. The proof is in the pudding I suppose, show us the studies.

 

[Veneficus]

I have never personally placed, nor ever witnessed the chest tube be inserted before the endotracheal tube in the patient who needed both. I suppose it could be done concurrently if there is sufficient personnel, but I would question why one would change a logical approach to treatment (i.e. the simple ABC's) with one on whim of perception it is better. The proof is in the pudding I suppose, show us the studies.

Not to answer for Zmedic, but just to toss in my perspective, I have seen treatment done chest tube first, et tube first, and concurrently on patients where both were indicated.

But the logical ABC was not the method of assessment, nor is it the method I use.

I think it has to do with what the most pressing problem is at the moment. Which of course is situation specific.

I don't think every GSW patient should be intubated.

 

[MasterIntubator]

assessment specific...

 

[zmedic]

http://books.google.com/books?id=eH...page&q="chest tube before intubation"&f=false

First one that I found: some surgeons have recommended prophylactic placement of a chest tube before intubation and positive pressure ventilation.

Another trauma book suggests chest tube before surgery because positive pressure ventilation can convert a pneumothorax to tension pnuemo:

http://books.google.com/books?id=se...t trauma intubation before chest tube&f=false

Not finding good studies on this, but enough of my attendings are concerned about this that it might be what the docs in your case were concerned about.