Tbi

[Smash]

Can we avoid a hijack please

This isn't really the place for nonsense about prehospital EEG. If you need an EEG to work out that this pt has a traumatic brain injury then this clearly isn't the job for you.

For those good enough to reply sensibly, I'm curious about the 'why' regarding treatment. Why try to place an LMA or a tube (or not), and how do you expect your management to improve this persons outcome? If you do want to manage the airway, what would be your preferred method and why? (not worrying about protocol)

 

[ResTech]

The airway and head injury are obviously the priority injuries requiring treatment. Definitely immobilize however, if this patient is clenched and has what sounds like copious amounts of blood/fluids in the upper airway, initially I would consider placing a KED board under him and sitting him up (at least semi-fowlers) so the fluids don't accumulate and further occlude the airway. This positioning will also serve well for any ICP. Suction the best you can given the clenched jaw.

In Maryland, ground Paramedics do not have RSI so if the mouth isn't able to be opened and the patient is already at 89% on a NRB, this is a very dire situation given the head injury and airway compromise so the patient would need to be criched. Given the initial head injury, the secondary head injury occurring from the hypoxia, and the upper airway compromise, I see clear indication for getting an airway ne way u can.. ie cric.

Once the ETT is placed, I would ventilate to maintain EtCO2 at 35mmHG and continually monitor the airway and ventilatory status. Than the normal EKG and IV's x2 at KVO since blood pressure is sufficient.

Based on the info presented, I would rationalize the low O2 sat with the NRB is a result of obstruction of the upper airway from the large quantity of fluids present. If the SpO2 did not increase with intubation, then I would start searching for another cause such as a hemothorax or pneumothorax.

If you do want to manage the airway, what would be your preferred method and why? (not worrying about protocol)

You always want to try to stick with the less invasive treatment... RSI I think would be a good choice if available... a thought that comes to mind is what if for some reason the RSI doesnt work? Now you have an already critically head injured patient who is now more critical because he is not breathing and has no airway and no way to ventilate him. So perhaps in this scenerio going straight for the cric would be better than RSI.

I would love to hear others thoughts on cric over RSI. Airway management as an area that scares me more than anything right now. Its not the performing of the skills that scares me... its the knowing when and what is best that I have a fear of in these critical situations that dont play out everyday. I run the scenerio like presented and am afraid of being too aggressive and say doing a cric when I shouldnt have and getting in hot water because of it.

And beat feet to the bright lights and cold steel of the trauma room.

 

[Ridryder911]

It again all comes down upon education and not just training. My medics attend an aggressive airway management course that not has detailed anatomy and procedures taught by anesthesiologist, anatomist and ED physicians. Detailed study on specialized mannequins and then fresh cadaver performance.

http://www.oumedicine.com/Workfiles/college of medicine/csetc/News/CSETC_OverviewInsert_runweb.pdf

So yes, an airway is one of the few instances that can change the outcome on trauma patients. Unfortunately, most ground units have not became so educated and entrusted to carry O- as many flight services do, so hemodynamically we are a race against time (no not the "golden hour" myth).

So yes if RSI cannot provide an adequate airway only two other options of alternative airway such as King or similar, then as last resort crich. Which again, if properly educated upon is not that difficult of a procedure to perform successfully.

Our neuro still prefer if possible the patient to be closely monitored as in EtCo2 and small PEEP to reduce ICP. Semi-fowlers is a great idea but in the field setting not a routine as most are on LSB and to really place in a degree of good is difficult to elevate the LSB with restriction within the aircraft (one can attempt if possible, though).

One emphasis though is a good and thorough neuro assessment of the patient. Not the routine PEARL but a detailed CNS and evaluation of reflexes, etc. is important and noting changes is as important than some of the treatment.

R/r 911

 

[Smash]

Good answer ResTech, whether one agrees or disagrees with your treatment, you have provided a rationale that is clearly thought through.

I agree with Ridryder, in that advanced airway management (RSI and cric) are not things to be scared of, providing that the practitioner is suitably educated, trained and supported. RSI in particular is treated by many as the boogyman, whereas it actually makes life easier for the medic and improves the outcome of TBI patients providing it is done appropriately. This is not to say that one should not have a healthy respect for the risks involved of course.

Ridryder: I agree with careful assessment of neuro prior to RSI, and no EtCO2 (waveform + numbers) means no RSI for me. However I am interested to know whether you would consider ongoing paralysis (vec/panc/whatever) and sedation following intial induction and intubation, or would allow resumption of airway reflexes and respirations?

 

[VentMedic]

RSI in particular is treated by many as the boogyman, whereas it actually makes life easier for the medic and improves the outcome of TBI patients providing it is done appropriately.

The boogyman implies RSI can't be done because of the unknown. We know the things that hinder the addition of RSI for the Paramedic.

Too many things that are not standard:
Education
Training
Competencies
Certifications
Licensing
Leadership
Medical Oversight

 

[TransportJockey]

Here in NM if a pt presents like that our sequence would be:
immobilize, cric, initiate transport, 2 large bores en route, PEEP valve inline with BVM, ETCO2 monitoring.
We are contraindicated for a Nasal ETT with facial trauma of the type described. We could call HEMS for RSI here, and possibly get an MCEP for it, but cric would be our first choice for a pt like this. He needs aggressive airway management, not calling and waiting.

 

[Smash]

The boogyman implies RSI can't be done because of the unknown. We know the things that hinder the addition of RSI for the Paramedic.

Too many things that are not standard:
Education
Training
Competencies
Certifications
Licensing
Leadership
Medical Oversight

providing that the practitioner is suitably educated, trained and supported.

..............................

 

[ResTech]

I am curious why a few had mentioned using PEEP on this patient? I did a quick search on Google with PEEP and head injuries and the literature I read said that PEEP with the head injured patient really doesnt offer any effect and while the increase is inconsequential, it can raise ICP slightly.

The Shock-Trauma portion of my program did not mention anything about using PEEP on the trauma patient.

 

[VentMedic]

smash,


So why do you think RSI is still the bougey man?

The other problem even with some EMS agencies that do RSI is that the recipe they are allowed is too conservative to even knock out a 80 y/o grandmother who only takes ASA as a med. There have been times when a patient has been half-arsed paralyzed aften they had a decent respiratory drive and now are respiratory compromised and still fighting intubation. Calling the doctor for more orders can be difficult as you have your hands full with an airway compromised patient and the doctor may be cautious with allowing more sedation/paralytics if you have exhausted your own Medical Director's protocol.

The same for the hypothermia protocol. Some are unable to sedate and paralyze after initiating the protocol when the patient shivers. Some patients are now being documented upon arrival to the ED with almost a higher than normal temperature with this therapy.

 

[Akulahawk]

smash,


So why do you think RSI is still the bougey man?

The other problem even with some EMS agencies that do RSI is that the recipe they are allowed is too conservative to even knock out a 80 y/o grandmother who only takes ASA as a med. There have been times when a patient has been half-arsed paralyzed aften they had a decent respiratory drive and now are respiratory compromised and still fighting intubation. Calling the doctor for more orders can be difficult as you have your hands full with an airway compromised patient and the doctor may be cautious with allowing more sedation/paralytics if you have exhausted your own Medical Director's protocol.

The same for the hypothermia protocol. Some are unable to sedate and paralyze after initiating the protocol when the patient shivers. Some patients are now being documented upon arrival to the ED with almost a higher than normal temperature with this therapy.

And there are those systems that do not allow the full-on RSI aka no paralytics, just benzos. I wouldn't be surprised if some systems don't (or can't) go to RSI because of the inability to do what's necessary in the event that the medic can't get the tube. Fortunately, those issues should be occurring less and less commonly now with use of the Combitube (and similar devices) and the use of the LMA in the field. Surgical cric and retrograde intubation techniques work too... but...

In other words, I feel that if a medical system is going to authorize RSI, that system has to authorize the full spectrum of airway procedures in the event (and it will) that RSI results in a failure to secure the airway. Lots of training would be required to ensure that everyone is trained in the technique and all necessary back-up airway measures. That's not too horrible a proposition if you're dealing with a relatively small number of providers. If you have hundreds... then you have to find a way to schedule all of them to have the appropriate training... and that can be a nightmare, no matter how you delegate the training...

Boogeyman? Not by far. Logistical training nightmare? Quite Possibly.

 

[Smash]

smash,


So why do you think RSI is still the bougey man?

The other problem even with some EMS agencies that do RSI is that the recipe they are allowed is too conservative to even knock out a 80 y/o grandmother who only takes ASA as a med. There have been times when a patient has been half-arsed paralyzed aften they had a decent respiratory drive and now are respiratory compromised and still fighting intubation. Calling the doctor for more orders can be difficult as you have your hands full with an airway compromised patient and the doctor may be cautious with allowing more sedation/paralytics if you have exhausted your own Medical Director's protocol.

The same for the hypothermia protocol. Some are unable to sedate and paralyze after initiating the protocol when the patient shivers. Some patients are now being documented upon arrival to the ED with almost a higher than normal temperature with this therapy.

I would rather have not been tied up in the semantics of the term 'boogyman', however:

If you read my post you will see that I don't think that RSI is the boogyman. I refer instead to those agencies, such as you yourself describe that are overly cautious in the application of advanced airway management for whatever reason, or do not allow it at all (as seen in this thread with attempts to place LMAs or going straight to crics in this patient)

The service I work for performs approximately 200 drug assisted intubations per quarter, and this number is rising. That doesn't include the intubations where sedation/paralysis are used post cold intubation. So that is around 800 RSIs per yer. We have a 97% first attempt success rate, and to date have not had to resort to cric in any RSI patients (it has been used in other patients) and the LMA as a rescue device has been used once. We have been performing RSI for over 5 years on the ground and 10 on HEMS.

I was (and am) curious as to the rationale particularly of those providers who do not carry out RSI, and in asking what the 'preferred' method would be to treat this patient I wanted to guage to some extent the mindset of some (at least on this forum) who don't RSI in respect to airway/TBI management.

ResTech gave an excellent response, but most have been "Stick an EGD in" or "poke a hole in them and go to hospital". Hardly optimal treatment for TBI with a poor airway.

 

[arsenicbassist]

Let's not forget that Versed for RSI increases ICP... Vecuronium would be my choice for a paralytic, as it is non-depolarizing.

 

[Akulahawk]

Let's not forget that Versed for RSI increases ICP... Vecuronium would be my choice for a paralytic, as it is non-depolarizing.

Is it Versed, the intubation attempt itself, or use of a depolarizing paralytic agent that causes the increased ICP?

 

[Smash]

Versed may increase ICP. The studies that I am aware of are extremely small series (10s of patients) that aren't really powered to show that. If you are aware of larger trials please post them they would be good to see.

It is unusual to find a service that advocates the use of a non-depolarizing NMBA as the primary agent used in induction, particularly a medium duration one such as vecuronium. Sux is more commonly used for it's rapid onset and short duration which is seen as safer in the prehospital field. Longer term paralysis is commonly achieved by either vecuronium or pancuronium.

If I was going to use a non depolarizer during induction I would choose a sHort acting one such as mivacurium or atracurium followed by panc or vec. Thus would allow resumption of respirations in a short time frame should intubation fail thereby minimizing the likelihood of of a can't intubate can't ventilate situation.

 

[Lifeguards For Life]

Is it Versed, the intubation attempt itself, or use of a depolarizing paralytic agent that causes the increased ICP?

the intubation procedure itself or sux could both cause increase in ICP, midazolam causes hypotension not icp

 

[Lifeguards For Life]

Versed may increase ICP. The studies that I am aware of are extremely small series (10s of patients) that aren't really powered to show that. If you are aware of larger trials please post them they would be good to see.

It is unusual to find a service that advocates the use of a non-depolarizing NMBA as the primary agent used in induction, particularly a medium duration one such as vecuronium. Sux is more commonly used for it's rapid onset and short duration which is seen as safer in the prehospital field. Longer term paralysis is commonly achieved by either vecuronium or pancuronium.

If I was going to use a non depolarizer during induction I would choose a sHort acting one such as mivacurium or atracurium followed by panc or vec. Thus would allow resumption of respirations in a short time frame should intubation fail thereby minimizing the likelihood of of a can't intubate can't ventilate situation.

I think Rocuronium is the fastest acting non depolarizing agent, with the fastest onset

 

[Smash]

Versed has high potential to cause hypotension, however there has been at least one small series that showed an increase in ICP subsequent to the administration of versed, so there is that potential. However it was a small series and not statistically significant. I'm not aware of any otheres, although there may be some larger studies.

Intubation/laryngoscopy will cause an increase in ICP. The larynx is one of the most highly inervated structures in the body, and messing around with it will cause significant sympathetic response which is something we want to avoid in TBI. This is why it is advisable to have as part of your process fentanyl (or something similar) to blunt that sympathetic response and minimize the rise in ICP.

Rocuronium indeed has the fastest onset time of the Nondepolarizing NMBA (about 60 seconds), however it also lasts for about 45 minutes, which defeats the purpose of using a short acting drug such as mivacurium or atracurium.

The reason why sux is popular is because it very rapidly achieves complete muscle relaxation, however it also wears off very quickly, allowing resumption of spontaneous resps should you be unable to ventilate. Using atracurium will achieve a similar goal. If you use roc you are leaving yourself open to having a patient whom you can't ventilate being paralysed for 45 minutes or so. Not a good plan!

 

[Akulahawk]

Versed has high potential to cause hypotension, however there has been at least one small series that showed an increase in ICP subsequent to the administration of versed, so there is that potential. However it was a small series and not statistically significant. I'm not aware of any otheres, although there may be some larger studies.

Intubation/laryngoscopy will cause an increase in ICP. The larynx is one of the most highly inervated structures in the body, and messing around with it will cause significant sympathetic response which is something we want to avoid in TBI. This is why it is advisable to have as part of your process fentanyl (or something similar) to blunt that sympathetic response and minimize the rise in ICP.

Rocuronium indeed has the fastest onset time of the Nondepolarizing NMBA (about 60 seconds), however it also lasts for about 45 minutes, which defeats the purpose of using a short acting drug such as mivacurium or atracurium.

The reason why sux is popular is because it very rapidly achieves complete muscle relaxation, however it also wears off very quickly, allowing resumption of spontaneous resps should you be unable to ventilate. Using atracurium will achieve a similar goal. If you use roc you are leaving yourself open to having a patient whom you can't ventilate being paralysed for 45 minutes or so. Not a good plan!

That's my understanding with Roc too, in that it does have a fast onset, but a relatively long duration... which I'd hate to be stuck in a paralyzed, can't intubate/ventilate situation... Knowing that Sux does work fast and has a short duration makes it attractive for field use. I'm not familiar with mivacurium or atracurium... but that's mostly because I haven't been exposed to those agents to include in my knowledge base.

 

[Smash]

Atracurium and mivacurium are fast acting non-depolarising NMBAs with a reasonably short duration of action. Atracurium is used reasonably widely in ORs, mivacurium is a relatively new drug and I haven't seen it around much. There is another even newer one cistracurium (I think, not sure on spelling) in a similar vein.

The advantage of use in the OR is that there are less concerns with a can't intubate, can't ventilate scenario than in the field. Theoretical advantages also include the increased range of patients who could be RSI'd, such as hyperkalemic, penetrating eye injurys, pt's with sux apnoea or malignant hyperthermia and so forth. However given that these conditions are relatively rare, I suspect the risk/benefit scales will continue to swing towards sux for a while yet.

Going back to sux, the putative rise in ICP caused by fasciculations can be attenuated by a number of methods such as pretreatment with a small dose of a non-depolarizing NMBA, lidocaine, or easier still, adequate induction agent

 

[thegreypilgrim]

What do you do, and why?

Delegate spinal axis immobilization and cutting off clothes with shears.
Delegate OPA insertion and assisted-ventilation with BVM while trying to suction the crap out of his mouth as much as possible and while I set up RSI equipment.
Have someone strip out a line, and hopefully I have another medic on scene with me to get the IV started.
Go ahead and execute RSI:
- make sure pt is being preoxygenated
- Lidocaine 1.5 mg/kg IVP
- Fentanyl 3 mcg/kg or MS 10-20 mg IVP
- Etomidate 0.3 mg/kg IVP
- Succinylcholine 2 mg/kg IVP
Confirm tube placement with EtCO2 and waveform capnography - use capnography to guide ventilations
LOAD PT AND GET GOING
Rapid Trauma Assessment en route
Have someone finish patching pt up to ECG
Start 2nd large bore IV, be aggressive with fluids to maintain BP/vitals at current values
Check glucose...kind of irrelevant but it's on my PCR and technically the pt is "altered" so it should be done
Notify trauma center of what we're bringing in and our ETA
Slap the defib pads on the pt's chest in case he codes en route