Trauma Scenario: Thoughts? RE: RSI/Intubation

[medichopeful]

I'm trying to wrap my head around one of the scenarios we recently did in medic school, so I figured I'd run it by everybody here (I'll try to remember it the best I can. It was a few days ago so I can't remember a lot of the information):

Dispatched for an explosion at a building. Upon arrival, you have one patient (middle-aged male) found laying on the ground. Going head to toe: decreased level of responsiveness (can't recall exact GCS, but 12-13 range maybe?), singed nose hairs, mucous membranes intact. Burns to chest, forearms. I don't remember much about the respiratory rate, but I remember that we did place an NPA and provided ventilation with a BVM. Lung sounds clear and equal. Bilateral lower leg fractures. I don't recall exact vitals, but I believe they were relatively stable (with exception of resps).

I wish I could remember more of the scenario and paint a better clinical picture, but unfortunately I'm lacking on the details.

My question is this: would you consider RSI for this patient? I wasn't the team leader, but I was arguing that the patient should be intubated: decreased level of responsiveness, multi-system trauma, and potential airway burns. Others were saying that you shouldn't RSI in this situation due to the fact that lung sounds were clear (they were arguing that you don't RSI without stridor or wheezing in a case like this) and because BLS airway interventions were working.

I've been thinking about this scenario for a few days and have convinced myself that I'm on the right track saying that this patient needs a tube. However, I'm obviously open to having that belief changed.

Anybody have any thoughts on this?

 

[zFrostyy]

You're not really giving enough info here, how bad are the burns? Is there any soot in his airways? what does his airway look like upon visualization? What's his O2 sat & end tidal?

 

[ERDoc]

If you are at the point of NPA and BVM, you need to RSI. BLS airway interventions are only temporizing measures until someone who can properly intubate comes along. The pt has declared that they need airway so don't screw around with half useful interventions.

 

[medichopeful]

You're not really giving enough info here, how bad are the burns? Is there any soot in his airways? what does his airway look like upon visualization? What's his O2 sat & end tidal?

I'll be back in class on Tuesday, I'll try to get more info for you then. I put down what I know, I don't remember too much more unfortunately but my classmates might!

 

[medichopeful]

If you are at the point of NPA and BVM, you need to RSI. BLS airway interventions are only temporizing measures until someone who can properly intubate comes along. The pt has declared that they need airway so don't screw around with half useful interventions.

The argument one person was making was basically that PHTLS states even one episode of hypoxia can be dangerous, which can happen during RSI. In addition, people kept making the argument that if a BLS airway is working, stay with a BLS airway according to PHTLS. I find both of these arguments to be ridiculous. It's impossible to place a patient on a vent with a BLS airway, and the ER isn't going to pay someone to stand around and BVM someone. In addition, my concern is subsequent swelling of the airway, even though it looked fine at the moment (with the exception of the nose hairs).

I'm glad I wasn't coming out of left field with thinking RSI was appropriate. I just didn't like the idea of such a minimally secured airway.

 

[Carlos Danger]

The argument one person was making was basically that PHTLS states even one episode of hypoxia can be dangerous, which can happen during RSI. In addition, people kept making the argument that if a BLS airway is working, stay with a BLS airway according to PHTLS. I find both of these arguments to be ridiculous. It's impossible to place a patient on a vent with a BLS airway, and the ER isn't going to pay someone to stand around and BVM someone. In addition, my concern is subsequent swelling of the airway, even though it looked fine at the moment (with the exception of the nose hairs).

I'm glad I wasn't coming out of left field with thinking RSI was appropriate. I just didn't like the idea of such a minimally secured airway.

This is actually a really good point to consider, or at least to bring up for discussion.

In severely brain-injured patients specifically, a single, even brief episode of either hypoxemia or hypotension will increase the chances or mortality by something like 50%, and if both happen, then it's something like 90%. Hypoxemia and hypotension are not uncommon complications of prehospital RSI. In fact it is my strong suspicion that this (along with poor post-intubation management) is a large part of the reason why prehospital intubation has been shown in several studies to be detrimental to these patients. So it's not something to just gloss over; it is a real concern and many in EMS don't have nearly enough respect for it, IMO. You really can hurt your patients if you screw this stuff up, even if you get the tube on your first try.

For the purposes of the scenario though, yes, it sounds to me like the guy should be intubated.

I find both of these arguments to be ridiculous. It's impossible to place a patient on a vent with a BLS airway, and the ER isn't going to pay someone to stand around and BVM someone. In addition, my concern is subsequent swelling of the airway, even though it looked fine at the moment (with the exception of the nose hairs).

Well, isn't it kind of obvious that the Prehospital Trauma Life Support guidelines don't apply to the ED? When they recommend sticking to a BLS airway if it works, they are talking about the prehospital phase? They aren't saying that the patient should never be intubated.

 

[Bullets]

I would also say that RSI would be my choice. With the possibility of burns to the airway, if you dont RSI now and secure the airway, should it swell then youre facing something like and emergency cric, which i assume is much less used than intubation.

One of my problems with PHTLS is that it sometimes pretends that there is this hard line between us and the hospital, not that we are just an extension of the hospital. We do many things that do not show immediate benefit here but will as the patient is in the ER.

 

[CANMAN]

How substantial were the burns to his chest? Are we talking circumferential full thickness which could be impeding your respiratory effort, or like partial thickness...? What was the patients respiratory effort when you arrived and what factors caused you to assist him with BVM?

I would be tubing this guy. Obviously as other have stated there's a lot of other things we like to know about this guys, but decreased LOC, and singed nasal hairs post explosion is about all the reason I need to make a decision. The lightly good that the rest of the airway exam is going to show some signs of superheated gas inhalation is probably high, and you don't want to wait around until you have stridor and hypoxia to intubate some with those findings and mechanism.

I would certainly be concerned for hypoxia and hypotension during the RSI based off the potential for head injury and poor outcomes as Remi highlighted really well. If your already assisting with BVM great, bag him up, and I would also put on a nasal cannula at high flow for apneic oxygenation during the intubation. Hang fluids and select appropriate agents for induction and post RSI sedation, and it sounds like this guy would be fine based off the limited info we have.

The biggest thing in my opinion that leads to the issues Remi was talking about is a lack of SUFFICENT training, and a blanket approach used by most places.... You can't use a blanket approach to all RSI's, each scenario is going to be different, and how you manage it should be based off multiple factors. Educating providers on which agents to utilize and why, and giving them protocols that not only allow them to pick different agents, but also heavily focuses on great preparation and oxygenation, as well as good post RSI management is key.

 

[Nova1300]

This is actually a really good point to consider, or at least to bring up for discussion.

In severely brain-injured patients specifically, a single, even brief episode of either hypoxemia or hypotension will increase the chances or mortality by something like 50%, and if both happen, then it's something like 90%. Hypoxemia and hypotension are not uncommon complications of prehospital RSI. In fact it is my strong suspicion that this (along with poor post-intubation management) is a large part of the reason why prehospital intubation has been shown in several studies to be detrimental to these patients. So it's not something to just gloss over; it is a real concern and many in EMS don't have nearly enough respect for it, IMO. You really can hurt your patients if you screw this stuff up, even if you get the tube on your first try.

For the purposes of the scenario though, yes, it sounds to me like the guy should be intubated.





Well, isn't it kind of obvious that the Prehospital Trauma Life Support guidelines don't apply to the ED? When they recommend sticking to a BLS airway if it works, they are talking about the prehospital phase? They aren't saying that the patient should never be intubated.

I'm not sure if the numbers are exact, but they are very close if not. In a brain injured patient, hypoxia and hypotension dramatically increases mortality and worsen outcomes.


And both of these things are relatively common with induction and intubation. But again, those statistics are in reference to brain injury.

I'm going to argue against intubation here. Given the exam, the clear and equal lung sounds, and under the supposition that the patient was not dyspneic, but breathing comfortably, I would hold off and transport immediately on high flow oxygen.

I think the risk of intubation here outweighs the benefit.

There are generally three reasons this guy is going to have respiratory failure and require intubation:
1. Carbon monoxide If there was also fire post-explosion
2. Pulmonary edema from the lung injury
3. Loss of the airway from burns.

If the mucosa is intact, the saturations are normal, he is protecting his own airway, and the breathing is non-labored, I personally would not intubate him until one of these things was no longer true.

Pulmonary edema would not hinder your need to intubate, should the need arise. Nor would carbon monoxide. And quiet, unlabored breathing is not an airway at imminent risk.

I think the rush to intubate burn patients is a bit overzealous at times.

 

[Nova1300]

I missed the ventilating part. I do agree that if you need to support ventilations, you need to intubate this patient

 

[Akulahawk]

Given the limited information known to us, the fact that you've inserted an airway adjunct and have to provide additional mechanical ventilation via BVM, the patient needs to be intubated. The question that remains is how. Given that the patient has a decreased GCS but not seriously low, probably has an intact gag reflex, and the like, I would suggest that RSI would be very appropriate for this patient.

Burning the nares means that seriously hot gas has at least reached the face long enough to cause damage. I wouldn't wait with this patient to get a secure airway. If you do wait for airway symptoms to show themselves, you've probably waited too long because airway edema would be quite advanced at that point.

 

[SpecialK]

Yes, I'd give this pt a general anaesthetic and intubate him for the following reasons:

1. He is likely to be in severe pain (general anaesthesia with fentanyl and ketamine will remove not only his perception of pain but also the deleterious pathophysiological effects from his pain)
2. Even if he does not have poor airway due to burns, it has the high potential to become poor at very short notice
3. If his airway does become poor due to burns, it will likely make intubation difficult

Given our standard approach to burns is 20 minutes of cooling with cool water I'd be happy to wait on scene for an RSI Officer unless it was going to be much faster to just take him to hospital instead.

 

[medicsb]

If you have the skills (having the drugs and an RSI protocol does not equal skills), then you intubate this patient all day, everyday, and twice on Sunday.

 

[Carlos Danger]

We are all taught to have a high index of suspicion for airway compromise in burn patients, and that if you wait until there are signs of airway involvement, it's too late. I wonder how much of a concern that really is. In other words, how likely is lower airway injury if a patient presents with soot in the mouth, or singed nasal hairs?

The HEMS program I used to work for had a contract with a major burn center, and we transported patients there from all over the southeast. My experience with that leads me to believe that we probably significantly exaggerate the risk of airway involvement in these cases. I've transported many burn patients who had the classic warning signs and I don't remember one ever having lower airway involvement. Especially not the very rapidly developing kind (where they are fine one moment and their airway has swollen shut the next moment) that we are always warned about. I'm not saying it doesn't happen, but I think it is a lot less of a risk than we are taught. For sure I've seen lots of smoke inhalation cases where they needed albuterol, and even ventilatory support, but that's a totally different thing.

A large percentage of patients with bad burns will end up intubated - even if the burns are nowhere near the face - because of high opioid requirements and the fluid shifts that eventually do cause some facial and pharyngeal edema, but it isn't usually something that has to happen immediately.

 

[NomadicMedic]

I think this post from @Remi nails it. I had a patient that was in a house fire, trapped in the house, and was rescued by fire fighters. When I arrived, she was a bit confused, but the confusion cleared up quickly following some oxygen. She had soot around her mouth and in her airway, but no burns. I was questioned by the Doc and the senior FTO about why I didn't RSI the patient. Well, she was conscious, had no respiratory difficulty or pain and was mentating correctly. Turns out she never needed airway management, but I was questioned about knocking down and tubing a woman with a dirty face because we're so brainwashed that anyone who was in a fire with soot in their oropharynx buys a tube.

 

[CANMAN]

I agree that we tend to be over aggressive in some burn patients. That being said, and having worked in a burn institution, I typically associate explosion type burns with a higher incidence of respiratory issues. I doubt there's evidence to prove that, however almost every patient I have some in contact with that had exposure to a significant explosive type injury facial involvement eventually has some respiratory component. We have lots of dumb farmers who love to "clean up" with gasoline around my way...

Sure lower airway stuff is a concern, and you can listen to lung sounds etc etc, but what I see more often is upper airway issues which present with hoarseness and stridor, and those scare me more.... That person is buying plastic before then become too inflammed to where it's now a problem. All else fails, they do well and didn't need it, you extubate them and all is well. I would rather be slightly over aggressive in that scenario then waiting til last minute, end up not being able to get that patient intubated, then looking at a surgical airway because I was being passive.

 

[Nova1300]

We are all taught to have a high index of suspicion for airway compromise in burn patients, and that if you wait until there are signs of airway involvement, it's too late. I wonder how much of a concern that really is. In other words, how likely is lower airway injury if a patient presents with soot in the mouth, or singed nasal hairs?

The HEMS program I used to work for had a contract with a major burn center, and we transported patient there from all over the southeast. My experience with that leads me to believe that we probably significantly exaggerate the risk of airway involvement in these cases. I've transported many burn patients who had the classic warning signs and I don't remember one ever having lower airway involvement. Especially not the very rapidly developing kind (where they are fine one moment and their airway has swollen shut the next moment) that we are always warned about. I'm not saying it doesn't happen, but I think it is a lot less of a risk than we are taught. For sure I've seen lots of smoke inhalation cases where they needed albuterol, and even ventilatory support, but that's a totally different thing.

A large percentage of patients with bad burns will end up intubated - even if the burns are nowhere near the face - because of high opioid requirements and the fluid shifts that eventually do cause some facial and pharyngeal edema, but it isn't usually something that has to happen immediately.

100% yes.

Granted, I have only managed a few of these cases when called by the ER to be on standby for the intubation. But in all of those cases, the airway compromise was not immediate. There had been signs and symptoms of respiratory distress prior to being called.

Even in those cases, I have delayed induction until someone brought me a perc trach kit to bedside and pressors hanging.

And every time, the ER residents have managed the airway just fine while I sip my coffee and chat up the medics.

Rarely is something absolutely wrong in medicine. I would just keep in mind that every induction has some degree of risk, no matter how skilled of an intubator you are.

These patients are very likely to have capillary leak syndrome. You induce him, he is probably going to get hypotensive, no matter which agent you chose. Between that and his enormous inflammatory response, the likelihood of knocking his beans off is pretty high.

Again, if you are needing to assist respirations, yes intubate him. But, if you don't have a hard indication (burned mucosa, noisy respiration, depressed mental status) I personally would transport emergently on high flow O2.

That is simply my opinion, take it for what it's worth.

Just to make one other point. If you are going to intubate this patient in the field, he absolutely needs rapid sequence. He is a multi system trauma and is considered full stomach, even if he was on hunger strike for the last 3 days.

 

[Jim37F]

Just out of curiosity, what if this patient was in a system that doesn't have RSI? You medics wouldn't attempt to intubate unless the GCS was closer to a 1-1-1 right?

 

[CANMAN]

Just out of curiosity, what if this patient was in a system that doesn't have RSI? You medics wouldn't attempt to intubate unless the GCS was closer to a 1-1-1 right?

Great post Nova.

And yes Jim like Nova said, without RSI this guy needs rapid transport and 100% oxygen, a heads up to the ED, and let them do the show therefor the reasons Nova stated above.

 

[Tigger]

Great post Nova.

And yes Jim like Nova said, without RSI this guy needs rapid transport and 100% oxygen, a heads up to the ED, and let them do the show therefor the reasons Nova stated above.

Nasal tube perhaps?

Certainly not to replace RSI, but an option for those that don't have it.