Intubation in trauma patient stem

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vector2 said:
The stem doesn't explicitly say ICH, but it also doesn't provide or hint toward any other likely causes (alcohol breath, positive tox) of an altered sensorium, GCS 9, combative state other than head trauma. And even if ICH is ruled out, we still want intubation to be smooth when the patient is at high risk for various facial/cerebral bleeding, CSF leaks, etc.
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I’m not qualified to comment on an anesthesiology oral board exam since I’m an EP. However, I can describe our trauma surgeon’s expectations on how all trauma patients are to be intubated at our obesity center of excellence:

All get RSI’ed with in-line cervical stabilization.
1) 90% get a first visualization attempt with a hyper-angulated blade (glidescope or C-MAC “D” blade).Although some might try a first attempt with VL and a standard angulated blade +/- Bougie, most of us would go straight to a hyperangulated blade. This yields first attempt success in the vast majority of obese trauma patients at our shops. For the 5% that are difficult, we generally go through steps 2-4.
2) I-Gel and try to correct barriers
3) I-Gel fiberoptic intubation
4) Cric

Anyone trying to topicalize for awake fiberoptic in an altered trauma patient would be told by the trauma attending to leave the bedside. The same goes for anyone trying to raise the head of the bed, give the patient dexmedetomidine, etc.

This has been my general experience at every trauma center that I’ve encountered. I cannot recall a sedation only or awake fiberoptic intubation in all of the obese patients who have had their faces rearranged by windshields, fists, or guns.
 
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ShockIndex said:
I’m not qualified to comment on an anesthesiology oral board exam since I’m an EP. However, I can describe our trauma surgeon’s expectations on how all trauma patients are to be intubated at our obesity center of excellence:

All get RSI’ed with in-line cervical stabilization.
1) 90% get a first visualization attempt with a hyper-angulated blade (glidescope or C-MAC “D” blade).Although some might try a first attempt with VL and a standard angulated blade +/- Bougie, most of us would go straight to a hyperangulated blade. This yields first attempt success in the vast majority of obese trauma patients at our shops. For the 5% that are difficult, we generally go through steps 2-4.
2) I-Gel and try to correct barriers
3) I-Gel fiberoptic intubation
4) Cric

Anyone trying to topicalize for awake fiberoptic in an altered trauma patient would be told by the trauma attending to leave the bedside. The same goes for anyone trying to raise the head of the bed, give the patient dexmedetomidine, etc.

This has been my general experience at every trauma center that I’ve encountered. I cannot recall a sedation only or awake fiberoptic intubation in all of the obese patients who have had their faces rearranged by windshields, fists, or guns.
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What is an EP?

That bravado type talk of asking people to leave doesn't really impress anyone.


5 out of every 100 traumas get an igel or a cric? Wow.
 
Newtwo said:
What is an EP?

That bravado type talk of asking people to leave doesn't really impress anyone.


5 out of every 100 traumas get an igel or a cric? Wow.
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If you re-read my post, you will notice that I narrowed my comments to the specific patient population being discussed - obese trauma patients and especially those with mangled faces. I pulled 5% out of my ass because the aggregate trauma literature suggests that roughly 1-10% trauma intubations wind up being difficult airways requiring multiple operators and/or techniques. There is a wide range because some include prehospital airways. So no, 5% of all traumas do not get an I-Gel or cric. On the other hand, close to 95% of our obese trauma patients are successfully intubated on the first attempt by a skilled operator using RSI that is the modality of choice in probably every trauma center in America for this patient population.

I’ve seen plenty of trauma and EP attendings tell unhelpful people to leave the bedside during traumas. It happens often enough that at one hospital we had a red line that only the trauma team could cross during the primary survey. That is because we have people doing all kinds of crazy stuff while we were trying to proceed with the initial survey - things like chaplains asking about next of kin, cops trying to conduct interrogations, orthopedists trying to reduce mangled extremities, etc. To be honest, most anesthesiologists who come down for traumas are polite, helpful, and seem content to stay on their spectalink phones and relay the unfolding disaster to the OR. However, I could easily see a couple of trauma attendings telling a CA2 or 3 to bugger off if they tried to jack-up the head of the bed on a trauma patient or whipped out the Hurricane spray during a primary survey. That is because jacking up the head of the bed on someone with the potential for thoracolumbar fractures is dangerous; trying to tube a trauma patient with just Precedex is dangerous; and awake fiberoptic intubation in altered trauma patients with a mangled face is dangerous.
 
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ShockIndex said:
If you re-read my post, you will notice that I narrowed my comments to the specific patient population being discussed - obese trauma patients and especially those with mangled faces. I pulled 5% out of my ass because the aggregate trauma literature suggests that roughly 1-10% trauma intubations wind up being difficult airways requiring multiple operators and/or techniques. There is a wide range because some include prehospital airways. So no, 5% of all traumas do not get an I-Gel or cric. On the other hand, close to 95% of our obese trauma patients are successfully intubated on the first attempt by a skilled operator using RSI that is the modality of choice in probably every trauma center in America for this patient population.

I’ve seen plenty of trauma and EP attendings tell unhelpful people to leave the bedside during traumas. It happens often enough that at one hospital we had a red line that only the trauma team could cross during the primary survey. That is because we have people doing all kinds of crazy stuff while we were trying to proceed with the initial survey - things like chaplains asking about next of kin, cops trying to conduct interrogations, orthopedists trying to reduce mangled extremities, etc. To be honest, most anesthesiologists who come down for traumas are polite, helpful, and seem content to stay on their spectalink phones and relay the unfolding disaster to the OR. However, I could easily see a couple of trauma attendings telling a CA2 or 3 to bugger off if they tried to jack-up the head of the bed on a trauma patient or whipped out the Hurricane spray during a primary survey. That is because jacking up the head of the bed on someone with the potential for thoracolumbar fractures is dangerous; trying to tube a trauma patient with just Precedex is dangerous; and awake fiberoptic intubation in altered trauma patients with a mangled face is dangerous.
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I consider myself center lane anesthesiologist. I take plenty of call, see plenty of trauma and sick as **** patients. I don't jump to awake intubations or fiberoptic unless it is clearly indicated.

Having said this..

Seems like some people in your department have a huge ego problem. I would choose safety over a predetermined one size fits all plan. Inducing and trying to VL everyone regardless of how their airway looks and how mangled their face is a recipe for badness. Aspiration and surgical airway rates must be through the roof. Of course these wont be surgical complications so I'm sure the trauma surgeon would be all too happy to throw you under the bus.

If anyone other than an ENT surgeon I trust tells me how to handle my airway management I would tell them to gtfo
 
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eikenhein said:
I consider myself center lane anesthesiologist. I take plenty of call, see plenty of trauma and sick as **** patients. I don't jump to awake intubations or fiberoptic unless it is clearly indicated.

Having said this..

Seems like some people in your department have a huge ego problem. I would choose safety over a predetermined one size fits all plan. Inducing and trying to VL everyone regardless of how their airway looks and how mangled their face is a recipe for badness. Aspiration and surgical airway rates must be through the roof. Of course these wont be surgical complications so I'm sure the trauma surgeon would be all too happy to throw you under the bus.

If anyone other than an ENT surgeon I trust tells me how to handle my airway management I would tell them to gtfo
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How many obese, GCS 9 trauma cases have you topicalized for a fiberoptic first attempt in the past year? Five years?
How many have you just given Presedex to and tried to intubate?

I ask because I’ve never seen or heard of these strategies being done or advocated anywhere other than this thread.
 
ShockIndex said:
How many obese, GCS 9 trauma cases have you topicalized for a fiberoptic first attempt in the past year? Five years?
How many have you just given Presedex to and tried to intubate?

I ask because I’ve never seen or heard of these strategies being done or advocated anywhere other than this thread.
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Re read what I wrote. I never said I would do such things. But I did say that I do whatever I think is safest given the clinical scenario. So let me throw this simple question out to you. How many horrible airway patients have you intubated, period? And how many horrible airway patients do you think I've intubated? I reckon my experience and expertise in managing challenging airway situation is 10x more than yours. So if you ask for an anesthesiologist to manage a trauma airway and you want to dictate how to do it you can butt out.

The fact it is trauma with whatever physiologic concern is just another clinical scenario we deal with in our work. Aspiration risk? C spine precautions? Low GCS score? You think we haven't seen that **** before?
 
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eikenhein said:
Re read what I wrote. I never said I would do such things. But I did say that I do whatever I think is safest given the clinical scenario. So let me throw this simple question out to you. How many horrible airway patients have you intubated, period? And how many horrible airway patients do you think I've intubated? I reckon my experience and expertise in managing challenging airway situation is 10x more than yours. So if you ask for an anesthesiologist to manage a trauma airway and you want to dictate how to do it you can butt out.
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I’m going to go out on a limb and say that we have both have handled enough difficult airways to be competent at what is a core competency. I’m going to get real daring and say that both of us tailor our approach to airways based on a number of patient and disease trajectories.

Where I sense that we have a disconnect is my position (and several others it seems) that RSI is generally the safest method of establishing an airway in the overwhelming majority of trauma patients regardless of obesity or facial trauma. If we are talking about altered, obese trauma patients with facial trauma, RSI is still the overwhelming method of choice to the extent that trauma team leaders (ie the trauma attending) who are ultimately responsible for leading the team (and likely performing the surgical airway if things go bad) expect it to be used. Moreover, anyone suggesting awake intubation, sedation-only, or some other high-risk maneuvers simply because a patient is obese or has facial trauma is practicing so far out of the mainstream that they will quickly lose the confidence of the doctors around them. That is to say, someone advocating these techniques would need to have such a highly unique set of circumstance that they cannot be considered first line and neither you nor I can recall ever seeing despite thousands of trauma intubations between us. Is that fair to say?
 
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T-burglar said:
It IS a little embarrassing for our specialty that someone suggested lightly sedated fiber optic for the confused gorilla that was most likely balls deep in a case of milaukees best when he did demolition derby
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An emergency physician offering that up to this case on their oral boards would fail in glorious fashion. They would also fail if they tried Presedex or raised the head of the bed.
 
ShockIndex said:
An emergency physician offering that up to this case on their oral boards would fail in glorious fashion. They would also fail if they tried Presedex or raised the head of the bed.
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You are an emergency physician board exam examiner?
 
Newtwo said:
You are an emergency physician board exam examiner?
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Was. I left EM for another speciality after practicing for 15 years.

Feel free to voir dire my credentials. It will not change reality.
 
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this is a standard trauma airway in most of america. Ketamine/roc/VL/bougie/extralaryngeal manipulation. In line stabilization for all traumas. Can't crack the bed so use some reverse trendelburg to unload the belly from the chest. Intubating with the collar in place is lol. If you can't get a view and there's time and the airway is okay and can vent can consider FOI (never seen it done in a trauma bay) if not, cut. A surgical airway in this guy when all else fails is a win not a fail.
 
migm said:
this is a standard trauma airway in most of america. Ketamine/roc/VL/bougie/extralaryngeal manipulation. In line stabilization for all traumas. Can't crack the bed so use some reverse trendelburg to unload the belly from the chest. Intubating with the collar in place is lol. If you can't get a view and there's time and the airway is okay and can vent can consider FOI (never seen it done in a trauma bay) if not, cut. A surgical airway in this guy when all else fails is a win not a fail.
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yeah you forgot one big part of your trauma airway management.

ASA-768x637.png


Hint: it is on the top left

And yes, in the right clinical situation the use of awake intubation or awake trach is valid for trauma situations as your primary plan. Just because you haven't seen it done doesn't mean it isn't so.
 
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migm said:
this is a standard trauma airway in most of america. Ketamine/roc/VL/bougie/extralaryngeal manipulation. In line stabilization for all traumas. Can't crack the bed so use some reverse trendelburg to unload the belly from the chest. Intubating with the collar in place is lol. If you can't get a view and there's time and the airway is okay and can vent can consider FOI (never seen it done in a trauma bay) if not, cut. A surgical airway in this guy when all else fails is a win not a fail.
Click to expand...

I would never use roc in a million years unless sux was clearly contraindicated.
 
eikenhein said:
yeah you forgot one big part of your trauma airway management.

View attachment 295433

Hint: it is on the top left

And yes, in the right clinical situation the use of awake intubation or awake trach is valid for trauma situations as your primary plan. Just because you haven't seen it done doesn't mean it isn't so.
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where it says cancel case?
 
Arch Guillotti said:
I would never use roc in a million years unless sux was clearly contraindicated.
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because you're going to wake this person up who needed to be intubated, instead of establishing a definitive airway?
 
but seriously, cancel case? i love it. this combative as **** patient doesn't have time to titrate ketamine to effect for a sedated trach/cric. it's going to be a 4mg/kg IM dart or 1-2 per kilo IV. The risk of loss of respiratory effort is large.
 
migm said:
but seriously, cancel case? i love it.
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Hubris. I am sure that if you see a trauma patient with a near impossible airway, YOU probably shouldn't be the one doing it.

I've seen too many of you cowboy ER docs muck up easy airways, and you sound just like one of them.
 
eikenhein said:
Hubris. I am sure that if you see a trauma patient with a near impossible airway, YOU probably shouldn't be the one doing it.
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we must live in different worlds. I'm not intubating someone who should not be intubated. I see a near impossible airway that needs to be ventilated? I'm going for a cric.
 
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ShockIndex said:
Was. I left EM for another speciality after practicing for 15 years.

Feel free to voir dire my credentials. It will not change reality.
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That's interesting. Why did you leave or when?

Just wondering how crics you have done then?
How do you cut? Horizontal or vertical in these behemoths? Ever had any problems with it?
Do you pre mark the neck or even put a transtracheal catheter?

Or also do you/did you do many fibre optic intubation?

Did your igels sit well regularly? How did you find intubation thru them? What size tube would you use and how? How would you exchange the lma for The tube? Or would you even do an exchanger?

Thank you.
 
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Sugammadex would restore strength in a patient faster than waiting for sux to wear off. I would always use a huge dose of roc for trauma. I always use a huge overdose of roc for my cardiac cases.
 
T-burglar said:
Sugammadex would restore strength in a patient faster than waiting for sux to wear off. I would always use a huge dose of roc for trauma. I always use a huge overdose of roc for my cardiac cases.
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So how much suggamadex would you have in the ER then?
How long does it take for suggamadex to reverse this huge dose of roc vs sux wear off time?
 
Are you asking because you truly don’t know? It’s instantaneous, one circulation time
 
The 16 mg/kg for RSI roc reversal is also nonsense. I dont care how much roc someone got....you give anyone 2-3 vials and they're gonna be coming at you hulkamania strength in 30 seconds. They might need some doses later to prevent recurarization but they'll be breathing, that's for damn sure.
 
Are you gaslighting me? I use the drug like every day, as soon as you push the plunger the patient is strong again.

What exactly do I need to read more about?
 
vector2 said:
The 16 mg/kg for RSI roc reversal is also nonsense. I dont care how much roc someone got....you give anyone 2-3 vials and they're gonna be coming at you hulkamania strength in 30 seconds. They might need some doses later to prevent recurarization but they'll be breathing, that's for damn sure.
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Wow.
Adding visuals and expletives makes me want to believe you but unfortunately those articles and researchers say differently which is a pity
 
T-burglar said:
Are you gaslighting me? I use the drug like every day, as soon as you push the plunger the patient is strong again.

What exactly do I need to read more about?
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You reverse 1.2/kg of roc with suggamadex every day?

I'm not gaslighting whatever that is?

There is a considerable delay. You can read about it if you like
 
Why are we waking this patient up instead of doing a surgical airway again?
 
economycian said:
why?
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Rocuronium at 1.2 mg/kg or more is OK for an RSI, but it'll never be as fast or as good as succinylcholine. I am a card carrying member of the Sux Hater Society but it's still the fastest route to ideal intubating conditions and it should be used for true RSI indications, barring any contraindications.


@Newtwo you sure are posting a lot of weird stuff in this thread.

1) Advocating AFOI with Precedex in a combative GCS 9 trauma patient with facial trauma? Seriously? Have you ever actually seen a combative GCS 9 patient with facial trauma? Word of caution for the day you do - this plan is an invitation to some facial trauma of your own at the hands of the patient.

2) Now you're doubting that sugammadex works quickly, and posting condescending attempts at a leading gotcha question -

Newtwo said:
How long does it take for suggamadex to reverse this huge dose of roc vs sux wear off time?
Click to expand...

Any anesthesiologist who's ever used either sux or sugammadex (one G, two Ms) more than three times knows that it takes a LOT longer for an RSI dose of sux to wear off than for a reversal dose of sugammadex to take effect. It's dramatically different. We're talking minutes vs a circulation time or two. Have you used this drug or just read about it?
 
There are lots of things that you can read about that aren’t reality. For example there is no descending limb on the frank starling relationship.

Obviously you haven’t actually used sugammadex. You should probably listen to those of us that have or better yet get some for yourself and form your own opinion.

lastly, try mixing your 1.2 mg/kg and induction agent in one syringe and use a flush to bang it. The onset of general anesthesia and intubating conditions is nearly simultaneous. This has been studied in a series of patients and none had any recollection of paralysis. I do it for all crash sections too, although obviously I don’t mix roc in for those
 
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Ok easy now.
Lets try a different track. What do you say to this paper?

Screenshot_20200213-131016_Evernote.jpg


As for my usage well I've no intention of detailing any of that.
 
Newtwo said:
Ok easy now.
Lets try a different track. What do you say to this paper?

View attachment 295517

As for my usage well I've no intention of detailing any of that.
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that graphic seems to confirm you will be reversed much more quickly with Roc/Suggamadex compared to just letting Sux wear off, although should I really trust anything that suggests it takes 5 minutes to intubate somebody?
 
nimbus said:
So roc/suga provides better intubating conditions and faster recovery than sux. I’ve used sux maybe 3 times in the last 5 years. I’ll stick with roc.
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Yes. But they're the numbers.
Rox/sug is better but..
If people think Sugammadex will save you from hypoxic brain injury in cico well you're very not correct.

Plus what Emerg has 6x500vials of sug lying around? None I know of. Mobilising that much bridion will take 10 mins

This is very important.
I'm not sure why people don't know this
 
How long do you think it takes to cric in CICO?
 
Newtwo said:
Yes. But they're the numbers.
Rox/sug is better but..
If people think Sugammadex will save you from hypoxic brain injury in cico well you're very not correct.

Plus what Emerg has 6x500vials of sug lying around? None I know of. Mobilising that much bridion will take 10 mins

This is very important.
I'm not sure why people don't know this
Click to expand...

You don’t need that many but....

7F839040-5A07-4FAE-9589-63C63F9252EB.jpeg
 
Nobody cares about your stupid article. Anyone that uses sugammadex knows that it does not take 1 minute, let alone several minutes, to see an effect.

You shouldn’t just believe everything that you read. This is very important. i’M not sure why you don’t know this
 
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