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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.
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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