Intubation in trauma patient stem

[deleted697535]

Yes. We got it in 2012. Free supply for 6 months so every single case for that time actually. So yes I've used it in about 1000 cases over the last 8 yrs. When was it fda approved? 2017?

Wonderful drug. It works exactly as the ppl above say it does when you have given just a regular dose of roc or the roc is mostly worn off. It works in seconds. But that's not at all what we're talking about.

I've never had to reverse with 16mg/kilo tho in a hurry. I hope to never have to do that.

The 180kg gentleman in this hypothetical case of cico after RSI roc would need 2.88 grams. That's what we're talking about right? So 3 of those full drawers you have there if they're 200s. 15amps of 200s.

Delegating that to someone to draw up and push while they may not have a clue what you're talking about while you're frantically trying to bag a dying person would be hell I'd imagine. I don't think it would have any kind of a better outcome than having the sux wear off. Nor will it really be faster. So the point is that it's no guarantee off a saviour either...

Waking him up just is not a great option... Probably worse than FOI option...

I think what ppl are missing here is this is oral exam prep. It's not real life. There's such a huge difference.

How many times will you run last or MH or anterior mediastinal mass etc in real life career vs the exam?

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[vector2]

Sugammadex trials have harder endpoints like T4:T1 0.9 or return to spontaneous ventilation which has to be 8 breaths per minute with X or Y tidal volume etc. That doesn't obviate the fact that the pt is reversed much, much sooner than that (30-60 secs) to a significant degree and likely is going to be able to pull some oxygen in on their own with just a little help.

But ANYWAY, to get back to the issue at hand, if we're talking about a combative morbidly obese GCS 9 trauma pt with facial fractures and a bloody mouth, I am totally putting the "wake the pt up" part of the airway algorithm out of my mind. Sux vs roc is only relevant for me is as far as the fact that sux might need to be redosed if the airway is difficult. Even if sug worked in 0.5 seconds, the pt will have needed a good dose of whatever induction med, and even using ketamine, a guy who was satting 96 on 15L NRB mask has zero reserve once you've sedated him a bit. He's going to desat immediately, ergo, the endpoint is death or a surgical airway.

 

[ShockIndex]

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 -

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?

This whole debate of sux vs. roc has been an ongoing discussion among the larger community that spends a lot of time caring for trauma patients (surgery, EM, anesthesia, etc.). There have been several reviews, podcasts, and meta-analysis. It seems to fall into two camps and both can point to evidence that their side is the better option. My personal opinion is that people who handle trauma airways for a living need to be comfortable with both.

As for sugammadex in trauma patients, I personally sense a growing sentiment among this trauma community that this drug has a very limited role on the back end of RSI in the ED so that neurosurgeons can get a timely exam, but should be used with extreme caution in a cannot intubate/cannot oxygenate trauma situation. This belief stems from the fact that reversing paralysis is going to leave a sedated and possibly apneic patient that is more difficult to bag or place a supraglottic rescue airway than a paralyzed patient. I think this caution and the time to get, mix, and administer sugammadex in a dire situation where seconds count means that I’m reaching for an I-Gel.

Finally, I finished residency almost 15 years ago and have seen the evolution of DL to ever better VL capabilities. While there is a paucity of evidence that VL is significantly superior to DL in routine intubations, I’m not convinced that these studies are powered to tease out advantages in trauma airways. My experienced gestalt is that VL improves the safety of trauma intubations (especially hyper-angulated blades) and I recommend some form of video assistance for all trauma intubations so that at least the team can see the challenges that may lay ahead.

 

[Mman]

I use succinylcholine frequently. It's cheap and works and provides great intubating conditions in extremely fast time. However if I have the ultimate oh **** airway that I am worried about but still want to go full paralysis and intubate I always go for rocuronium 1-1.5 mg/kg with the vials of suggamadex sitting nearby. It costs literally nothing to have them in the room if you don't use them. But I 100% guarantee you can reverse the rocuronium a lot faster than it takes succinylcholine to wear off to the point where a patient will ventilate spontaneously and effectively. Suggamadex reaches a clinically relevant effect in maybe 30-60 seconds.

Anybody ever give maybe 200 mg of succinylcholine and wait to see how long it took the patient to breathe effectively afterwards? You are talking like 10+ minutes.

 

[anbuitachi]

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

i'm not sure why mix 1.2 with induction agent. the last RSI i did, i pushed roc first and then propofol. from my experience, propofol always works faster than 1.2 of roc.

not a pretty sight giving mixed propofol + sux... though none of the patients ever remember (small n though)

This whole debate of sux vs. roc has been an ongoing discussion among the larger community that spends a lot of time caring for trauma patients (surgery, EM, anesthesia, etc.). There have been several reviews, podcasts, and meta-analysis. It seems to fall into two camps and both can point to evidence that their side is the better option. My personal opinion is that people who handle trauma airways for a living need to be comfortable with both.

As for sugammadex in trauma patients, I personally sense a growing sentiment among this trauma community that this drug has a very limited role on the back end of RSI in the ED so that neurosurgeons can get a timely exam, but should be used with extreme caution in a cannot intubate/cannot oxygenate trauma situation. This belief stems from the fact that reversing paralysis is going to leave a sedated and possibly apneic patient that is more difficult to bag or place a supraglottic rescue airway than a paralyzed patient. I think this caution and the time to get, mix, and administer sugammadex in a dire situation where seconds count means that I’m reaching for an I-Gel.

Finally, I finished residency almost 15 years ago and have seen the evolution of DL to ever better VL capabilities. While there is a paucity of evidence that VL is significantly superior to DL in routine intubations, I’m not convinced that these studies are powered to tease out advantages in trauma airways. My experienced gestalt is that VL improves the safety of trauma intubations (especially hyper-angulated blades) and I recommend some form of video assistance for all trauma intubations so that at least the team can see the challenges that may lay ahead.

why iGel. do you like it better than other LMAs?

also can any EM physician tell me why i see so often, trauma patients come in with C collar, and then gets intubated in ED with collar off, with NO stabilization. head is freely moving back and forth, then after the tube is in, the c collar goes back on? anyone else commonly see this on their trauma bays?

 

[nimbus]

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

You don’t even need 1.2/kg. I frequently used 0.4-0.6/kg and get great intubating conditions every time.

Also, why don’t you use roc for crash c-sections?

 

[ShockIndex]

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.

I left for CCM fellowship because I enjoy a sicker patient population than typically found in most EDs. I now take care of the sickest patients in the hospital and airways are still part of my daily routine.

I’ve probably placed a few hundred supraglottics over the years - most LMAs and a couple of ILMAs. However, I’m old enough to have used Combitubes, PTLs and Kings in the field. That includes multiple anesthesia OR rotations (paramedic, EM residency, fellowship), out of hospital cardiac arrests (LMAs were our go-to), floor codes, and numerous times as an EM attending where I’ve made resident trainees work through their problems rather than me just taking the tube from them.

My first experience with I-Gels came about 24 months ago when my institution replaced their LMAs. I’ve used them a handful of times for fiberoptic intubation (size 3 with 6.5 or 7 tube; size 4 with 7.0 or 7.5 tube). I recall a couple of instances where fiberoptic intubation was difficult through the I-Gel requiring it to be reset or the tube was not adequately lubed.

I’ve done 4 crics in 20 years. All but 1 was a vertical incision with whatever scalpel was handed to me. One was a kit using a Seldinger technique. They all bled.

Finally, I spent a good chuck of my career doing operational medicine in the Army as well as local and federal law enforcement. I’ve been deployed more times than you have fingers since 1992. I’ve intubated under circumstances that you probably couldn’t imagine.

 

[ShockIndex]

i'm not sure why mix 1.2 with induction agent. the last RSI i did, i pushed roc first and then propofol. from my experience, propofol always works faster than 1.2 of roc.

not a pretty sight giving mixed propofol + sux... though none of the patients ever remember (small n though)





why iGel. do you like it better than other LMAs?

also can any EM physician tell me why i see so often, trauma patients come in with C collar, and then gets intubated in ED with collar off, with NO stabilization. head is freely moving back and forth, then after the tube is in, the c collar goes back on? anyone else commonly see this on their trauma bays?

My institution replaced the LMAs with I-Gels. I use what I’m given, but have years of experience with LMAs.

As for your second question, I’ve only seen that when anesthesia was intubating in the ED back in the late 90s. .

 

[coffeebythelake]

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.

Just need one of you to state the obvious. Not every trauma patient needs an ER doc to do the "standard trauma airway" induce and muck around and cause blood and vomit everywhere before you calling it quits and go for the neck. I know that's what you've been taught... But how about getting ENT surgery and anesthesiologist around when you deal with a truly difficult airway? There is no shame in asking for help. Ideally earlier and not when the patient is peri-arrest after your attempts. Or Maybe in this alternative universe, bizarro world you are better than ENT (and your other surgeons?) for crics?

 

[coffeebythelake]

also can any EM physician tell me why i see so often, trauma patients come in with C collar, and then gets intubated in ED with collar off, with NO stabilization. head is freely moving back and forth, then after the tube is in, the c collar goes back on? anyone else commonly see this on their trauma bays?

I know that my gomerblog post about trauma airway is meant to be tongue in cheek... But sometimes it seems way too real. Induction without preoxygenation then wondering why patient desats to 50%. No in line stabilization for c spine precautions. Unrecognized esophageal intubation even with video laryngoscope. Knocking out teeth like they are at the carnival. Intubating patients that kind of "look bad" but were actually talking and giving history and without true emergent indication for intubation. Thanks smucks, now we cant even figure out their medical issues before they go for their emergent surgery.

Yes I have personally witnessed this from ER docs in trauma bays across several different hospitals. Because they think they could handle it.

 

[migm]

Just need one of you to state the obvious. Not every trauma patient needs an ER doc to do the "standard trauma airway" induce and muck around and cause blood and vomit everywhere before you calling it quits and go for the neck. I know that's what you've been taught... But how about getting ENT surgery and anesthesiologist around when you deal with a truly difficult airway? There is no shame in asking for help. Ideally earlier and not when the patient is peri-arrest after your attempts. Or Maybe in this alternative universe, bizarro world you are better than ENT (and your other surgeons?) for crics?

Despite working at a level 2 trauma center where I work is a typical large community hospital. Some forget this is where the vast majority of rubber meets the road. In the perfect world not needing a surgical airway is ideal for both pt and provider. Good luck overhead paging for ENT or asking them to come in from home, please, while this guy kicks your nurses in the teeth.

But yeah I see difficult airway up front I am calling for help and have done so Everytime.

No wait, I don't know obvious **** and so I'm just going cowboy. Leeeeeroy Jennnnkins!

Come on.

 

[zizzer]

To all you guys who are suggesting sugammadex, are you not concerned about the apnea from your other induction medications? In addition to the aforementioned problem of high dose sugammadex possibly being difficult to mobilize in the ER, this patient wasn't breathing great spontaneously before anyway. If you reverse, but the patient remains apneic, are you just thing to keep waiting for a wake up? For how long? I highly favor committing to establishing an airway, even if it ends up being surgical.

 

[T-burglar]

None of us were really advocating waking him up. The discussion was just around the obselescence of sux for the often quoted but never practiced strategy of waking someone up.

If you truly wanted to wake someone up as a backup plan, you would have to use a opioid benzo roc induction. And have a reversal syringe with narcan, flumazenil, and sugammadex on hand.

I’ve actually done this for a case of torrential TR and severely diseased right ventricle that needed GETA for upper and lower caval Transcatheter valves. I wasn’t sure if induction of GA and PPV was going to cause cardiac arrest so my plan was to reverse everything with an epinephrine chaser

Wasn’t an airway issue, I just thought she was exceptionally high risk for arrest on induction. Pre induction a and central lines with inhaled pulmonary vasodilators by face mask

She survived induction so we did the case but she didn’t leave the hospital after being under GETA for 6 hours

 

[anbuitachi]

patients start breathing pretty fast with pure propofol and paralytics once paralytics wear off or is reversed. a trauma patient w low gcs score barely needs much propofol.

or ketamine, paralytic
or etomidate paralytic

all work pretty well in respirations in low doses

 

[sigrhoillusion]

yes, you have to know how to proceed when the inevitable failures happen but that doesn't mean that you awake FOI every scenario. Just be ready in case they make whatever you do fail.

This, this and THIS! You can explain why you feel that prop/sux/tube is best... you want the patient PARALYZED to prevent bucking and increased ICP (which is far worse than the minimal/transient ICP increase that sux may cause. The faster the patient is asleep and paralyzed the faster you can get that tube in, so you can control their airway. And of course you need to mention your backup plan... Difficult airway algorithm. Can't ventilate? Call for help (heck say help is already in the room). Oral airway, nasal trumpet, LMA or whatever backup devices you have. DL... Glidescope... Fiberoptic in room... ENT at bedside... WHATEVER! As long as you can go down that algorithm. In the end they may "back you into" doing a trach, but per the algorithm, that's the final outcome anyways, so although it wasn't the best outcome, it was the ultimate outcome and you got the airway cause you're prepared. And if they ask you if you would do the trach, you say **** NO! That's why I had ENT in the room prepared. Cause if you say you would do it, then you're gonna be forced to explain, and that's just a waste of time...

Of course they will try to make you change your mind... "well why did you put him to sleep?" "would you have done a fiberoptic?" To which you would say, I considered doing that, but THESE are my concerns... X... Y... Z...

And honestly it could be the opposite, where you choose the fiberoptic and all the bad stuff with that happen, and then you'll have to defend on why you didn't just do prop/sux/tube.

It's all a game... a frustratingly, annoying, stressful one... but as long as you don't do something that is a guaranteed kill you should be fine. My resident colleagues had patients die in their orals. Every one passed. Because that's jsut what happened... but whatever they did was the appropriate action.

 

[Mman]

My resident colleagues had patients die in their orals. Every one passed. Because that's jsut what happened... but whatever they did was the appropriate action.

Every stem is going to end in the patient dying, or at least that's the attitude you should have. Don't feel bad or like you did something wrong when they tell you that. I mean occasionally they let the patient live because they got bored with the line of questions and wanted to move on to something else. Your job as the examinee is to at least make it a struggle for the patient to die because you could articulate several backup plans whenever things failed.

 

[sigrhoillusion]

Every stem is going to end in the patient dying, or at least that's the attitude you should have. Don't feel bad or like you did something wrong when they tell you that. I mean occasionally they let the patient live because they got bored with the line of questions and wanted to move on to something else. Your job as the examinee is to at least make it a struggle for the patient to die because you could articulate several backup plans whenever things failed.

I remember one colleague said that a baby died in the C-section cause he stayed with the mother who was bleeding out. Correct answer. Don't abandon your patient. Let the neonatologist deal with the baby, unless the mother is 100% stable. It's traumatzing in the moment during the exam, but if you go to help the baby, you're gonna end up with two dead patients.

 

[dchz]

Topicalizing that bloody mouth full of broken teeth is just a fantasy too.

That's a weird fantasy... i usually think about swedish blondes.. but whatever floats your boat...

 

[nimbus]

That's a weird fantasy... i usually think about swedish blondes.. but whatever floats your boat...

What can I say. I’ve inhaled too much surgical smoke and sevo over the years.

And then there’s always topicalizing the non-bloody airway of a Swedish blonde.......never mind

 

[deleted162650]

And then there’s always topicalizing the non-bloody airway of a Swedish blonde.......never mind

Do you make them gargle?

 

[dchz]

Despite working at a level 2 trauma center where I work is a typical large community hospital. Some forget this is where the vast majority of rubber meets the road.

WHAT? lvl 2 trauma is where the rubber meets the road???! :troll:

Also do all EM people have such ego problems??? dude this is an internet forum, you don't need to flex on us. we know you lift. Come on!

You don’t even need 1.2/kg. I frequently used 0.4-0.6/kg and get great intubating conditions every time.

Also, why don’t you use roc for crash c-sections?

This needs to be stressed. This is a super morbid obese pt. his weight is already inflated by vessel poor fat. I bet 0.4-.6/kg of actual body weight is probably more than 1.2mg/kg of lean body weight. either way, you don't really need 1.2mg/kg of lean body weight to get workable intubating conditions, it's just an oral boards answer.

Finally, i'm REALLY surprised not one person has mentioned a retrograde wire. If you're gonna put them to sleep with a bloody mouth, might as well do a retrograde so you have a wire to guide your ett. If the wire doesn't work, you've already accessed the cric, just vent through that or dilate.

edit:

Without sarcasm, may be a great scenario for retrograde wire! You'll already have angiocath in the trachea to boot, if all else fails

I take that back. It has been mentioned. Wonder why we were so focused on who's peepee is bigger that we didn't pay attention to the real genius. Please redirect the derailed thread towards the legit solution of a retrograde wire.

 

[coffeebythelake]

Despite working at a level 2 trauma center where I work is a typical large community hospital. Some forget this is where the vast majority of rubber meets the road. In the perfect world not needing a surgical airway is ideal for both pt and provider. Good luck overhead paging for ENT or asking them to come in from home, please, while this guy kicks your nurses in the teeth.

But yeah I see difficult airway up front I am calling for help and have done so Everytime.

No wait, I don't know obvious **** and so I'm just going cowboy. Leeeeeroy Jennnnkins!

Come on.

Hey, remember, you were the one who mocked my response to your post about standard trauma airway induction. There are plenty of ER docs that think they could handle it and realize too late they are in over their depth. I could only conclude that you were just another big dummy.