Intubation of major trauma patients

[leviathan]

In the interests of reducing scene time, we are being advised to avoid intubation for major trauma patients. What is everyone's opinion on which factors would suggest we should delay transport to intubate?

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[TerraMedicX]

Ideally? I'd say you shouldn't delay transport to intubate. If you can intubate during extrication or packaging, great! If not, you should probably be intubating en route. Trust me, I KNOW how hard it is to intubate a patient (particularly a trauma patient) in a moving ambulance, but its probably better than delaying transport. Also, BLSing them if you have a short transport time is always an option, just be sure you keep up on suctioning the airway if there's bleeding (which I would say is one of the primary reasons to intubate obtunded trauma patients).
Anther option, if you've got the man power, is to have your partner and the other first responders extricate and package the patient while you set up your lines and intubation supplies in the back of the ambulance. Then, when they roll the patient in, you're waiting with laryngoscope in hand! Hopefully you can have them tubed before anyone even makes it to the driver's seat!

Just my two cents...

Nate.

 

[MadMack]

I suppose it all comes down to how many hands you have on scene and how good the medic on the airway is at intubation. Down here, a major trauma is going to get the rescue, an engine company and an EMS Captain; so thats at least four Paramedics and three EMTs. We can get that guy packaged, tubed and rolling pretty fast. Even with that, if we can't get the tube and an RSI is contraindicated we've got no issue dropping an alternative airway like the king or combi and getting them on their way. That said, in severe cases we generally will RSI severe trauma, but that call is made by the EMS Captain.

You can't go off scene with an unresponsive patient who doesn't have a secured airway, best way to do that is with a tube; if you can't get or the airway is too trashed, go with the king or combi. If its a gross facial or neck trauma, grab the cric kit . The airway needs to be secured; getting someone to the trauma center in 8 minutes doesn't mean much if they're not being effectively ventilated.

-e-

Wow, I managed to get lost in my reply. Conditions requiring delay of transport to intubate: any patient who isn't breathing or a patient who looks like they're going to suffer complete respiratory arrest or at a high risk for aspirating blood, vomit or other fluids into their airway. Also, if a patient has airway obstruction resulting from facial or neck trauma, there's a good chance you might have to cric them. Like I said above, if you get on scene and they're not breathing because of an obstruction, you have to give them a patent airway and get them somewhat stable before you move them.

 

[MedicFL]

There is a push on the national level to take ET's away as a pre-hospital skill and replace it only with the King and other supra-glottic airways... Research is showing we are spending too much time on scene trying to get tubes and it is decreasing survivability.. That being said... I agree if you transport time is small don't play around on scene trying to get a tube, drop a king, lma or other and get moving...

 

[pseudoknot]

The airway needs to be secured; getting someone to the trauma center in 8 minutes doesn't mean much if they're not being effectively ventilated.

Your EMTs (and medics, perhaps) need retraining if they can't effectively BVM a patient for 8 minutes.

 

[BostonEMT]

Your EMTs (and medics, perhaps) need retraining if they can't effectively BVM a patient for 8 minutes.

Agreed.

 

[MadMack]

Your EMTs (and medics, perhaps) need retraining if they can't effectively BVM a patient for 8 minutes.

Maybe you just didn't get what I was saying, you can't effectively ventilate a patient with an obstructed airway. Working the BVM is fine if the airway isn't already obstructed or the patient isn't vomiting. But you can't bag if the patient's having a laryngospasm or has a trashed airway because of facial or throat trauma or is incapable of protecting their own airway.

 

[pseudoknot]

But you can't bag if the patient's having a laryngospasm

True, but pretty rare...

or has a trashed airway because of facial or throat trauma

...true...

or is incapable of protecting their own airway.

...false.

 

[MadMack]

True, but pretty rare...


...true...


...false.

Okay, I can bag the patient who's bleeding or vomiting into their airway, but its not going to be effective, either because I have to suction all the time due to bleeding or vomit or because the patient is aspirating vomitus that's made its way around the adjunct. Vomit, if its not passive or if its in copius amounts, can get around the balloon on the distal end of a combi or king tube, and I'm pretty sure it could get around an LMA too. Squeezing a bag and getting poor compliance is not effective ventilation.

Intubation isn't just about sticking a tube in someone's throat so that they can breath, its about protecting the lower airway.

-e-

Maybe you missed the part of my point where I said that you should drop alternative airways if you're not able to intubate. I'm not saying we should sit around and let every Medic on scene try and drop the tube, but you should give your best guy at least 1 shot if not two at it, if your situation allows for it. But I can't stress it enough, you've got give the patient some kind of patent airway and an ET tube is the best at providing a patent airway and if you can drop it, you should.

-e2-

I don't think we really disagree, I think it might have just been my wording or your interpretation of it. I'm really aggressive with airway management and the system I'm training in have enough hands on scene that we can put 2 people on just airway management. I think we can both agree that mortality and morbidity are substantially reduced if we can prevent the aspiration of fluids, especially vomit into the lungs and that providing the patient with some form of secured airway should be a top priority.

 

[deleted92121]

I know that an ET tube is the gold standard but after two years and 20+ cardiac arrests and numerous other instances where advanced airway management is indicated, i'm all in favor of strictly using the King LT (my services tool of choice). Too often we fool around on scene trying to tube a Pt when the priority should be effective CPR. Obviously i'm not adovcating the removal of intubation but maybe more discretion is needed. If I have a multisystem trauma and need a quick airway, i'll use the King LT.

dxu

 

[leviathan]

I'm not talking about dropping a combitube or other airway isolation device...I'm talking about popping an OPA/NPA in and going to the hospital. If you can ventilate the patient at inspiratory pressures that are not too high in relation to the esophageal opening pressure, then my own opinion is that you do not have to establish any sort of airway beyond BLS maneouvres. But I wonder if there are any indications where you should in fact still intubate, for instance if there are facial or airway burns.

 

[MadMack]

I'm not talking about dropping a combitube or other airway isolation device...I'm talking about popping an OPA/NPA in and going to the hospital. If you can ventilate the patient at inspiratory pressures that are not too high in relation to the esophageal opening pressure, then my own opinion is that you do not have to establish any sort of airway beyond BLS maneouvres. But I wonder if there are any indications where you should in fact still intubate, for instance if there are facial or airway burns.

Thats going to vary from agency to agency depending on your Medical Director. Though I don't think that helps you out too much.

 

[TarHeelEMT]

I'm not a fan of extended scene times, so I'd be very hesitant to intubate on-scene except in limited circumstances like evidence of burns to the airway. Just do it en route.

 

[MedicJ]

If it is an issue fot the medic, they shouldn't intubate but find another way instead. I always do all of my patient care(IVs,intubation..and stuff) while en route.

 

[MedicJ]

Your EMTs (and medics, perhaps) need retraining if they can't effectively BVM a patient for 8 minutes.

Actually, they need training if they can't do it en route. You NEVER hang around on scene to tube a trauma. That's elementary.

 

[firecoins]

Staying on scene to get a tube is not good. Get it enroute. If BLS procedures are getting air in, than just take it and run. Get the combitube or king tube out if you can't tube enroute. Just get transport going.

 

[Sunfire]

You all are my heroes, just needed to tell you.

 

[fiznat]

I guess I haven't been in that situation too many times (who has, really). I'd like to say that I would hang around as little as possible, but then again if I've got an at-risk airway (blood/vomit/otherwise difficult to ventilate), I'll probably take 60 seconds to get a proper airway of some kind. Of course I will make every effort to streamline the process and do it enroute if possible. I understand major trauma patients need an ED as soon as possible, but then again nobody is going to shake my hand for a short on-scene time if the patient is in hypoxic arrest as I roll though the ED doors.

 

[Medic MD]

In my dept, we carry the King LT as an alternative to OTI. I always tell people that if you're busy doing other stuff, or you're trying to get off scene quickly (whether it be a trauma or medical situation), to just drop the King and be done with it. If you've got a patient who's main problem is an airway compromise and you have a few minutes to really focus on it, then you can play around with the intubation. Our medics were resistant to that line of thinking at first, but over time they've come to appreciate how much more efficiently they can treat the rest of the patient's issues if the airway only takes a few seconds to control.

 

[nsx]

incapable of protecting their own airway.
...false.

So patients can ALWAYS protect their own airways? Care to explain this?

 

[leviathan]

So patients can ALWAYS protect their own airways? Care to explain this?

He was referring to the ability to ventilate when they can't protect their own airway.

 

[nsx]

Thanks, that was unclear.

 

[pianoman511]

I'm not talking about dropping a combitube or other airway isolation device...I'm talking about popping an OPA/NPA in and going to the hospital. If you can ventilate the patient at inspiratory pressures that are not too high in relation to the esophageal opening pressure, then my own opinion is that you do not have to establish any sort of airway beyond BLS maneouvres. But I wonder if there are any indications where you should in fact still intubate, for instance if there are facial or airway burns.

I would definitely support intubation in that case since you are looking at a high probability of airway compromise within a short period of time such as facial burns or even certain types of facial traumas. Otherwise load and go is the name of the game.

I think sometimes we as EMS providers don't necessarily do things because they need to be done, but sometimes just because they can be done.