LMA after trauma

[Sonny Crocket]

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Took over a case the other night. 8 year old. Radius fracture that happened at noon. Kid brought to the OR at 7pm. ASA 1. My partner put in. LMA. I get called to wake the kid up and she starts vomiting/aspirating. Turns blue. Sats 15. Suction and try to ventilate but can’t get any air in. We are doing compressions as the heart rate was now 35 and dropping. I intubate. And she comes back pretty fast to sats over 95 on 100 % O2. Put in an OG tube. 150 ml of brownish pink gastric fluid comes out.

We take her to the ICU for a bronch and her sats begin to do much better after she coughed in the tube. Decide to extubate her with sats of 96% at 0.4 FiO2. She was fine the next morning. But damn.

I asked the parents if she had any pain before the anesthesia. They said yes. And she was a bit nauseous but hungry.

LMA in this case? Seems like she should have gotten a tube. What would you all typically do for airway here. Thanks.

 

[nimbus]

Yes tube for exactly this reason.

We had a trauma patient who was npo>24hrs vomit into an lma during an ankle orif.

 

[deleted697535]

If tube rsi?
Rsi on a kid isn't fun for anyone! Most parents & some theatre nurses don't understand and think you're attacking them for no reason.

Interested to hear thoughts on lma/tube/rsi

 

[facted]

If the kid is npo, lma is fine. I've had vomiting with an LMA twice on overnight NPO patients... It happens. But, if you're on call, by yourself, I always go ett.

 

[DrAmir0078]

Took over a case the other night. 8 year old. Radius fracture that happened at noon. Kid brought to the OR at 7pm. ASA 1. My partner put in. LMA. I get called to wake the kid up and she starts vomiting/aspirating. Turns blue. Sats 15. Suction and try to ventilate but can’t get any air in. We are doing compressions as the heart rate was now 35 and dropping. I intubate. And she comes back pretty fast to sats over 95 on 100 % O2. Put in an OG tube. 150 ml of brownish pink gastric fluid comes out.

We take her to the ICU for a bronch and her sats begin to do much better after she coughed in the tube. Decide to extubate her with sats of 96% at 0.4 FiO2. She was fine the next morning. But damn.

I asked the parents if she had any pain before the anesthesia. They said yes. And she was a bit nauseous but hungry.

LMA in this case? Seems like she should have gotten a tube. What would you all typically do for airway here. Thanks.

Thanks for sharing Dr. Soony Crocket, such a brave work !

May I comment, and thanks for reading me!

For learning purposes : Did you give muscle relaxants for your RSI? What was your steps? I have witnessed many in my practice for RSI for children without muscle relaxants as long as you parameters help you, despite the fact of agitation (probably in your case). How long the operation was? From afternoon to 7 PM (been NPO) , was she truly NPO? beside the color of the vomit (questionable? isn't it?)

Why did you ask her parents for pain before anesthesia (stress factor)? was she in the ER? or hadn't have any pain control medicine by protocol? for a kid who can't tolerate pain, she will of course get her parents attention at the bedside, and was her Nurse monitoring the pain scale every one hour after they admitted her Or wasn't admitted to the ER prior, or for short period?

"she was a bit nauseous and hungry", this sentence describes lots of things, nauseous (narcotic effect, no antiemetic with it?), even though with LMA (I am talking loudly with myself), and you came for extubation, but did you get the full report regarding her med given (premed, induction, maintenance), have you checked for antiemetic in her chart? (excuse me and forgive me, I am just asking to get the full picture, and if I were in your shoe, I wouldn't have time for all these, but we are learning)

Thanks a lot

 

[anbuitachi]

agree that LMA is fine is patient was appropriately NPO. bad stuff happen, including vomiting. had a patient vomit today during the case even though he was NPO, and we hadnt given any anesthetic yet

 

[somedumbDO]

I have done MANY, of these through my career Lma all the way. Rare to aspirate but thats why we go to school/training for so damn long. Non particulate aspiration in Healthy kids also never causes increased morbidity.

 

[Urzuz]

I’ve had one too many trauma patients puke in otherwise simple cases though they were more than fully fasted by NPO guidelines. My threshold to sink a tube in is way lower than for elective cases...just isn’t worth the anxiety if having a patient potentially aspirate.

Most parents & some theatre nurses don't understand and think you're attacking them for no reason.

Granted I don’t do peds but IDGAF what anyone thinks. My sole responsibility is to the patient and no one else.

 

[deleted171991]

Took over a case the other night. 8 year old. Radius fracture that happened at noon. Kid brought to the OR at 7pm. ASA 1. My partner put in. LMA. I get called to wake the kid up and she starts vomiting/aspirating. Turns blue. Sats 15. Suction and try to ventilate but can’t get any air in. We are doing compressions as the heart rate was now 35 and dropping. I intubate. And she comes back pretty fast to sats over 95 on 100 % O2. Put in an OG tube. 150 ml of brownish pink gastric fluid comes out.

We take her to the ICU for a bronch and her sats begin to do much better after she coughed in the tube. Decide to extubate her with sats of 96% at 0.4 FiO2. She was fine the next morning. But damn.

I asked the parents if she had any pain before the anesthesia. They said yes. And she was a bit nauseous but hungry.

LMA in this case? Seems like she should have gotten a tube. What would you all typically do for airway here. Thanks.

Textbook tube and RSI (and this is coming from a LMA fan). NPO is measured BEFORE the trauma, not after. So the kid should have been NPO for 8 hours at noon, which probably wasn't true. Pain and pain meds decrease/stop stomach evacuation. Plus kids are so easy intubations that it's very tough to defend the choice of an LMA versus RSI/ETT.

Even when using an LMA in an elective perfectly NPO adult case, if one is wondering about bilious stomach contents (e.g. stressed or obese patient), one should always use a Supreme LMA (or similar), suction the stomach, and give some metoclopramide.

 

[T-burglar]

Very low threshold to just intubate these cases. Lost airways are still one of the top offenders in the closed claims project.

Side note: i also have a low threshold to intubate young patients, including children. Old sick people have garbage airway reflexes and don't cough or gag on LMA's as much in my opinion. Young people even after a whole vial of propofol can immediately vomit after placing the LMA because they have such robust airway reflexes. If the case is going to be long enough that intubating won't slow the whole day down, and the patient is young, i frequently just paralyze and intubate because i believe it's truly safer.

 

[Justice4all]

Took over a case the other night. 8 year old. Radius fracture that happened at noon. Kid brought to the OR at 7pm. ASA 1. My partner put in. LMA. I get called to wake the kid up and she starts vomiting/aspirating. Turns blue. Sats 15. Suction and try to ventilate but can’t get any air in. We are doing compressions as the heart rate was now 35 and dropping. I intubate. And she comes back pretty fast to sats over 95 on 100 % O2. Put in an OG tube. 150 ml of brownish pink gastric fluid comes out.

We take her to the ICU for a bronch and her sats begin to do much better after she coughed in the tube. Decide to extubate her with sats of 96% at 0.4 FiO2. She was fine the next morning. But damn.

I asked the parents if she had any pain before the anesthesia. They said yes. And she was a bit nauseous but hungry.

LMA in this case? Seems like she should have gotten a tube. What would you all typically do for airway here. Thanks.

How long was the case? Had similar experience taking over case 4 hrs orthobcssein,extubate and just emesis all over. I usually is >2 hrs for LMA

 

[PainDrain]

No offense to your partner but it’s kinda lazy and sloppy to use an LMA in this case. What’s the benefit or upside of an LMA vs tube? Avoiding muscle relaxant? That’s a pretty weak excuse before a jury. Delayed gastric emptying and ileus due to trauma and pain are well documented physiologic conditions. I tube all my patients with any traumatic injury until >24 hours post event and if they have any other factors such as severe pain, nausea, DM, ect then they always get tubed.

I once had a young healthy woman come in for a cysto stent at 8pm. Last intake was a large coffee with cream at 6am just before the pain started in her back and she was in the ED at 8am. Urologist said it would be a quick ten minute case. I discussed the plan with the woman and was going to use an LMA but on questioning she reported nausea just prior to the pain starting at around 630am and something didn’t feel right about using an LMA. I tubed her and threw an OG down and got back a liter of coffee and gastric juice. Her gut clearly stopped moving almost 12 hours prior to surgery.

 

[vector2]

Trauma pts puke as if it's their job, even with 8 hr NPO (stress response on GI motility plus many get a healthy dose of fentanyl down in the ED). I RSI, suck out with OG, and awake extubate about 99.9% of the time.

 

[BeatriZZ]

I would have gone with an LMA in this case too.
Just out of curiosity, did you wake the kid up with the LMA in place? Might a deep removal of LMA helped?

For those who say "low threshold to intubate for trauma" is there any flexibility in what makes a trauma? A high speed crash vs old lady falling in her yard, vs kid falls off swing . Are they all traumas?

 

[kmurp]

Similar thing (but not as bad) happened to me when I used an LMA in a three year old for a spica cast around10pm a couple years ago. Go with the ett

 

[Monty Python]

To paraphrase others (with whom I fully agree): "I have NEVER regretted putting in an ETT. In contrast, there have been a few times I wish I had."

 

[Twiggidy]

1) Decreased gastric emptying and increase gastric secretion from a stress response
2) Likely pain meds in the ER to slow gastric emptying
3) Potential PONV from the anesthetic itself

RSI with intubation

 

[vector2]

I would have gone with an LMA in this case too.
Just out of curiosity, did you wake the kid up with the LMA in place? Might a deep removal of LMA helped?

For those who say "low threshold to intubate for trauma" is there any flexibility in what makes a trauma? A high speed crash vs old lady falling in her yard, vs kid falls off swing . Are they all traumas?

When I say significant trauma I'm talking about someone who has a significant vascular, solid organ, CNS, or long bone injury. I may also include those found down with unexplained mechanism, pts with prolonged exposure, and prolonged auto extrications. I wouldn't necessarily tube every lac repair or digit fixation who's been NPO for 8+ hrs.

 

[Twiggidy]

When I say significant trauma I'm talking about someone who has a significant vascular, solid organ, CNS, or long bone injury. I may also include those found down with unexplained mechanism, pts with prolonged exposure, and prolonged auto extrications. I wouldn't necessarily tube every lac repair or digit fixation who's been NPO for 8+ hrs.

Agree. I think the approach to "hurting, stressed out kid with stressed out parents coming from a stressful environment" when evaluating the situation. NPO for 8 hours at home in your own bed is different than NPO for hours in an ER. That's from the hip. I have no studies to prove that.

 

[fakin' the funk]

There is an adage I love; I think I got it from SDN.

"If you look outside and it's dark, put a tube in"

 

[vector2]

There is an adage I love; I think I got it from SDN.

"If you look outside and it's dark, put a tube in"

Same goes for extubating ICU pts after hours. If I had a nickel for the number of times I've had to do an urgent tube in the unit at 2am cause the pgy2 and the RT extubated based on parameters without understanding the gestalt of the situation.

 

[Twiggidy]

There is an adage I love; I think I got it from SDN.

"If you look outside and it's dark, put a tube in"

We may be boxin' it out in another thread, but I'm 100 with you on this. If you even look at the larygoscope then just intubate

 

[deleted59964]

Not sure what you gain in kids by using an lma - you put the tube without muscle relaxants anyway.

 

[IlDestriero]

I will selectively use an LMA in some of these kids, but it’s >90% ETT, especially if the fracture was recent, ~8 hours.
I also look at the MAR for what was given and when. One dose of morphine in the ED 12 hours ago is different from q4 overnight.
#PropSuxTube4Life
I think that’s going to be the license plate on my super car. PSTZZZ.
Keep an eye out for it.

 

[jthedestroyr]

I’ve had one too many trauma patients puke in otherwise simple cases though they were more than fully fasted by NPO guidelines. My threshold to sink a tube in is way lower than for elective cases...just isn’t worth the anxiety if having a patient potentially aspirate.



Granted I don’t do peds but IDGAF what anyone thinks. My sole responsibility is to the patient and no one else.

Mid training with my more cowboy attendingd, LMA trauma >12-18hr, now at the end and when discussing things with an attending low threshold for tube.

We always talk about fight or flight and how it can cause delayed in gastric emptying. Majority of our attendings within that 24hr period their are getting tube.

I would now be on the ETT trauma pt in 24hr window, and also potentiallu next day while at the end of training of my training.

One attending said he would often drop ngt and suction, that alone gave him enough to confirm ETT was right course as he suctioned a ton out.

I also look it at through could you get away with placing an LMA and yes, the vast majority of time, yes.

Although I dont think the risk is worth the benefit of the 5-10min total time you might add with save ETT and extubation.

Def getting "PrpSuc2b" too bad thats 8 characters and i need 7. 🙂

 

[Mman]

agree that LMA is fine is patient was appropriately NPO. bad stuff happen, including vomiting. had a patient vomit today during the case even though he was NPO, and we hadnt given any anesthetic yet

i go tube every time on these patients. Trauma patients are considered full stomach to me. 7 hours post trauma and probably had some narcotics in the ED? LMA is a big no go. There is literally no real benefit to it and potential risk of aspiration which ain't worth it to me. If it's my kid, just the tube in. If they have a hoarse voice for the next couple hours I'll get over it. If they aspirate and spend several days in the ICU, I will not take it well.

I know some people are fans of LMAs. I use them on appropriate patients, but trauma is a big no no IMHO.

 

[anbuitachi]

i go tube every time on these patients. Trauma patients are considered full stomach to me. 7 hours post trauma and probably had some narcotics in the ED? LMA is a big no go. There is literally no real benefit to it and potential risk of aspiration which ain't worth it to me. If it's my kid, just the tube in. If they have a hoarse voice for the next couple hours I'll get over it. If they aspirate and spend several days in the ICU, I will not take it well.

I know some people are fans of LMAs. I use them on appropriate patients, but trauma is a big no no IMHO.

so if a old man comes in with a fractured hip going for repair, been 20 hours since he last drank or ate. you would go straight to tube? no spinal?

 

[B-Bone]

so if a old man comes in with a fractured hip going for repair, been 20 hours since he last drank or ate. you would go straight to tube? no spinal?

different story. with SAB you're not (supposed to be) obliterating airway reflexes.

 

[anbuitachi]

different story. with SAB you're not (supposed to be) obliterating airway reflexes.

oh sorry i meant to type more but forgot. i meant adding on sedation on top of spinal like what many places do.

 

[Mman]

so if a old man comes in with a fractured hip going for repair, been 20 hours since he last drank or ate. you would go straight to tube? no spinal?

I said no LMA, I didn't say no spinal. Cases can be done without general anesthesia. But if I'm going for GA, I'm going with the ETT.

 

[anbuitachi]

I said no LMA, I didn't say no spinal. Cases can be done without general anesthesia. But if I'm going for GA, I'm going with the ETT.

i mean with a spinal would you give sedation? if during the case w spinal alone and patient gets agitated would you just convert to GA

 

[deleted171991]

i mean with a spinal would you give sedation? if during the case w spinal alone and patient gets agitated would you just convert to GA

Yes and yes. In the former case, you make sure you maintain good airway reflexes (people sleep with full stomachs without aspirating every night). In the latter, you do RSI.

 

[Noyac]

I tend to lean towards ETT in these cases. The length of surgery and prior pain meds always come into account but my philosophy is, if I think about putting a tube in then I’m putting a tube in. With that being said I have also done short trauma case that are hours out from the event with an LMA. But I am very cautious.

 

[Sonny Crocket]

Okay. Why would we not intubate these patients? I’m hearing a lot of “that patient should get a tube, but sometimes I will do it with LMA.” I realize things aren’t black and white all of the time and there in lies the art of anesthesia. But what are we really saving by here by dropping an LMA instead of a tube?