retrograde intubations?

[nev]

How often are retrogade intubations done on head injury patients? I read about it on :

http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ija/vol10n2/retrograde.xml

Thanks
Nev

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[VentdependenT]

How often are retrogade intubations done on head injury patients? I read about it on :

http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ija/vol10n2/retrograde.xml

Thanks
Nev

Uhh...pretty rare in this country.

Most everyone has a fiberoptic scope somewhere. Retrograde should be a bail out technique for an urgent airway situation where ventilation is getting tougher and you can't see crap and you don't have an LMA and never considered/had a fiberoptic scope. You have to do it FAST because if you diddle in the aforementioned scenerio your next step is to slash a hole and stick a tube through the cricothyroid membrane.

In the posted case they could have just put an oral ETT over the wire. They can futz with wiring the mandible later, head bleed comes first. I ain't putting a nasal ETT in a head injury.

 

[nev]

Uhh...pretty rare in this country.

Most everyone has a fiberoptic scope somewhere. Retrograde should be a bail out technique for an urgent airway situation where ventilation is getting tougher and you can't see crap and you don't have an LMA and never considered/had a fiberoptic scope. You have to do it FAST because if you diddle in the aforementioned scenerio your next step is to slash a hole and stick a tube through the cricothyroid membrane.

In the posted case they could have just put an oral ETT over the wire. They can futz with wiring the mandible later, head bleed comes first. I ain't putting a nasal ETT in a head injury.

Thats what I couldnt figure out, why would they place a nasal ETT in a head injury....
But I've heard (and please correct me if I'm wrong) if there is a suspected neck injury, the standard is to use nasal intubation rather than oral intubation. Can you educate me on this?
Thanks
Nev

 

[Ferdie]

Ive heard (and seen) that with a mandible fx you use a nasal tube because of limited mouth opening and the surgeon needing to work in the mouth. with an emergent head injury though... ?? I agree with vent - worry about the jaw later.

What I'm wondering about in that paper - what are they doing with her eyes? if they're open under that gauze she's gonna get corneal abrasion...

 

[VentdependenT]

I can only assume they were using the retrograde as some sort of crappy guarantee that the tube wasn't going to get shoved into some occult basilar skull fracture. If they figure the tube is going down the "rail" of the catheter, then they can presume it didn't ram into some grey matter. Screw that. Gimme a fiberoptic anyday.

Head Trauma = Unstable Neck. PERIOD. If the patient has altered mental status then why bother "clearing" the c-spine anyways. Can you clear a C-Spine on X-Ray findings only? I don't think so my man. Guess who can't read C-Spine films for $hit. ME. Thats who. So forget it.

Unstable Neck = BAD IDEA to MANIPULATE. I don't wanna do anything to make this patient a quad or paraplegic. So use "in-line" or better yet, use a fiberoptic!

To get a good view of the larynx and thus glottis you gotta do some neck manipulating. Its gonna happen. Just look in any textbook at the 3 axis of the airway.

If you have someone holding the head onto the table there is less chance you can manipulate the head. The books also say you need a THIRD person to stabilize the neck. Bottom line, if in-line stabilization is done correctly you are gonna have a crap view with direct laryngoscopy.

If you're cranking like a MO-FO then you're begging for trouble. Mask the patient or put in an LMA until you get a scope. Nobody dies from lack of intubation. Just from lack of ventilation (Thats from Dr. Ganzouri's mouth. Rush's airway guru).

 

[gasnewby]

But I've heard (and please correct me if I'm wrong) if there is a suspected neck injury, the standard is to use nasal intubation rather than oral intubation. Can you educate me on this?

in my limited experience: my understanding is that oral intubation with a scope usually requires atlanto-occipital extension, to bring the cords in sight. If you have C1 or C2 injury, you want to avoid this. Manual in-line stabilization can decrease this disruption of the c-spine.

blind nasotracheal intubation won't disrupt the C-spine, and therefore is preferred. you want to avoid nasotracheal intubation in midface or basilar skull fractures.

there's always orotracheal fiberoptic but in a trauma pt you may not have time (you mght be in the trauma bay, the pt is crashing)

so that's why nasal intubation with unstable neck injuries.

 

[gasnewby]

Nobody dies from lack of intubation. Just from lack of ventilation (Thats from Dr. Ganzouri's mouth. Rush's airway guru).

also just read that in "how to survive in anesthesia." from the website you listed with the free texts! thanks

 

[nev]

in my limited experience: my understanding is that oral intubation with a scope usually requires atlanto-occipital extension, to bring the cords in sight. If you have C1 or C2 injury, you want to avoid this. Manual in-line stabilization can decrease this disruption of the c-spine.

blind nasotracheal intubation won't disrupt the C-spine, and therefore is preferred. you want to avoid nasotracheal intubation in midface or basilar skull fractures.

there's always orotracheal fiberoptic but in a trauma pt you may not have time (you mght be in the trauma bay, the pt is crashing)

so that's why nasal intubation with unstable neck injuries.

That makes sense! Thanks for the explanation