Trauma from last week

[napman]

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23 y/m healthy Stabbed on trachea, called to ED for airway managment. Patient maintaining Spo2 95% on mask 02, consious and air leaking out of tracheal site, coughing blood but not too bad. no other injuries

How do you manage the airway?

 

[Jay K]

with an ETT

 

[Depakote]

I'll bite...

For this injury, it would be a level 1 trauma at my institution, meaning I would have the surgery team in the room as I'm managing the airway (emergent trach available). Let them know that may be required.

Generous pre-oxygenation. Proceed with RSI (assume full stomach), propofol and sux, DL with cricoid assuming the injury to the neck is not going to prevent effective application. Put the tube in.

Edit: plan on advancing the tube below the level of injury (confirm with absence of air coming through wound and fiberoptic).

 

[anes]

Dexmedetomidine, Awake retrograde wire through the stab wound

 

[dhb]

Wait for ENT then induce and intubate as usual if for some weid reason you can't get the tube in the ENT should be able to slide a tube in easily.

 

[dhb]

Dexmedetomidine, Awake retrograde wire through the stab wound

 

[Noyac]

Dexmedetomidine, Awake retrograde wire through the stab wound

I would not. I have not been very impressed with this ****. In a revved up trauma it is not very likely to work well alone. You will have to add an adjunct.

In my book: dexmedetomidine is crap!!!

Now everyone can start firing away telling me how full of **** I am. But I believe it is an expensive form of very weak propofol. Should be reserved for ICU sedation or as a backup sedative added to something that works.

 

[pgg]

I'm not a big fan of dexmedetomidine but it does need time to work. Not a great choice for trauma and this airway. Ketamine, OTOH ...

 

[deleted9493]

Dexmedetomidine will allow you to do to someone what they might tolerate during a nap. Otherwise, you're going to need to add an opioid if you want legitimate procedural/ICU sedation.

 

[Noyac]

Dexmedetomidine will allow you to do to someone what they might tolerate during a nap. Otherwise, you're going to need to add an opioid if you want legitimate procedural/ICU sedation.

Exactly, this pt would be too revved up for dex to even make an impact even if you give it time.

Now, possibly if you added some versed and a Remi infusion to it then you might get somewhere. But I'm still a fan of the other approaches here.

 

[anes]

Exactly, this pt would be too revved up for dex to even make an impact even if you give it time.

Now, possibly if you added some versed and a Remi infusion to it then you might get somewhere. But I'm still a fan of the other approaches here.

Our institutition is BIG on dexmedetomidine. Dilute a 200mcg vial in a 20 cc syringe to 10mcg/ml. Bolus 10-20 mcg at a time. Just make sure the pulse stays above 50 or so, you can easily get 200mcg in within 5-10 minutes (with NO hypotension). I've placed Cordis central lines and arterial lines with no local on people "induced" with dexmedetomidine. They sit perfectly still and tolerate it. You guys probably aren't using it in the doses we do. We don't get hypotension with dex (unless we add opioids to the mix).

 

[Noyac]

Our institutition is BIG on dexmedetomidine. Dilute a 200mcg vial in a 20 cc syringe to 10mcg/ml. Bolus 10-20 mcg at a time. Just make sure the pulse stays above 50 or so, you can easily get 200mcg in within 5-10 minutes (with NO hypotension). I've placed Cordis central lines and arterial lines with no local on people "induced" with dexmedetomidine. They sit perfectly still and tolerate it. You guys probably aren't using it in the doses we do. We don't get hypotension with dex (unless we add opioids to the mix).

BS! I've used it in every way. The way you describe works most times but not EVERY time. And I don't want to ever be in a position where I need something to work like I expect it to and then find out it doesn't.

I gave a guy with and oral tumor who was suffocating from obstruction right in front of my eyes 200mcg over about 5 minutes. I got nothing from him. He would not let anyone come close to his airway. I quickly had to change course. Also had it fail on a lady with an unstable high cervical fracture.

I'm not worried about hypotension or bradycardia cuz I can deal with that. I need them to get sedated enough for me to assault them. Placing a central line is not an assault in my book. Awake intubations are viewed by pts as an assault at times even when done as smooth as silk. When pts are frightened and/or extremely anxious this stuff isn't a good choice. They are too revved up.

So you can continue to use it all you want. You may or may not ever see this occur. But for me, it's no longer an option.

 

[anes]

BS! I've used it in every way. The way you describe works most times but not EVERY time. And I don't want to ever be in a position where I need something to work like I expect it to and then find out it doesn't.

I gave a guy with and oral tumor who was suffocating from obstruction right in front of my eyes 200mcg over about 5 minutes. I got nothing from him. He would not let anyone come close to his airway. I quickly had to change course. Also had it fail on a lady with an unstable high cervical fracture.

I'm not worried about hypotension or bradycardia cuz I can deal with that. I need them to get sedated enough for me to assault them. Placing a central line is not an assault in my book. Awake intubations are viewed by pts as an assault at times even when done as smooth as silk. When pts are frightened and/or extremely anxious this stuff isn't a good choice. They are too revved up.

So you can continue to use it all you want. You may or may not ever see this occur. But for me, it's no longer an option.

That's your experience with the drug. Ours is different. We've used 800-1000mcg prior to induction for certain subsets of patients (people ramped up on meth). Never had an issue. In my book, it's a wonder drug (if used appropriately).

 

[BLADEMDA]

Easy case:

No time for ENT as they would need 30 minutes to arrive in a private practice setting.

General Surgery ready to trach patient in E.R.

Glidescope in ER (they have one)

Proceed with RSI (this guy is 23 years old so Propofol or Ketamine plus SUX)

Place the ETT past the level of injury and even mainstem the ETT if needed. A 23 year old will survive and leave the hospital with Saturations in the 80s for an extended period of time. Hence, don't give up on him; the patient can tolerate low saturations while you solve his problem.

 

[Noyac]

That's your experience with the drug. Ours is different. We've used 800-1000mcg prior to induction for certain subsets of patients (people ramped up on meth). Never had an issue. In my book, it's a wonder drug (if used appropriately).

If you can say this then I say you haven't used it enough.

So why would you mix up 800-1000mcg and give it prior to induction when you can just use propofol? I don't doubt that if you give enough eventually it will work but WHY? Do you see what I'm saying here? I'm not telling you it isn't a good drug at times. I'm just telling you my experiences and why I don't like the stuff. You can tell me all the times you've used it all day, you won't change my opinion on the crap.

I have seen many people come from fancy residencies using this stuff in all sorts of ways. After a year or so in PP they seem to be using it much much less.

 

[BuzzPhreed]

0.4 mg scopalamine. There's a reason they call it the 'mind eraser'. You may need an adjunct but you can do whatever you want after that. They ain't gonna remember ****.

 

[anes]

If you can say this then I say you haven't used it enough.

So why would you mix up 800-1000mcg and give it prior to induction when you can just use propofol? I don't doubt that if you give enough eventually it will work but WHY? Do you see what I'm saying here? I'm not telling you it isn't a good drug at times. I'm just telling you my experiences and why I don't like the stuff. You can tell me all the times you've used it all day, you won't change my opinion on the crap.

I have seen many people come from fancy residencies using this stuff in all sorts of ways. After a year or so in PP they seem to be using it much much less.

I'm not necessarily disagreeing with you. I'm just saying that I've seen it used in INSANELY large doses with complete hemodynamic stability. It's not a drug that I use for every patient. But some of our best anesthesiologists use it almost exclusively (in lieu of opioids), with great results.

 

[BLADEMDA]

I'm not necessarily disagreeing with you. I'm just saying that I've seen it used in INSANELY large doses with complete hemodynamic stability. It's not a drug that I use for every patient. But some of our best anesthesiologists use it almost exclusively (in lieu of opioids), with great results.

Great drug for awake intubations and for the "wild man" patients who you know will come out of a GA ready to beat the RN to death. I like it for extubating patients with PTSD or ETOH who have had their jaws wired shut as well.

Great for sedating sleep Apnea patients/morbidly obese in the ICU/Step Down unit by augmenting low dose Benzos and Opioids.

Great for Neurosurgical cases where Monitoring is required of the SSEPs, etc.

POOR DRUG FOR USE IN TRAUMA- K.I.S.S. is the mantra for trauma whenever possible.

 

[anes]

Great drug for awake intubations and for the "wild man" patients who you know will come out of a GA ready to beat the RN to death. I like it for extubating patients with PTSD or ETOH who have had their jaws wired shut as well.

Great for sedating sleep Apnea patients/morbidly obese in the ICU/Step Down unit by augmenting low dose Benzos and Opioids.

Great for Neurosurgical cases where Monitoring is required of the SSEPs, etc.

POOR DRUG FOR USE IN TRAUMA- K.I.S.S. in the mantra for trauma whenever possible.

I completely agree with everything you have to say. However, that being said. I've seen it used in ruptured aortic aneurysms with patients SBP in the 60's. I've seen it used in massive traumas. It's not the mainstream, but it can be (and has been) safely used in these situations.

 

[BLADEMDA]

 

[BLADEMDA]

I completely agree with everything you have to say. However, that being said. I've seen it used in ruptured aortic aneurysms with patients SBP in the 60's. I've seen it used in massive traumas. It's not the mainstream, but it can be (and has been) safely used in these situations.

Sure, an Alpha 2 agonist can have many uses but I prefer to defer to SIMPLE whenever the **** hits the fan.


There are no absolute contraindications to the use of dexmedetomidine. Limiting its usefulness is the caution that the drug cannot be bolused due to concerns about peripheral α2-receptor stimulation with resulting hypotension and bradycardia


http://forums.studentdoctor.net/threads/precedex-bolus-no-loading-dose.691950/
(go ahead and read the thread)

 

[BuzzPhreed]

Great for Neurosurgical cases where Monitoring is required of the SSEPs, etc.

I disagree on this point.

Dex is a totally unnecessary and costly adjunct that often does nothing more than delay the patients wake-up at the end of the case. People using it (ahem... CRNAs) don't know when to turn it off. I've seen all manner of costly and unnecessary drugs used in these cases. You just run propofol and fentanyl infusion and you can get the job done at a fraction of the cost to the hospital. When I do a solo IONM case my patients don't move. And when I flip them back over the tube is ready to come out. With CRNAs I've "directed" (that's a stretch) in the past used all manner of stupid-ass and expensive drugs, it wasn't uncommon to flip and then sit there for 30-40 minutes waiting for the patient to wake up.

 

[Noyac]

I completely agree with everything you have to say. However, that being said. I've seen it used in ruptured aortic aneurysms with patients SBP in the 60's. I've seen it used in massive traumas. It's not the mainstream, but it can be (and has been) safely used in these situations.

This ^^^ is crazy. Never do this in my book. Yes we can get away with stupid **** but why?

But then again there are more than a few ways to skin a cat!

 

[anes]

Sure, an Alpha 2 agonist can have many uses but I prefer to defer to SIMPLE whenever the **** hits the fan.


There are no absolute contraindications to the use of dexmedetomidine. Limiting its usefulness is the caution that the drug cannot be bolused due to concerns about peripheral α2-receptor stimulation with resulting hypotension and bradycardia


http://forums.studentdoctor.net/threads/precedex-bolus-no-loading-dose.691950/
(go ahead and read the thread)

Okay, I've read the thread. And again, several of our attendings will bolus dexmed in hypotensive patients for its pressor effect. Dexmedetomidine will RELIABLY cause hypertension (albeit transiently..ie 20-30 mins) when bolused. Like I said in one of the previous posts, just keep an eye on the pulse. If they're bradycardic to begin with (like the patient in the thread you referred), then it's stupid to use it. Also, the patient was on an ACEI. Not the proper patient for dexmedetomidine. From my experience, the pulse rate is the determining factor in how to use dexmedetomidine , not the blood pressure.

 

[BLADEMDA]

I disagree on this point.

Dex is a totally unnecessary and costly adjunct that often does nothing more than delay the patients wake-up at the end of the case. People using it (ahem... CRNAs) don't know when to turn it off. I've seen all manner of costly and unnecessary drugs used in these cases. You just run propofol and fentanyl infusion and you can get the job done at a fraction of the cost to the hospital. When I do a solo IONM case my patients don't move. And when I flip them back over the tube is ready to come out. With CRNAs I've "directed" (that's a stretch) in the past used all manner of stupid-ass and expensive drugs, it wasn't uncommon to flip and then sit there for 30-40 minutes waiting for the patient to wake up.

Precedex is going generic soon. Prices will fall dramatically over the next 18 months. I've used Precedex in Spine cases lasting over 8 hours. These patients are extubated in PACU several hours after the case is completed. The cost of these cases routinely exceed $30,000. If I feel inclined to use some Precedex for a $30K operation whose indication itself is questionable I'm going to do it. Of course, I've used Propofol mixed with Ketamine plus Sufenta as well with excellent results.




Under the terms of the settlement agreement, Sandoz may launch generic version of Precedex on 26 December 2014, unless certain conditions relating to launch, if triggered, lead to an earlier Sandoz market entry date.

 

[anes]

This ^^^ is crazy. Never do this in my book. Yes we can get away with stupid **** but why?

But then again there are more than a few ways to skin a cat!

Agreed. It's not something I personally do. But I know of people who ROUTINELY will do that. It's only stupid if it doesn't work.

I remember once early in residency we were doing a spine. Patient was on low dose sevo, low dose remifentanil, and phenylephrine infusions (for hypotension). One particular attending walks into the room and says "why are you bothering with all of this???". He turns off the remi, turns off the phenylephrine, and begins bolusing dexmed. Blood pressure improves, no more pressors for the rest of the case (3-4 hours). Just intermittent boluses of dexmedetomidine if blood pressure was starting to come down and patient wasn't bradycardic. At the end of the case the patient woke up promptly and was extubated.

Like you said, there are more than a few ways to skin a cat.

 

[BLADEMDA]

Okay, I've read the thread. And again, several of our attendings will bolus dexmed in hypotensive patients for its pressor effect. Dexmedetomidine will RELIABLY cause hypertension (albeit transiently..ie 20-30 mins) when bolused. Like I said in one of the previous posts, just keep an eye on the pulse. If they're bradycardic to begin with (like the patient in the thread you referred), then it's stupid to use it. Also, the patient was on an ACEI. Not the proper patient for dexmedetomidine. From my experience, the pulse rate is the determining factor in how to use dexmedetomidine , not the blood pressure.

http://www.drugs.com/pro/precedex.html

What is the cost of Precedex? Why choose it over low dose Ketamine plus a little Midazolam which costs pennies?

 

[anes]

Precedex is going generic soon. Prices will fall dramatically over the next 18 months. I've used Precedex in Spine cases lasting over 8 hours. These patients are extubated in PACU several hours after the case is completed. The cost of these cases routinely exceed $30,000. If I feel inclined to use some Precedex for a $30K operation whose indication itself is questionable I'm going to do it. Of course, I've used Propofol mixed with Ketamine plus Sufenta as well with excellent results.




Under the terms of the settlement agreement, Sandoz may launch generic version of Precedex on 26 December 2014, unless certain conditions relating to launch, if triggered, lead to an earlier Sandoz market entry date.

Nice. Hopefully this will allow it to become a mainstream anesthetic drug.

 

[anes]

http://www.drugs.com/pro/precedex.html

What is the cost of Precedex? Why choose it over low dose Ketamine plus a little Midazolam which costs pennies?

I agree. Dexmed is an expensive drug. Ketamine and midaz is likely much more economical. I'm just arguing the point that dexmedetomidine is a great drug in appropriate patients.

[ Addendum]
I can't find our expense report at this time. But I recall that of ALL drugs used in our department, Dexmedetomidine cost something like 150 thousand dollars more than our next most costly drug. Again, our department is HUGE on dexmedetomidine.

 

[Noyac]

Nice. Hopefully this will allow it to become a mainstream anesthetic drug.

I doubt it will become mainstream except with the crna's.

 

[anes]

I doubt it will become mainstream except with the crna's.

Low blow man, low blow

 

[OB1🤙]

I think Dex is fine for the occasional awake FOI and extubating the excitable as Blade describes, but for procedural sedation, I think it's absolute crap. Expensive crap too, for now.

There's a poker term called "fancy play syndrome." FPS. Some people just can't help themselves, and have to make elaborate, over the top plays just to appear expert. In reality the expert play is often the simplest one.

Same thing for anesthesia. The people I work with that use Dex for procedural sedation have anesthesia FPS. And every time I go take over a case where they're running dex instead of propofol, the proceduralist will say something along the lines of "thank god, can you please actually sedate the patient now?"

 

[anes]

I think Dex is fine for the occasional awake FOI and extubating the excitable as Blade describes, but for procedural sedation, I think it's absolute crap. Expensive crap too, for now.

There's a poker term called "fancy play syndrome." FPS. Some people just can't help themselves, and have to make elaborate, over the top plays just to appear expert. In reality the expert play is often the simplest one.

Same thing for anesthesia. The people I work with that use Dex for procedural sedation have anesthesia FPS. And every time I go take over a case where they're running dex instead of propofol, the proceduralist will say something along the lines of "thank god, can you please actually sedate the patient now?"

What's your proceduralist's and your defintion of sedation? Typically surgeons who want MAC are asking for GA without an endotracheal tube. Dex will get you into that moderate sedation range (what a MAC truly should be), without going to deep sedation/GA.

 

[Noyac]

What's your proceduralist's and your defintion of sedation? Typically surgeons who want MAC are asking for GA without an endotracheal tube. Dex will get you into that moderate sedation range (what a MAC truly should be), without going to deep sedation/GA.

So will propofol and much cheaper and easier.

 

[Noyac]

I think Dex is fine for the occasional awake FOI and extubating the excitable as Blade describes, but for procedural sedation, I think it's absolute crap. Expensive crap too, for now.

There's a poker term called "fancy play syndrome." FPS. Some people just can't help themselves, and have to make elaborate, over the top plays just to appear expert. In reality the expert play is often the simplest one.

Same thing for anesthesia. The people I work with that use Dex for procedural sedation have anesthesia FPS. And every time I go take over a case where they're running dex instead of propofol, the proceduralist will say something along the lines of "thank god, can you please actually sedate the patient now?"

Love it, FPS!
The other problem with those with FPS is their lack of awareness.

 

[anes]

So will propofol and much cheaper and easier.

I agree. I'd likely use propofol too. But when surgeons complain that a patient isn't sedated, it's because they want a GA without a tube. They don't know the true definitions of sedation.

 

[OB1🤙]

I don't understand why people, when handed with a nearly perfect drug in propofol, have to complicate things.

I like meds that go away quickly when I turn them off. That achieve their target effect quickly. That reliably produce amnesia. That leave the patient feeling good afterward. That are predictable in their action. Fast, predictable offset. Propofol gives all that.

I DON'T like meds that linger when I turn them off. That take multiple minutes to achieve their effect. That cause variable, significant hemodynamic changes (i.e. bradycardia). Maybe some hypertension, maybe hypotension, who knows? That may not result in amnesia. That can leave the patient too uncomfortable for the procedure at hand, without a way to predict who will or won't be "adequately" sedated.

Just give me a stick of propofol, have the proceduralist give some local, and KISS.

 

[OB1🤙]

I agree. I'd likely use propofol too. But when surgeons complain that a patient isn't sedated, it's because they want a GA without a tube. They don't know the true definitions of sedation.

I agree in principle but not in practice. Many surgeons/proceduralists in fact do expect what amounts to GA with an unprotected airway. And you know what? If the patient is appropriate, I'll give it to them. All might not agree, but if the patient is not an aspiration risk or a possible difficult airway, I'll hang out in that grey area between "deep sedation" and "GA."

If I don't feel that's appropriate, I'll communicate that and do what's right.

 

[anes]

I agree in principle but not in practice. Many surgeons/proceduralists in fact do expect what amounts to GA with an unprotected airway. And you know what? If the patient is appropriate, I'll give it to them. All might not agree, but if the patient is not an aspiration risk or a possible difficult airway, I'll hang out in that grey area between "deep sedation" and "GA."

If I don't feel that's appropriate, I'll communicate that and do what's right.

I have no problem doing a GA with unprotected airway either. I was just pointing out semantics. When you said that the proceduralist asked you to actually sedate the patient, they pretty much meant GA. They think ETT/LMA = GA and no ETT/LMA = sedation.

 

[GhostTree]

Re. Precedex. I've used it for a lot of stuff. I don't like it for MAC because it takes too long to kick in and it's a pain to titrate. For 12 hour cranis its nice for propofol sparing, run a low background rate 0.2 mcg/kg/h.

Trying to get back on track...

The classic teaching I've recieved for laryngeal/tracheal trauma is they are supposed to get awake trachs or at least a flexible nasal laryngoscopy prior to intubation to assess for mucosal/tracheal disruption. I realize this is different than whats done in the real world where consultants aren't in house all night.

The pt above is holding his own, so there is some time, can move him towards the OR but no rush to put the tube in. What level is the trauma at? Above thyroid cartilage/below?

If he tolerates it, I am comfortable with the pediatric fiberoptic and would have a look prior to induction for something that the tube is going to get hung up on or a false lumen. If he's combative then standard trauma RSI with somebody who can trach standing by.

How'd the case go?

There is a published algorithm, referenced below.

Schaefer, S.D. The treatment of acute external laryngeal injuries. Arch Otolaryng HNS. Vol 117:
35-39. January 1991

Here is a good pdf also:
http://www.utmb.edu/otoref/Grnds/Laryng-trauma-070328/laryng-trauma-slides-070328.pdf

 

[napman]

Re. Precedex. I've used it for a lot of stuff. I don't like it for MAC because it takes too long to kick in and it's a pain to titrate. For 12 hour cranis its nice for propofol sparing, run a low background rate 0.2 mcg/kg/h.

Trying to get back on track...

The classic teaching I've recieved for laryngeal/tracheal trauma is they are supposed to get awake trachs or at least a flexible nasal laryngoscopy prior to intubation to assess for mucosal/tracheal disruption. I realize this is different than whats done in the real world where consultants aren't in house all night.

The pt above is holding his own, so there is some time, can move him towards the OR but no rush to put the tube in. What level is the trauma at? Above thyroid cartilage/below?

If he tolerates it, I am comfortable with the pediatric fiberoptic and would have a look prior to induction for something that the tube is going to get hung up on or a false lumen. If he's combative then standard trauma RSI with somebody who can trach standing by.

How'd the case go?

There is a published algorithm, referenced below.

Schaefer, S.D. The treatment of acute external laryngeal injuries. Arch Otolaryng HNS. Vol 117:
35-39. January 1991

Here is a good pdf also:
http://www.utmb.edu/otoref/Grnds/Laryng-trauma-070328/laryng-trauma-slides-070328.pdf

 

[napman]

Thanks Ghost Tree for bringing the case back on track
I agree with every bit that you posted
This is how we managed the case
1, patient was oxygenating well and so there was no reason to hurry so we moved the patient to OR for intubation
2, ours is a level 1 trauma center and had a trauma surgeon in the room to do trach
3, Direct laryngoscopy or glidescope intubation could disrupt the tracheal continuty and can potentially lead to airway disaster this can be fatal if Tracheal injury is more distal as it could push the distal segment of trachea into mediastenum ( In these cases one has to be ready to put patient on fem fem bypass). Fortunately in our case the injury was just below the cricoid cartilage
4, Paralysing the patient could be desasterous too, as it might be difficult to ventilate the patient because of big airleak from trachea
5, We tought we would do fiberoptic intubation but patient was too uncoperative and the blood in the airway was causing difficulty
6, We performed a tracheostomy below the injury under inhilational induction with a small suppliment of ketamine 30mg
7, My plan B ( always have a plan B) was to insert tracheostomy tube trough the injury in case patient becomes unstable, but this would hinder with the subsiquent repair of tracheal injury

 

[napman]

Off note I am not a great fan of precedex for AFOI.
Precedex = amnesia, analgesia, maintains spontanious ventilation, SLOW ACTING, DIFFICULT TO TITRATE, DID NOT USE REGULARLY SO LESS COMFORTABLE AND COSTLY
ketamine = amnesia, analgesia, maintains respiration and ventilation , FASTACTING, COMFORTABLE WITH REGULAR USE AND CHEEP

I like the protocol from precedex.com for AFOI but I just replace ketamine for precedex in the Protocol 😉
http://www.precedex.com/wp-content/uploads/2010/02/AFOI-Protocol.pdf