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Capnography’s Role in Traumatic Airway Intubation

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Does your system have specific protocols on managing ventilation of head-injured patients? Photo Courtesy Christopher T. Stephens, MD


Greetings colleagues,

To begin this last article in the three-part series on managing the traumatic airway, let’s review briefly what has been done at this point. Either you have successfully or unsuccessfully intubated your trauma patient, have gone for a supraglottic airway device or have chosen to hand ventilate the patient during transport with an oral/nasal airway and bag-valve mask (BVM).

The only other option is a surgical airway. We will briefly review these techniques but I warn that you MUST practice these on suitable mannequins or cadavers in a laboratory setting. Another alternative is to purchase some pig tracheas or similar and practice your surgical skills on these.

The point is that practice allows you to appreciate the anatomy and understand the skill. Most EMS protocols use a needle cricothyroidotomy technique in which the cricothyroid membrane is identified between the thyroid and cricoid cartilages. (I encourage you to identify this important landmark on yourself, then your family and friends, followed by practicing on your patients as part of your physical exam.) Once you’re comfortable finding this landmark on many people, it will come second nature in an emergency. Be certain that you’re familiar with the needle cric device/supplies that your system uses; once the needle is in place, either a wire is placed through it to allow for a trochar tracheostomy tube to be placed over the wire or the large bore catheter remains in place for ventilating with a BVM.

Again, however your service trains and uses this technique, be sure to cover it regularly with training. An alternate technique is the open surgical cricothyroidotomy, where a scalpel is used to make a vertical incision over the cricothyroid membrane to identify the membrane. Once identified, make a horizontal stab with the scalpel, followed by flipping the scalpel and placing the handle end in the incision and twisting 90 degrees to enlarge the opening.

At this point, there’s likely a fair amount of blood to deal with so make certain that your partner has suction and 4X4s to blot away the blood. Now you can do one of two things. You can go straight for a smaller endotracheal tube (ETT), such as a 6.0 or 6.5, and place it in the surgical opening. Or you can place a bougie intubating stylet into the opening so that you have something in the airway to guide your ETT over and into the trachea. This is a nice technique to use so that you don’t lose your surgical opening while trying to place the ETT into the hole. Try this on the cadaver, animal tracheas or appropriate mannequin. There are many ways to accomplish a surgical airway and these are some of the ways that we have found useful for teaching our local medics.

So now you have an airway to manage en route to the hospital. We will assume that you have an intubated patient from the case introduced in the first article of the series, “Managing the Traumatic Airway.” Once the tube is secured and you are ready for transport, be certain to re-assess the tube placement once packaged in the ambulance or aircraft. I still find many right mainstem intubations once delivered to me at the trauma center.

Once you’ve determined that the patient has bilateral breath sounds and equal chest expansion, take a quick look at your capnography monitor and pulse oximeter. Are you happy with the waveforms and numbers? These numbers can guide your therapy and airway management throughout transport. Is the patient on 100% FiO2? Be certain that oxygen is reaching the patient! Do you need to suction out the ETT? Make sure that you are able to adequately exchange gases via the ETT for your patient throughout transport.

This is where capnography is so valuable. If your patient still has a blood pressure and pulses, you should pay very close attention to your capnograph waveform. It will let you know if there’s an obstruction between your patient and the end of the ETT by the slope of the waveform. In addition, it will give you insight into your patient’s perfusion status. If a nice, normal waveform is present, then your patient is perfusing adequately enough for cellular respiration to take place.

Note: Your patient may still be in the early stages of shock, and you should always be vigilant for signs of continued blood loss. If your patient is in profound shock, in extremis or arresting, then your capnograph waveform will be distorted with low numbers. Again, this monitor is important for you to use and understand for your intubated patient management in the field. Please take the time to read about, practice and understand waveform capnography. Spend some time in the emergency department looking at ventilated patients who have capnography waveforms on the monitor. This will help you begin to understand the concepts of using this important monitor for sick patients.

If your patient has signs of a traumatic brain injury, what you do with your ventilation management becomes VERY important. You must maintain your end¬-tidal carbon dioxide numbers between 30–35 mmHG to prevent either hypo- or hyperventilation with subsequent cerebral perfusion abnormalities. Please read up on this and discuss with your medical director. Only patients showing signs of tentorial herniation should be mildly hyperventilated in the field, avoiding end tidals lower than 28 mmHg!

Poll Question: Does your system have specific protocols on managing ventilation of head-injured patients?

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If your system still isn’t using continuous capnography on your monitor, it will be important for you to at least monitor continuous pulse oximetry and end-tidal using a colorometric easy cap device during transport to ensure correct tube placement. We all need to aim for zero misplaced endotracheal tubes in the field. If there is ANY doubt, take the tube out! This is a very important concept. It’s much better to assist an airway with a BVM and oral/nasal airway (or a supraglottic device) than have a misplaced tube on arrival at the trauma center!

I hope that these articles have given you some tools to use in the field when faced with a trauma airway. Remember to read, discuss with colleagues and medical directors, and practice airway maneuvers whenever possible! A great place to start is by attending a cadaver airway lab in your area or sign up for one at a national conference. I wish each of you the best of luck in your EMS career and please feel free to contact me anytime with questions or concerns. I am here for all of you field providers! Work hard and do the very best for your patients.

Part I: Managing the Traumatic Airway
Part II: Trauma Airway Intubation Is a Team Effort

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Christopher T. Stephens, MD, MS, NREMT-P

Completed BS in Biology from Loyola Marymount University. Completed paramedic school at Houston Community College and trained with the Houston Fire Department. Paramedic in Houston, Texas and Galveston, Texas. University of Houston College of Pharmacy (MS in Pharmacology), University of Texas Medical Branch School of Medicine – (MD, Anesthesiology Residency) Trauma Anesthesiology Fellowship – University of Maryland Shock Trauma Center Currently Assistant Professor of Anesthesiology at University of Maryland School of Medicine and Attending Trauma Anesthesiologist - R Adams Cowley Shock Trauma Center, Baltimore, MD. Director of Education, Division of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center. Medical Director, Maryland Fire&Rescue Institute. Instructor for Maryland State Police Aviation Command; Flight Physician, Tactical Physician

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Managing the Traumatic Airway

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When considering airway management techniques for trauma patients, EMS providers should consider their resources.

Greetings colleagues,

Airway management seems to be at the forefront of “hot EMS topics” these days. I’ve had the pleasure of discussing this topic amongst the brightest and most experienced in our field. These discussions certainly stimulate our sympathetic nervous system and cause arguments, debates, tachycardia and for some, even hypertensive crisis!

So what has come of these debates and arguments? One thing is for certain: There are many critics out there discussing airway management in the field and what is and isn’t appropriate. Many of these folks believe that airway management by EMS providers should be limited to a bag-valve mask (BVM) and oral airway or a supraglottic device.

As a former paramedic turned anesthesiologist, I think that we shouldn’t limit ourselves to certain techniques. Rather, we should educate, train and arm our field providers with the very best that airway tools have to offer. In this next series of articles, we’re going to explore the concept of managing the traumatic airway.

I’ll begin with a case study so you can envision what’s going on with a patient you’ve likely cared for in the past or will definitely care for in the future as you progress through your EMS career. As you read the case, consider how you would assess the patient. Also picture when, during the primary and secondary survey, you might pause to treat the patient and what that treatment would include.

We will progress through the cycle of managing the trauma airway over the next several articles. In addition, you will see some polls along the way that we will ask use to determine your thought process and hopefully stimulate some good discussion and opinions. So let’s get started.

You’re called to the scene of a 30-year-old male involved in a high-speed motorcycle crash. On arrival, witnesses state that the patient was just seizing but has stopped. You take a quick look at the patient and see a male (approximately 110 kilograms) lying on the street supine without a helmet. When you reach the patient’s side, he is breathing with gurgling respirations. There are no obvious external signs of bleeding or trauma. The patient is moaning with a GCS of 9. What will your initial management steps consist of?

Would you intubate this patient now?

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Most of us have cared for this exact patient. Did you intubate them on scene? Scoop and run? Intubate during transport? Assist respirations with just a BVM and possibly oral or nasal airways? I’m sure that we would get a lot of conflicting answers on this one! But why? Haven’t we all taken basic trauma life support or an equivalent course as EMTs and medics? Is there really an airway protocol that we can follow for all trauma patients? What does your system use for airway/rapid sequence intubation protocols? Do you have a quality assurance/improvement process for all intubations or airway techniques provided in the field? Are all medics in your system allowed to intubate, or is this practiced only by veterans and supervisors?

Does your medical director take an active role in airway education and recurrent training?

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Now, back to our case! Let’s say you have elected not to intubate at this point. What are your priorities with this patient? This is a difficult question to answer because you have several priorities at this point. They include providing and maintaining a patent airway, packaging the patient and transporting to a designated trauma center. Seems simple enough but there are many things to consider.

Let’s start with the big question: How can we clear and maintain a patent airway in this patient? First off, call for help! The first thing I do at the trauma center is make sure I have plenty of sets of hands around to assist me with managing a traumatic airway that comes in. You should do the same thing. Hopefully you at least have one partner with you on the scene as first responders. Have your partner set up the suction and take out the airway equipment while you open the patient’s airway with a jaw thrust maneuver, which, by the way, takes a lot of practice to gain proficiency. Hopefully more help is on the way at this point, especially if you plan to intubate this patient.

Simple jaw thrust in trauma patients can usually get the airway open enough to exchange air if the patient is still breathing spontaneously. There are two good techniques to do at this point that are fast and effective. First off, make sure that you suction the patient’s oropharynx extensively, and try to get back to the posterior oropharynx where lots of pooled secretions and blood like to hang out. Next, attempt to place an oropharyngeal airway and see if the patient will tolerate it. If they gag or bite down, go with a nasopharyngeal airway that is much less stimulating and quite safe to use.

If the patient has multiple facial fractures or has evidence of a basilar skull fracture, I like to place a nasopharyngeal airway orally; it’s soft and less stimulating than an oral airway. This is a nice technique that most semi-conscious patients will tolerate. Now you can use your clinical judgment to determine if the airway placement is allowing enough gas exchange to place a non-rebreather face mask on the patient, or if you need to assist the ventilations with a bag-valve-mask (BVM). Assisting ventilations with a BVM is a lost art with all of our technology these days, including intubation and non-invasive techniques, such as continuous positive airway pressure and bilevel positive airway pressure. When I’m teaching veteran EMTs and paramedics in the operating room, I notice how many of them struggle to hand-ventilate patients with a BVM. This, too, is a very difficult technique to master as prehospital providers. We can all mask a mannequin without a problem, but patients come in all shapes and sizes and many with facial hair and blood/vomit to boot! All of this makes it more challenging to handle the traumatic airway.

Returning to our case, has your help arrived yet? If so, you have a much higher chance of success managing this challenging airway. If you’re struggling to assist your patient’s ventilations, you need to do a two-handed technique, grasping the mandible using c-clamps with both hands to effectively “pull” the patient’s face into the face mask and have your partner squeeze the bag just enough to get the chest to rise. Remember that aggressive “bagging” of patients can be bad for many reasons, including gastric insufflation, vomiting, hypocapnea and altered cerebral perfusion, and worsening of pneumothoraces if present.

Now, if you’re successful at maintaining a patent airway at this point, you have the option to continue doing this while packaging the patient and transporting. If you still are unable to ventilate your patient, then you should consider intubation or use of alternate airways, such as a supraglottic device. Intubation attempts will be covered in the next article so stay tuned! If your patient is unconscious and breathing, you should be able to maintain the airway throughout transport. If indicated, use of a supraglottic airway is a good option if your protocol allows you to do so.

Do you think that use of supraglottic airways should be limited to EMT-intermediates and paramedics?

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Most EMS systems carry a Combitube, Easytube or King airway device. Some carry a laryngeal mask airway. Whichever device is at your disposal, it’s imperative that you train with it regularly to be comfortable using it. Put the device in mannequin heads, simulators and, better yet, in cardiac arrest patients on operating room training days! Many protocols are moving away from intubation in cardiac arrest patients, so this is a good population to practice using both a BVM with an oral airway, or a supraglottic airway if your protocol allows.

So now your patient has a patent airway, is packaged and is off to the trauma center! Don’t forget to monitor your patient carefully while en route and reassess your patient’s airway and assisted ventilations. We will cover more of how to approach the intubated trauma patient in the next two articles.

Which of the following closest describes the type of recurrent airway training you participate in?

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–Dr. Stephens

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Christopher T. Stephens, MD, MS, NREMT-P

Completed BS in Biology from Loyola Marymount University. Completed paramedic school at Houston Community College and trained with the Houston Fire Department. Paramedic in Houston, Texas and Galveston, Texas. University of Houston College of Pharmacy (MS in Pharmacology), University of Texas Medical Branch School of Medicine – (MD, Anesthesiology Residency) Trauma Anesthesiology Fellowship – University of Maryland Shock Trauma Center Currently Assistant Professor of Anesthesiology at University of Maryland School of Medicine and Attending Trauma Anesthesiologist - R Adams Cowley Shock Trauma Center, Baltimore, MD. Director of Education, Division of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center. Medical Director, Maryland Fire&Rescue Institute. Instructor for Maryland State Police Aviation Command; Flight Physician, Tactical Physician

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Should EMS Intubate?

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The Intubation Debate

Intubation is one of many tools in the EMS provider’s airway management toolbox. (Photo A.J. Heightman)

Did you make it to the 2011 EMS Today Conference & Exposition? What a great experience! I had the honor to moderate a panel discussion titled “Should We Intubate?” Four great panelists and about 200 folks in the audience resulted in lively debates and a challenge to be great EMS providers. As the moderator, I really didn’t get the chance to stand on my soapbox, so I’ll take that opportunity now.

Why does the thought of taking endotracheal intubation out of the hands of paramedics invoke such a visceral response? I didn’t whine when the EOA left. No heartburn when I put MAST back on the shelf. What is it about an ET tube? Because for decades, it’s all we had.

Endotracheal intubation via direct laryngoscopy has been used since the late 1800s.1 Numerous BLS airways were developed during World War II. Extraglottic airways appeared in our airway kits in the early 1980s.2 Flexible and rigid fiber optic laryngoscopes made their way into operating rooms in the early 1990s. It wasn’t until the turn of the century that laryngoscopy changed for EMS with the development of video laryngoscopes.

For about 110 years, direct laryngoscopy has been THE method to place an endotracheal tube. In EMS, we’ve relied on this method for about 40 years (depending on how you write the timeline). We reinforce the dogma that the endotracheal tube is the airway of choice by referring to all other devices as “rescue airways.”

Should we intubate?

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So I ask the question: Should we intubate? When it’s appropriate, absolutely. The endotracheal tube is a wonderful tool that has been successfully placed and managed for decades outside of the operating room. It continues to be used successfully by EMS professionals on a daily basis.

I’ve read a ream of studies professing the evils of prehospital endotracheal intubation. While there are descriptions of hypoxemia and trauma during endotracheal tube placement, the vast majority of the described evils come from what is done after the tube is placed; hyperventilation, hypocarbia, unrecognized misplaced tubes and reduction of blood return to central circulation.

Wait a minute; can’t those same evils occur with extraglottic airway devices or even a bag-valve mask? Why yes, they can. You can also add gastric distention, vomiting and reduced tidal volume to the BVM list. We have to do a great job managing any airway device.

As technology has progressed, we’ve been given fantastic new tools to help us do a better job. We’ve all seen studies that show the effectiveness of end-tidal carbon dioxide monitoring to verify tube placement and appropriately ventilate. Since 2003, studies from hospital and EMS settings have published results of the use of video laryngoscopy; shorter intubation times than direct laryngoscopy, high first pass success rates, and Grade I–II views with poor neck mobility.3-5 The gum elastic bougie, (and its plastic alternatives) is such a simple and incredibly effective tool, it should be mandatory in every airway kit. I’m quite sure you can list several other items. Proven technology must be embraced as the standard of care for our patients.

Are you allowed to intubate?

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So, I ask: Should you intubate? It’s entirely up to you. Are you willing to use the tool that best fits the patient, the conditions and your abilities? Are you willing to do what it takes to be a professional airway manager?

I’ll leave you with the challenge leveled at the end of the panel discussion. All of us must drive to excel as medical professionals, to refuse to accept mediocrity as a level of care and to simply do the very best for our patients.

I’m excited and humbled at the opportunity to provide information that will help all of us become better airway managers. I look forward to hearing from you.

Until next time, take care and be safe.

Charlie


References

  1. Bailey B (1996). “Laryngoscopy and laryngoscopes–who’s first?: The forefathers/four fathers of laryngology.” The Laryngoscope. 106(8):939–943, 1996.
  2. Donmichael TA. US Patent 4497318, Feb. 5, 1985.
  3. Agro F, Barzoi G, Montecchia F. “Tracheal intubation using a Macintosh laryngoscope or a GlideScope in 15 patients with cervical spine immobilization.” Br J Anaesth. 90(5):705–706, 2003.
  4. Nouruzi-Sedeh P, Schumann M, Groeben H. “Laryngoscopy via Macintosh blade versus GlideScope: success rate and time for endotracheal intubation in untrained medical personnel.” Anesthesiology. 110(1):32–37, 2009.
  5. Cormack RS & Lehane J. “Difficult tracheal intubation in obstetrics.” Anaesthesia 39(11):1105–1111, 1984.

Glossary

EOA = Esophageal obturator airway

MAST = medical anti-shock trousers

BVM = bag-valve mask

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Charlie Eisele, BS, NREMT-P

Charlie Eisele, BS, NREMT-P has been active in EMS since 1975. After 22 years of service, he recently retired from the Maryland State Police, Aviation Command where he served as a State Trooper, flight paramedic, instructor, flight operations supervisor, director of training, and tactical paramedic. For over 25 years, Charlie has been a collegiate level educator and curriculum developer. He has served numerous programs including the University of Maryland, and its R Adams Cowley Shock Trauma Center, College of Southern Maryland, Grand Canyon National Park, Marine Corps Base Quantico, Virginia Department of Fire Programs, and Maryland State Police. Charlie is the co-developer of the internationally delivered advanced airway program at the R Adams Cowley Shock Trauma Center. He is the Airway and Cadaver Lab Course manager for the University of Maryland critical care emergency medical transport program. He’s the co-developer of the EMS Today airway and cadaver lab program. Charlie has been recruited nationally to provide airway management curriculum and education for a variety of private, federal, state and local organization. Charlie is an Eagle Scout and a published author. He serves on the Journal of Emergency Medical Services Editorial Board and is a member of the program board for the EMS Today Conference & Exposition.

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