EMS Airway Clinic

Have a checklist for intubation of trauma patients, and assign your assisting colleagues a role to ensure success on the first attempt. Photo Courtesy Christopher T. Stephens, MD, MS, NREMPT-P

As the second part of this three-part series on the traumatic airway, we will now focus on intubating the trauma patient case that was introduced in the previous article, “Managing the Traumatic Airway.”

(Missed the first part of this three-part series? Click here to read Part I.)

Why is intubation of trauma patients being scrutinized across the nation, you ask? As an instructor of trauma airway management, I can assure you that it isn’t because you as field providers don’t know how to effectively intubate! In short, there are studies (whether sound or not) that are suggesting worse outcomes in patients who are intubated in the field.

So what, you ask? Sicker patients are sicker and need an endotracheal tube, right? Everyone agrees that there are some patients out there who just need to be intubated. Obstructed airways, vomit, blood and poor anatomy make traumatic airways challenging to manage in the field. In fact, these airways can be challenging in the trauma centers as well. Many patients simply can’t be oxygenated and ventilated effectively with a supraglottic airway—a or bag-valve mask (BVM) and oral airway for that matter, right? These are the cases that get our sympathetic nervous system going and put us in that position where “critical decision making” becomes extremely important.

The Intubation
So you have decided to intubate this trauma patient—who is 110 kg and looks like a small linebacker for your local professional football team. Here are some questions for you:

1. What help do you have?
2. What environment are you in (i.e., street, ditch or ambulance)?
3. Are you able to effectively oxygenate/ventilate this patient with basic tools as discussed previously?
4. Will you plan to do a blind nasal intubation or drug-facilitated oral intubation (rapid sequence intubation/RSI)?

These are some of the questions that must be thought about ahead of time, and a plan must have already been made so that the EMS team can be successful.

I like to teach EMTs and paramedics to think like pilots. Have a checklist and start at the top and work your way down. You will never miss anything this way. Assign your assisting colleagues a role to get the patient intubated successfully on the first attempt.

Ideally, you should have four EMS providers to intubate a trauma patient. The team leader is the one intubating. At this point, the team leader should be assisting the patient’s airway and pre-oxygenating with 100% oxygen via a BVM. Pre-oxygenation is VERY important. It will buy you more time to get that tube in the right hole. You should do this for blind nasal intubations as well. Trauma patients tend to desaturate at an alarming rate because most have been hypoventilating to this point due to pain, semiconsciousness, pneumo- or hemothoraces, etc. And remember, all trauma patients are full stomachs. Some have already aspirated prior to your arrival, which also works against you. All of these conditions make your intubation attempts less forgiving, and you must be prepared to act quickly if the patient becomes challenging and/or desaturates.

Once you have pre-oxygenated your patient for at least 60 seconds, attempt your intubation. If it’s a blind nasal intubation, you may have more time because the patient is still breathing. You also have the luxury to just assist them to the hospital if it fails. If you’re planning a drug-facilitated intubation, then all bets are off. Once you have decided to push drugs, you had better have your skills, colleagues and equipment ready for action.

During pre-oxygenation of the patient, the team leader must assign roles. The second medic will draw up and be responsible for pushing drugs, then handing supplies to the intubating team leader (i.e., endotracheal tube, suction, bougie, another blade, video laryngoscope, etc).

The third provider is responsible for removing the front of the cervical collar (yes, the front of the c-collar MUST be removed PRIOR to laryngoscopy) and holding cricoid pressure correctly. Note: Cricoid pressure needs to be learned correctly and practiced. Some protocols have done away with cricoid pressure; I feel that it’s still an important tool to be used in traumatic airways with full stomachs.

The fourth provider will hold in-line manual stabilization of the cervical spine throughout the intubation. When the team leader states that they’re ready, the second medic should push the appropriate drugs and appropriate doses. This is a decision that has to be made correctly and using expert paramedic critical decision techniques. Understanding the physiology/pharmacology of rapid sequence intubation (RSI) is as important as the skill itself. How sick is the patient? What are their vital signs prior to pushing drugs? Do they have pulses (central or peripheral?) Are they in shock? Do they have signs of a head injury?

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These are questions that must be answered during a rapid primary and secondary survey while preparing to intubate the patient. Is the patient combative due to shock, head injury, alcohol/drugs, or all of the above? If able, try and get a baseline set of vital signs prior to pushing drugs. This will help guide your drug choice and dosing. Drug selection and dosing is an EXTREMELY important topic for trauma patients and should be discussed at length with your medical director and training supervisors. Anesthetic agents are powerful and can make patients worse if used incorrectly.

There are many issues to think about when dealing with a traumatic airway, and hopefully you will have some time to work through a good plan of action so if things start to go wrong, your checklist and plan will be there for you to fall back on.

Once the patient has been relaxed with succinylcholine or an alternative paralytic agent, the team leader should perform their laryngoscopy with the blade they’re most comfortable using. Remember, your first shot is always your best shot! I teach trauma airways with a Macintosh 3 blade for most adults because I find it easier for medics and trainees to keep the tongue out of the way with the wider Macintosh blade.

As an alternative, you may also use a video laryngoscope, such as the Glidescope Ranger, for your intubation. The Glidescope Ranger has been useful for managing traumatic airways. It allows everyone assisting to see what the team leader is seeing, which can therefore help them anticipate what the team leader may need to get the job done, such as suction, bougie or a smaller endotracheal tube. As with any piece of airway equipment, there’s a learning curve with video laryngoscopy. You must practice it on mannequins, cadavers in airway labs and on live patients in the operating room, if possible.

I want to say a few words about the intubating stylet or bougie. Since I manage traumatic airways for a living, in my opinion, the bougie is the single most important piece of intubating equipment. This little flexible styllete has been my savior during many a difficult airway in the trauma center. That being said, a bougie and video laryngoscope is a VERY effective combination of equipment to intubate the trauma patient. I encourage each of you to grab an airway mannequin, a bougie and a demo Glidescope Ranger and practice this technique. This is going to be the wave of the future for airway management, especially in the uncontrolled field environment, where help can be lacking.

If you can’t see a view of the vocal cords or confirm the tube to be in the esophagus, you must go to Plan B. This may include changing blades, switching to a video laryngoscope, or perhaps allowing another, more-experienced airway operator to assist. Do NOT forget to attempt oxygenating and ventilating the patient with an oral/nasal airway and BVM between intubation attempts. Do your best to get the patient as close to 100% oxygen saturation as possible prior to your next intubation attempt.

If the second attempt fails, consider either placing a supraglottic airway device or simply performing BVM assisted ventilations with an oral/nasal airway throughout transport. Remember, this technique sometimes requires two rescuers to perform adequately. If you can’t intubate and can’t ventilate the patient, you must proceed to a surgical airway—either a needle or open surgical cricothyroidotomy. We will discuss this in the next article.

The Confirmation
Once the endotracheal tube is placed, it’s important for tube confirmation to be established. This can be done in many ways. Chest rise and bilateral breath sounds are important but can sometimes be misleading. If the patient is warm and still perfusing, tube fogging should be noted, as well as end-tidal carbon dioxide (ETCO2). Either an easy cap (calorimetric) ETCO2 or continuous waveform capnography should be employed as the gold standard for tube confirmation. Continuous waveform capnography ideally should be used by every medic unit that’s intubating patients in the field. This will be discussed further in the next article.

Once the correct tube location is confirmed, be certain that the tube is secured well, the cervical collar is replaced, and the tube location is reassessed after securing because tubes sometimes migrate into the right mainstem bronchus when being secured. At this point, you’re still not out of the woods! Now that you have successfully intubated the patient, you must worry about their physiology while transporting. This is a point that many field providers dismiss when managing airways in the field and a topic that may prevent medical directors from removing intubation from protocols around the nation. So there you have it—four providers ideally to get the task done correctly!

Stay tuned for the final article in this series of managing the traumatic airway.

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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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By Graham E. Snyder, MD

I spent the first four months of my emergency medicine residency slowly but steadily working myself into a nervous frenzy. Not because of the stress of being a young doctor, not because of the impending doom I faced from paying back my student loan debt, and not even because I was a southern boy thrust into the big city (NYC). But because, as ashamed as I am to admit it, I couldn’t intubate. However, after spending four long weeks in the operating room (OR), that was no longer the case. Actively involved with EMS, I decided to write this article to assist you in intubating and avoiding the stress I faced my first week of airway exploration.

What the anesthesiologists will tell you is: Open the mouth. If you’re using the Macintosh (curved) blade, sweep the tongue out of the way, stick the tip of the blade into the vallecula, lift the structures up and toward the far corner of the room, visualize the cords and stick the tube between the cords (see

If you're using the Macintosh (curved) blade, sweep the tongue out of the way, stick the tip of the blade into the vallecula, lift the structures up and toward the far corner of the room, visualize the cords and stick the tube between the cords. Illustration JEMS

the Figure).

What you’ll actually do is: Open the mouth, stick the blade in, lift up and not see a darn thing except a bunch of useless, confusing, pink tissue. In my case, I thought,Maybe I should lift harder. So you’ll strain and strain and strain, giving some poor patient a whopping soar throat and not end up any closer to the cords.

The anesthesiologist will also say, ?All right, come out.’ He’ll take one peek and snake it down there while you stand around like an idiot (and the surgeon might even say something like, ?What an idiot!’).

It’s incredibly frustrating because once you look at the interior of a patient’s airway, you don’t know whether to go deeper, go shallower, go left or right, lift more, lift less, or apply cricoid pressure. As a beginner, you don’t have a clue because you can’t see anything but pink mush.

So remember this first intubation pearl: Your initial goal isn’t to find the cords. It’s to find the epiglottis. If you insert the blade extremely slowly into the mouth (about 1 cm at a time), the progression will be tongue, tongue, tongue, tongue, tongue, tip of the epiglottis.

This intentionally slow blade insertion technique gives you the best opportunity to slip the blade into the vallecula, because if you insert the blade too rapidly and pass the vallecula by even just 1.0Ï1.5 cm (which I did around a dozen times), you’ll be looking into the esophagus and not the trachea!

If all you see is pink mush that’s not tongue, pull back. Everyone knows what the tongue looks like, and the epiglottis is obviously the epiglottis. So, the only mushy thing in there is the esophagus (and technically the posterior pharynx, but if you’re deep enough to no longer be seeing the tongue, yet shallow enough that you can still see the posterior pharynx, the epiglottis will also be in view in all but the most anatomically challenging intubations).

If you pass the epiglottis, you’re looking at either the trachea — which is obvious because it has vocal cords that are white and is a big open cave (since the tracheal rings don’t collapse) — or you’ve snuck the tip of the blade into the esophagus. And keep in mind that as soon as you lift up the esophagus, it opens up as big as the trachea and looks a lot like a trachea without vocal cords.

Getting the Pesky Tongue out of the Way
When using a Miller (straight) blade, if the tongue is flopping in your view, just shift the blade a little to the right of the tongue’s midline. That will pop the tongue over to your left and out of the way. With the Macintosh blade, if you can get the mouth open wide enough, insert the blade on the very far right side of the patient’s mouth, turning the handle of the blade 90º so the handle is almost pointing toward their left ear. Then, advance it just about to the depth of the epiglottis and rotate it back to the normal position (perpendicular to the teeth and pointing toward the far corner of the room). This technique will pack the tongue over like a can of sardines.

How to Make Yourselve a Liar
Now, here’s what you should not do: Take the blade of the laryngoscope, preferably a Miller blade, insert it past the tongue, past the epiglottis and into the esophagus. Look. See nothing. Lift up as hard as you can, and strain until blood vessels are bursting in your head. The esophagus will usually lift around the blade and the sides will slope down in the same exact shape as the vocal cords. The anesthesiologist will ask, “Do you see the cords?” You’ll say, “Yes, I do.” You’ll pass the tube between the two sides of the esophagus, and you’ll inflate the stomach as soon as you ventilate the patient. The anesthesiologist’s response will usually fit one of the following patterns:

A) They’ll shove you away, yank out the tube, bag them a couple of times and pass the tube themselves. (This occurs about 90% of the time.)

B) They’ll freak out, yell at you, hurt your feelings and say something like, “I don’t care if you can’t see anything, but don’t lie and say you see the cords if you don’t.” You’ll say something witty (like I did, which was “B-bb- b”) and then stumble away dazed.

C) Or, and you must always be ready for this: They’ll stare at you with a blank look, and say nothing. They’ll wait for you to realize you’ve screwed up and make you remove the tube and begin bagging the patient again. Do this quickly. You’re the one in charge. Trust no one to do it for you.

Are You In?
When learning to intubate in the blessed quiet of the OR, it may appear all you need to confirm that you’re in the trachea is your handy stethoscope. After all, as soon as you pass the tube, you listen to each lung and can quickly differentiate between a perfect intubation, a right mainstem intubation or an esophageal intubation. But in the back of an ambulance or on the side of a highway with sirens going and bystanders screaming, when you’re trying to intubate through blood and vomitus, you’ll be lucky if you can hear your partner, much less breath sounds. Even if you can hear breath sounds, your ears will lie to you. If you intubate the esophagus and distend the stomach with air, the sounds of the progressively dilating stomach will be transmitted through the entire thorax with every successive bag, making it seem as if there are bilateral breath sounds. Plus, the morbidly obese or patients with pneumothoraces or emphysema won’t have any breath sounds at all, even if you’re in the trachea. By the time their pulse ox drops and clues you in that you’ve entered the esophagus, the patient’s often near arrest (possibly from the liters of air that have squeezed into their stomach). The solution, of course, is capnography. As soon as you place a tube in the trachea, CO2 will come streaming out of the tube with every exhalation. If you have a quantitative capnometer, you’ll instantaneously get a CO2 level in the 30s or 40s. If you have a qualitative capnometer (the purple cap you put on the end of the ET tube), it will switch from purple to yellow the instant you’re in the trachea, but BE CAREFUL. Your eyes can lie to you. If the patient has been bagged and some of their expired CO2 has been forced into their stomach, when you pass the ET tube into the stomach, the cap will change color as the remaining CO2 is expelled. This, however, won’t continue. With subsequent breaths, the capnometer will quickly stop changing color and fade to a dull purple. That’s your clue you’re in the stomach. Get out and start bagging again.

The Art of Bagging
Bagging isn’t easy. It looks easy, and a lot of people think it’s easy, but that’s usually because they’re going through the motions but not actually getting enough air in the lungs. Bagging isn’t about pressing the mask on the face. If you don’t believe me, try this: Lie flat on your back. Take your right hand and press down on your chin, toward your chest. Now, try to breathe. If you can breathe at all, you’re lucky—and awake. But squash someone’s face down that way when they’re anesthetized and you’ll have better luck ventilating them through their stomach (which I tried and found it doesn’t work well either). The key to ventilating is to do the c-clamp technique they’ve shown you in class, but make sure you pull the chin up into the mask. Don’t press the mask down on the face. Hook the chin with one of your fingers and squeeze it up into the mask. It’s easiest to do if you put your pinkie on the angle of their jaw and pull up. The important trick here is to put your finger only on the outside of the bone, not into the soft tissue under the chin. (Try it on yourself. You can’t breathe with someone pushing inward on the soft tissue under your chin.)

Summary
The approach to intubation I learned during my month-long training is: 1.Walk down the tongue 1 cm at a time until I saw the epiglottis (with the Mac). If I looked inside and saw nothing but pink, I pulled out and went back in again slowly. 2.When I visualized the epiglottis, I slid the blade into the vallecula then lifted up and forward. If I couldn’t see the cords at this point, I would extend the patient’s head slightly, which brought the larynx into view nine out of 10 times. 3.If I still couldn’t see the vocal cords, I would ask for thyroid or cricoid pressure. If I couldn’t see the cords after posterior pressure was applied, I would lift hard toward the far corner of the room. If I still couldn’t see the cords at this point in my intubation attempts, I would say, “They’re very anterior,” (an anesthesiology catch-all phrase) and give the anesthesiologist the scope.

Conclusion
During difficult-to-intubate cases, I’ve seen skilled anesthesiologists intubate an esophagus, lacerate lips and chip teeth. So be careful. Be very careful whenever you attempt to intubate a patient, realizing that even when the experts do it, intubation isn’t a benign procedure and complications—cosmetic and otherwise—can occur. If you perform each of these tips discussed and still can’t see the vocal cords, your patient is justifiably a “hard tube,” and you need to have someone else attempt to intubate them, or try another rescue airway. JEMS

Graham E. Snyder, MD, is the medical director of the WakeMed Health and Hospitals Medical Simulation Center and the associate program director of the UNC Emergency Medicine Residency. Contact him at gsnyder@med.unc.edu.

Graham E. Snyder, MD FACEP

Graham E. Snyder, MD, FACEP, is medical director for the Center for Innovative Learning at WakeMed Health and Hospitals.

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