Tag Archive | "tube confirmation"

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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Trauma Airway Intubation Is a Team Effort

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Field intubation of trauma patients should be a team effort.

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


Greetings colleagues!

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?

Which of roles below do you most often play during the field intubation of a trauma patient?

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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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