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From: "Michael Damm" <[log in to unmask]>
Reply-To: [log in to unmask]
Date: Sat, 03 Feb 2001 13:04:39 -0800
To: [log in to unmask]
Subject: Re: RE: [ECO] RSI - Part 2 of a long mail
... some food for thought:
Trauma Patients - Whom and why do we intubate?
Who has ever looked at intubation as a true therapeutic and preventive
measurement in the traumatized patient?
Since we are all to well familiar with the pathophysiology of shock - in
particular hypovolemic shock due to trauma, I need not to go into detail,
but rather keep it brief and to the point.
When caring for a trauma patient who is (still) fully conscious & oriented
(GCS 15), able to protect his own airway and displays an O2-sat in the
high 90’s, the need for intubation does not come to mind for many of us;
especially when he’s still normotensive and only slightly tachycard. By
this, I am not referring to the simple or pure “mechanism” trauma who
gets his two standard I.V. lines and a ride up to the trauma center. I am
talking about the trauma patients we encounter, who have an either
obvious, serious injury (ies) i.e. GSW (s) to the trunk and/or highly
suspected internal injury (ies), i.e. blunt chest and/or belly trauma
despite stabe vital signs. Many of the readers would argue with me about
intubating these kinds of patients. Again, in particular if the patients
are conscious, oriented and oxygenate well. I know XYZ would definitely
argue with me, why to analgo-sedate, paralyze and intubate such a patient.
Well, XYZ, here are my rationales:
Impaired spontaneous respiration’s and a low oxygen saturation are not the
only intubation criteria’s for controlled ventilation (via ETT) – in
particular not, if we are dealing with suspected, severe internal injuries
and closed head trauma. By the way, the clinical assessment of oxygenation
and ventilation is often too unreliable in the (chaotic) field. Oximetry
is the noninvasive bedside monitoring of arterial oxygen saturation.
Remember that isolated oximetry yields no clue regarding the status of
true and I mean true alveolar ventilation. It’s about cell acidosis, fluid
and electrolyte derangement’s, regulatory disturbances in acid-base
balance, etc. – all the things we can hardly measure in the early,
prehospital phase but who untreated decide about the patients long time
outcome. With that, I do not mean if the patient arrives alive at the
trauma center. But rather in what condition will he leave the hospital
two, four or even six weeks later and in which way will he six or 12
months down the road have work wise, socio-economically and psychological
rehabilitated himself - and also socially reintegrated himself
successfully. In the same moment, we should also consider prehospital
stress inhibition and early, sufficient pain management (analgesia).
Regarding gun shot victims … The vegetative damages which occur secondary
to the impact of a projectile on the body’s surface and the late damages
of the expending cavitational wave are reasons enough, to intubate in the
field. (Of course as long as its not a simple gun shot wound to the
peripheral body without any major vessel involvement.)
Question #1:
What kind of pathophysiological events happen when dealing with impending,
hemorrhagic shock, that despite a patients sufficient spontaneous
respiration’s and oxygen saturation an early intubation is warranted?
A disturbed homeostasis with developing microemboli and subsequent
collapse of the entire peripheral metabolism. Due to this, an Acute
Respiratory Distress Syndrome (ARDS), multi-organ failure, DIC and the
Systemic Inflammatory Response Syndrome (SIRS) occurs mostly three or four
day’s post injury - and, if everything goes wrong even
Methicillin-Resistant Staphylococcus Aureus (MRSA) develops. Therefore
worst case scenario and ultimate consequence is exitus letalis in an
otherwise young, healthy patient who only (?) suffered a gun shot wound to
(for instance) his belly.
Question #2:
Are controlled ventilation’s in the intubated patient better than in a
conscious patient with (still) sufficient spontaneous respiration’s but
possibly severe injury (ies)?
The answer derives not only from what has already been mentioned but is of
course also, always a case by case situation. I am by no means proposing
to categorically intubate every trauma patient. But keep in mind, normal
breathing is an act of work, even if it appears to be non-labored. By that
I mean, it takes circulating blood volume, oxygen, and glucose, ATP, etc.
to keep the diaphragm going – all the things a traumatized (hemorrhaging)
patient is short of in the first place. Why would you (we) have such
patient use off a portion of his remaining metabolic demands for breathing
efforts when you (we) can easily take care of it for him?
En route to trauma center … Please, never underestimate “trauma suffered
during transport”. In our ambulances we produce, next to several braking
and acceleration maneuvers, the stress through use of lights and sirens
and situational hectic a basic oscillation, due to the combination of
vehicle and gurney suspension, at 8-12 Hz. This lies in a vegetative
highly sensible realm and contributes additionally to (unnoticeable)
stress build up. The easiest way to recognize such stress is when our
patients puke all over the place. Whoever does not believe me, I challenge
to undergo the following test:
Place yourself on the gurney in one of our medic units. Have your partner
hook you up to the LP12 (EKG, SPO2, NIBP) and have him start an I.V. about
an hour prior to the experiment. Have him also draw some bloods for stress
hormone determination. Then, have your partner drive you code red for 30
minutes through town or, on the freeway in rush hour traffic. During this,
have somebody else draw additional blood samples every 10 minutes and
later every half-hour up to 2 hours after the 30 minute ride. You’ll be
amazed what kind of peak levels you’ll reach before, during and after your
trip and how long it will take until you’ll reach again, a steady state.
Stress in particular with its unpredictable consequences on the body’s own
immune system constitutes one of the main dangers for the patient.
So let us re-think when and why to early intubate.
Another issue I would like to pick up on is volume resuscitation in the
field. We at Medic One on average infuse 4200ml of lactated ringer in the
polytraumatized patients, whereby Seattle infuses around 3200ml (due to
shorter transport times). Giving fluids in the field is pretty much out of
vogue for most EMS systems, based primarily on one very dumb study in
Houston. The bad thing about this is the fact, Dr. Paul Pepe, one of the
co-authors of the study at Ben Taub Hospital (by the way, he's no longer
in Houston) did his residency in Seattle. He was a big fan of Medic One
and the rumors still go around, he had to be kicked of the rigs a few
times, since he would spent too much time with the medics in the field
instead at the hospital. He is a great individual, but our surgeons think
the heat and sun in Houston got to him. Houston FD has paramedics whose
skill level and level of overall performance is rather low. These guys
attempting to start I.V.s on halfway exanguated victims placed a real
challenge on them. We at least have still central lines as a back up.
Also, their medics weren't very aggressive medics to begin with. Another
issue of the study was the fact, they only looked at, if I remember
correctly, victims with penetrating injuries to the box. Well, we in
Seattle and King County see more what is common for western Europe - blunt
trauma and longbone fractures with longer transport times outside of
Seattle. When encountering a trauma patient with stable vital signs, what
does it tell us? Nothing. A patient who has bilateral closed femur
fractures and blunt chest and or belly trauma but is still conscious
(GSC15), satting at 97% on room air and has a BP of 112/78 and HR of 92
needs fluids and intubation! (Come on guys, to encounter a trauma patient
with a pressure of 80 syst. and a thready pulse of 140 in regards to fluid
resuscitation is really a no-brainer. You know he needs volume or better,
is volume depleted and in shock.) The art of shock treatment is/should be
prevention! (Besides, in some cases also rapid transport). Why wait until
somebody becomes tachycard and/or drops his pressure? Give early on, at
least 2000ml of fluid, and counteract the process of shock. You might not
be able to stop certain internal bleeding sources but sure enough help in
maintaining a somewhat normal metabolism, electrolyte balance, ph, etc.
and through intubation, maintain somewhat physiological paO2 and pcO2
levels. And if the pressure is 124/80 and the heart rate 130, give volume!
Even if the injuries are not obvious and can only be presumed to be
internally. The prehospital arena is often too unpredictable to rely on
stable vital signs and clear lung sounds (when it comes to hemothorax).
Err on the safe side. To give you guys an example, two weeks ago, I took
care of the unrestrained front seat passenger in a pick up truck who got
t-boned by an SUV. The driver site had major, major damage, but my patient
only suffered some facial cuts. Although he had alcohol on breath, he
check out completely fine on exam. BP was 110/70, Pulse 96, Resp. 16 and
O2 sat 97% on NC. Only complaint was some back pain and he wanted to get
off the hard, uncomfortable board. Again, on exam, there were no signs of
bruising to chest or belly, no deformity, no distended, tender or rigid
belly, clear lung sounds, no crepitus, just nothing!!! I still started my
standard 3 I.V. lines (one at scene, two en route) and infused 2700ml of
ringers.) At the trauma center, the staff was not impressed by the patient
and concentrated their efforts on the driver, intubated and critical. Two
weeks later, I get finally feedback on the patient. Based on what he
suffered, I thought they mixed up the patients - serioulsy. My patient had
suffered:
diaphragmatic rupture - and stomach in chest
spleen rupture
left hemothorax
left eye laceration
nose fx
pelvic fx
alcohol level of 205
ph 7.31, pco2 46, pao2 91
BP 145 syst., P98, Res. 20
The responsible physician for the feedback made a very short remark:
NEEDED INTUBATION!
I know guys, by now you asked yourself, how in the world can someone miss
such injuries? "Dude, you must have done a lousy job in examining this
patient, no way you can miss such injuries."True, but I did a thorough
hands on exam. Believe me, I have enough years on my back... There is no
reason to make a fool out of myself in this forum/discussion group. I
would not have to write/reveal any of the information, but I do it,
because I can stand to my mistakes - failed to intubate. I didn't notice
any of these injuries, and there were no obvious/visible signs either. As
a matter of fact, pretty much all the injuries were detected within two
hours into the hospital time by means of x-ray, CT, etc. What does it tell
us? We often basically don't stand a chance with our limited assessment
tools compared to the hospital - that's right. So let us tighten our index
of suspicion for bad internal injuries in patients exposed to a sever
mechanism of injury, who check out fine (or only complaint of minor chest
and belly pain) but are intoxicated (even if they are fully oriented) as
well. I suggest to apply a low threshold of RSI and generous fluid
infusion. Having said all this, it is clear, most of you readers will not
agree with me at all, or only partially. Please continue to do business as
usual. I am not a medical authority, no MD... just a medic within the
Medic One system (for what its worth). Thanks to Dr. Copass, I am allowed
and expected to apply these "aggressive" measures. I enjoy sharing EMS
experiences and learning from ohers, always striving to excell...
Thank you,
Michael Damm
P.S. Below is at least one German study abstract in English language
http://www.med.uni-muenchen.de/gch/lit/lit_Seite14.html
Effect of intubation timing on the clinical course of polytrauma patients
with lung contusions
Abstract
SUMMARY: Aim of the study was to evaluate the influence of early
intubation at
the scene on the outcome of polytraumatized patients with lung-contusion.
METHODS: 377 patients with lung-contusion out of 1031 polytraumatized
patients were evaluated in this study. Patients, intubated at the scene
were compared with those, who were intubated later. We compared the
in-hospital time, the time at the ICU, the pneumonia-rate and the
ARDS-rate. Age and injury severity of the compared groups were comparable.
RESULTS: In-hospital time and time at the ICU were shorter in the early
intubated group than in the later intubated (in-hospital time 34.5 d and
39.4 d, time at the ICU 19.9 d and 23.7 d, resp.). For the time at the ICU
the difference is significant. Also a reduction was found in the
pneumoniarates (23.7% and 13.2%). The ARDS rate was reduced, too, but both
differences were not significant (pneumonia = 0.053, pARDS = 0.117). The
mortality also was not significantly reduced (23.4% and 22.7%, resp.).
CONCLUSION: Early intubation at the scene can reduce the inhospital-time,
the time at the ICU and the complications. In this way it becomes an
important factor of cost-reduction. Therefore early intubation at the
scene must become a standard for all patients with lung-contusion.
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