Thanks to everybody who commented and contributed to the discussion on our last "Flight!" If you missed out on the case, check it out here. We had a great discussion which we have recapped here. Take a look below and a listen to the commentary provided by Dr. Bill Hinckley in the embedded podcast. Look for our next flight to lift off in the next couple of weeks!
What medications could be used in the care of this patient? If the patient loses his IV, how does your treatment strategy change?
This first question sparked quite a bit of debate within the community. Everybody agreed that this patient requires sedation, intubation, and more sedation. There was, however, some significant differences in how the providers would go about attaining adequate sedation. Dr. Aalap Shah and Dr. Chris Zammit opted to start with versed (IV if IV access was available or IM if IV access had been lost). Ryan Ziegler opts to start with fentanyl in this case (a nice choice especially considering the patient is likely to be heading towards intubation). AC Flight NP Dan Rauh elected to use ketamine for sedation (and opened up a bit of a can of worms bringing out the opinions of Dr. Zammit and Dr. Minh LeCong). The debate of using ketamine in isolation in normotensive severe TBI patients has been well covered previously by Dr. Zammit and Dr. Minh Le Cong (Listen to the Debate Here). Dr. Minh Le Cong also brought up that in Australia they have the option of IM droperidol for sedation in this type of patient (an excellent therapeutic option sadly not available locally).
What about if/when this patient loses IV access? There were several possible solutions to this raised. Intranasal administration of a benzodiazepine or opioid analgesic is one possibility raised by Dr. Shah. Intramuscular administration of a benzodiazepine or ketamine were also mentioned as good next steps for this patient. Finally, depending on how feisty the patient was, several commenters also mentioned physically restraining following by IO placement and administration of sedative mediations through the IO.
Are there other transport options besides flying with the patient? What factors go into that decision?
There are a number of possibilities for transport of this patient. Most everybody was of the opinion that this patient ultimately requires intubation. Once intubated, it was thought that air transport would be safe for both crew and patient. Several commenters mentioned the possibility of transporting the patient by ground. In some instances the transport of patients is safest for patient and crew when the patient is sedated and transported by ground. In this particular patient, however, the patient’s GCS and the possibility of other significant intra-abdominal and intra-thoracic injuries led all the commenters to elect to sedate+intubate+fly the patient. As summarized by Ryan Ziegler “The name of the game here is… Is the patient safe for the aircraft, and if they are not, what’s the next best option. He will likely need neurosurgical support sooner than later."
If you decide to intubate the patient, outline your airway management strategy (with particular attention to crew resource management, induction and paralytic medication choices, method of laryngoscopy).
Several commenters did a fantastic job laying out their approach to intubating this patient. Collating all the comments into a single approach:
Preparation - As Ryan Ziegler outlined, utilizing the ground EMS crew is key in any field intubation. Making sure the patient is on the monitor, ensuring your equipment is functional and appropriately positioned, and briefing the entire crew that is present on what is going to happen is crucial to ensuring a successful intubation. As Dan Rauh, flight NP, and others pointed out, you can have the flight nurse drawing up medications as the person performing the intubation is preparing their equipment. You can give specific ground EMS crew members specific tasks (hand me this BVM with a PEEP valve when I ask for it, this is a bougie - hand it to me when I ask for it, hold in-line stabilization for me, etc)
Pre-treatment - As pointed out by Dr. Shah, this is a patient in whom pre-treatment with fentanyl is classically indicated.
Pre-oxygenation - Pre-oxygenation (or as better termed by Ryan Ziegler - denitrogenation) is the cornerstone of preparation for RSI. (As an aside, this article by Scott Weingart and Rich Levitan is essential reading on this topic). Effective pre-oxygenation in this patient would, as pointed out by the commenters, include nasal cannula oxygen (which could be continued during intubation as apneic oxygenation) plus a non-rebreather face mask or BVM+PEEP valve set up. Depending on the patient’s ventilatory effort one may need to provide actual breaths through the BVM (squeeze the bag). If you are to do this, remember to avoid excess inspiratory pressures (leading to gastric insufflation) and use good mask seal techniques (as seen in the pic below from Jim DuCanto)
Induction and Paralysis - There was some variability in terms of choice of induction agent and paralytic amongst the community. Dr. Shah opted for etomidate and succinylcholine with other commenters preferring ketamine and succinylcholine or ketamine and rocuronium. There is no perfectly correct, evidence based choice in this patient. Ketamine given in isolation (as pointed out by Dr. Zammit) has not been proven to be neutral in terms of ICP elevations.
Method of Laryngoscopy - The only predictors of difficulty (as laid out in the case) for this patient would be the presence of a cervical collar (in and of itself not a contraindication for RSI). Assuming normal anatomy and assuming there was not a significant amount of secretions or vomitus, the commenters equally felt comfortable with direct laryngoscopy (+/- bougie) and video laryngoscopy (using the King Vision).
If you decided to intubate the patient, discuss the principles of post-intubation management given the patient’s injuries.
The commenters honed in on several key aspects of post-intubation management for this patient. First, ensuring adequate pain control and sedation was felt to be crucially important. As pointed out by Dr. Thompson and Dr. Shah, fentanyl would be a possible choice for pain control. Scott Long also would use fentanyl but would also add in some versed for sedation. Ryan Ziegler felt that ketamine + versed would also be an option in terms of providing pain control and sedation.
Several commenters were unsure if this patient would meet criteria for the administration of 3% hypertonic saline with half electing to give it another half electing to follow the patient’s exam. Dr. Chris Zammit, however, advocated strongly for its administration in this patient, “YES, HTS for sure. This patient is described as potentially deteriorating neurologically. Just as we don’t wait until our trauma patient’s lose their pulse to give them blood, we shouldn’t wait until we observe a convincing herniation syndrome to give HOT.”
Dr. Shah also outlined a simple measure often forgot to help with ICP, raise the HOB to 30 degrees. This can be tough if there is a backboard present (and there usually is) but it can be done.
Take a listen to Dr. Hill’s and Dr. Hinckley’s thoughts on this case in the podcast below!