Title: Where and when should we intubate unstable trauma patients?<br/>Author: Robert Flint<br/><a href='http://umem.org/profiles/faculty/2561/'>[Click to email author]</a><hr/><p class="p1" style="margin: 0px; font-variant-numeric: normal; font-variant-east-asian: normal; font-stretch: normal; line-height: normal; font-family: Helvetica; -webkit-text-stroke-color: rgb(0, 0, 0);">
<span style="font-size:16px;"><span style="font-family:arial,helvetica,sans-serif;"><span class="s1" style="font-kerning: none;">At this month’s Eastern Association for the Surgery of Trauma annual meeting there was a presentation asserting that hemodynamically unstable trauma patients have worse outcomes when intubated in the emergency department vs the operating room. This was not a study diminishing the intubating skills of EM providers but a look at the fact that hemorrhaging patients will crash after intubation and if they are not in a position for immediate surgical<span class="Apple-converted-space"> </span>intervention they will die. The loss of sympathetic tone, positive inter-thoracic pressure, loss of muscle tone as well as the agents used all contribute to peri-intubation arrest. This month’s EmCrit episode tackled this topic as well.<span class="Apple-converted-space"> </span></span></span></span></p>
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<span style="font-size:16px;"><span style="font-family:arial,helvetica,sans-serif;"><span class="s1" style="font-kerning: none;">Synthesizing all of the opinion and literature regarding hemodynamically unstable trauma patients requiring operative intervention the take home points are:</span></span></span></p>
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<span style="font-size:16px;"><span style="font-family:arial,helvetica,sans-serif;"><span class="s1" style="font-kerning: none;">Resuscitate with mass transfusion and TXA</span></span></span></li>
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<span style="font-size:16px;"><span style="font-family:arial,helvetica,sans-serif;"><span class="s1" style="font-kerning: none;">If the OR is ready, do nothing else but facilitate rapid transfer to the OR</span></span></span></li>
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<span style="font-size:16px;"><span style="font-family:arial,helvetica,sans-serif;"><span class="s1" style="font-kerning: none;">If there is a delay in going to the OR, carefully monitor the patent's work of breathing and CO2. If they are tiring or have normal or rising CO2 then intubate.</span></span></span>
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<span style="font-size:16px;"><span style="font-family:arial,helvetica,sans-serif;"><span class="s1" style="font-kerning: none;">Weingart suggests that Ketamine dissociative intubation is the safest and most physiologic neutral way to accomplish airway control in these patients. (A skill that must be practiced!)</span></span></span></li>
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<span style="font-size:16px;"><span style="font-family:arial,helvetica,sans-serif;"><span class="s1" style="font-kerning: none;">Consider push dose pressors at the time of intubation</span></span></span></li>
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<span style="font-size:16px;"><span style="font-family:arial,helvetica,sans-serif;"><span class="s1" style="font-kerning: none;">Much of this is counter to historical teaching of early airway management on ED arrival. It certainly fits with recent literature supporting resuscitation prior to airway management whenever feasible.<span class="Apple-converted-space"> </span></span></span></span></p>
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<fieldset><legend>References</legend>
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<span class="s1" style="font-kerning: none;">EMCrit – Ghali Grills 2 – Should You Tube the Patient in Severe Hemorrhagic Shock if there is a Delay to OR?</span></p>
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<span class="s2" style="font-kerning: none; color: rgb(0, 0, 0);">January 21, 2023 by <a href="https://emcrit.org/author/emcrit-2/">Scott Weingart, MD FCCM</a></span></p>
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<span class="s2" style="font-kerning: none; color: rgb(0, 0, 0);"><a href="https://emcrit.org/emcrit/should-you-tube-the-patient-in-severe-hemorrhagic-shock-if-there-is-a-delay-to-oremcrit-ghali-grills-2-should-you-tube-the-patient-in-severe-hemorrhagic-shock/"><span class="s3" style="font-kerning: none;">https://emcrit.org/emcrit/should-you-tube-the-patient-in-severe-hemorrhagic-shock-if-there-is-a-delay-to-oremcrit-ghali-grills-2-should-you-tube-the-patient-in-severe-hemorrhagic-shock/</span></a></span></p>
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