UMEM Educational Pearls

Title: Considering "The Lethal Duo" when Intubating the patient with TBI

Keywords: intubation, neurocritical care, mechanical ventilation, direct laryngoscopy, video laryngoscopy (PubMed Search)

Posted: 4/20/2014 by John Greenwood, MD (Updated: 4/22/2014)
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Direct vs. video laryngoscopy in the patient with an acute TBI

Hypoxia and hypotension are considered the "lethal duo" in patients with traumatic brain injury. In a recent randomized control trial (by our own Dr. Dale Yeatts at the Shock Trauma Center) mortality outcomes were compared between 623 consecutive patients who were intubated with either direct laryngoscopy (DL) or video laryngoscopy (VL). Here is what they found:

1. No significant difference in mortality for all comers (Primary Outcome)
2. In the subset of patients with severe head injuries, there was:

A significantly higher mortality in patients with TBI if VL was used
A significantly longer intubation duration for VL (74 sec) than DL (65 sec)
A greater incidence of low oxygen saturations of 80% or less in the VL group (27 patients) than DL (15 patients) - objectively recorded data, not self reported.

There is a reasonable amount of literature that shows hypoxia and hypotension significantly contribute to morbidity & mortality in the TBI patient, and a growing body of literature that suggests intubation with VL takes longer than DL.

Bottom Line: When choosing a method of intubation for the TBI patient, remember the "Lethal Duo" and consider direct laryngoscopy with manual inline stabilization first.

References

Reference

Yeatts DJ, Dutton RP, Hu PF, et al. Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial. J Trauma Acute Care Surg. 2013;75(2):212-9.

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Email: johncgreenwood@gmail.com