UMEM Educational Pearls

Category: Trauma

Title: Where and when should we intubate unstable trauma patients?

Keywords: trauma, unstable, intubation, arrest, resuscitate (PubMed Search)

Posted: 1/22/2023 by Robert Flint, MD (Updated: 2/4/2023)
Click here to contact Robert Flint, MD

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 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. 

 

Synthesizing all of the opinion and literature regarding hemodynamically unstable trauma patients requiring operative intervention the take home points are:

 

  1. Resuscitate with mass transfusion and TXA
  2. If the OR is ready, do nothing else but facilitate rapid transfer to the OR
  3. 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.
    1. 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!)
    2. Consider push dose pressors at the time of intubation

 

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. 

 

References