Esophageal intubation clinical tid-bit

[sevoflurane]

So... I was on call last night. Stat call to the ED for a GSW to the abdomen. Long story short, she had a generous BMI (>35), had a horrible airway (only saw hard palate) and was not npo. Didn't waste much time in the trauma bay. Went up to "theater" and bought her self an RSI. The senior resident was having a little bit of trouble putting in the tube... Finally sunk it in. Oh-Oh... no condensation in the tube, no end tidal, no breath sounds and a audible bubbling in the stomach....
As he began to take the tube out our attending quickly told him to leave it in place.... Then... as he took over the airway she vomited.... BUT THORUGH THE TUBE AND ONTO HER FACE AND OR TABLE!!!! He secured a tube through the vocal cords and then put suction to the first tube in the esophagus. As things mellowed out he reinforced the fact that there was not a drop of vomit in her oropharynx and for that matter in her lungs!!!

Moral of the story... if you get an esophageal intubation on someone who is not npo and in the trauma bay... LEAVE IT IN. You will :

a) find it very difficult to get a 2nd tube in the esophagus and will likely go through the path of least resistance (vocal cords) and

b) they might VOMIT with NO consequece to the lungs

I thought this was an excellent pearl for clinical practice.

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[Conflicted]

oh my

As someone who intubates trauma patients on a regular basis I would say to never, EVER follow that advice.

Its hard enough to tube someone with trauma to the face but much harder when there is another tube in the way. Not only is the tube itself an issue for visualization but it elevates the (normally flat) esophagus often pushing the trachea more anterior.

Pull the tube, intubate the patient correctly. There is NO guarentee that aspiration will not occur with a tube in an esophagus which can stretch to accomodate the pressure of the vomit.

 

[sevoflurane]

oh my

As someone who intubates trauma patients on a regular basis I would say to never, EVER follow that advice.

Its hard enough to tube someone with trauma to the face but much harder when there is another tube in the way. Not only is the tube itself an issue for visualization but it elevates the (normally flat) esophagus often pushing the trachea more anterior.

Pull the tube, intubate the patient correctly. There is NO guarentee that aspiration will not occur with a tube in an esophagus which can stretch to accomodate the pressure of the vomit.

I see what you mean. My trauma experience is very limited and as such I can't comment on how hard it is to try and intubate someone with a tube in the esophagus, because I've never been in that situation. I can definately see it obstructing the view in some patients.

However, physically watching vomit traverse up and out the tube on to the OR table and avoiding the patients lungs was very satistying to see. She was hypoxic at the time and about 300cc of yellow gunk woudn't have setteled very nicely.

I don' see much harm in taking a look if a 2nd tube is in. You can always look and if you don't like what you see, there should be 2 pairs of hands available to pull the tube out in about 1-2 seconds.

 

[Noyac]

oh my

As someone who intubates trauma patients on a regular basis I would say to never, EVER follow that advice.

Its hard enough to tube someone with trauma to the face but much harder when there is another tube in the way. Not only is the tube itself an issue for visualization but it elevates the (normally flat) esophagus often pushing the trachea more anterior.

Pull the tube, intubate the patient correctly. There is NO guarentee that aspiration will not occur with a tube in an esophagus which can stretch to accomodate the pressure of the vomit.

WRONG!

 

[militarymd]

I've done it both ways......I say 50 50.

 

[sevoflurane]

oh my

As someone who intubates trauma patients on a regular basis I would say to never, EVER follow that advice.

Its hard enough to tube someone with trauma to the face but much harder when there is another tube in the way. Not only is the tube itself an issue for visualization but it elevates the (normally flat) esophagus often pushing the trachea more anterior.

Pull the tube, intubate the patient correctly. There is NO guarentee that aspiration will not occur with a tube in an esophagus which can stretch to accomodate the pressure of the vomit.

I see what you mean. My trauma experience is very limited and as such I can't comment on how hard it is to try and intubate someone with a tube because I've never have been in that situation.

I can say this much though: Physically watching vomit traverse up and out the tube on to the OR table adn avoiding the patients lungs was very satistying to see. She was hypoxic at the time and about 300cc of yellow gunk woudn't have setteled very nicely.

I don' see much harm in taking a look if a 2nd tube is in the esophagus. You can always look and if you don't like what you see, there should be 2 pairs of hands available to pull the tube out in about 1-2 seconds.

 

[Conflicted]

Sevo:

Nicely said. I have to agree with how you are looking at it. Shows excellent thought process. I should also know better than to say the words "Never Ever" ehehehe.

Everyone has their biases when it comes to intubation. However, i will say that intubation is 80% recognizing anatomy and 20% style. If you cannot identify the anatomy, style is irrelevant.

Noyac, id hazard to guess ive done alot more trauma intubations than you have in the last 10 years. Please justify your comments.

 

[aredoubleyou]

oh my

As someone who intubates trauma patients on a regular basis I would say to never, EVER follow that advice.
.

Never been in that situation...(probably cause I'm an intern doing my prelim!)...but I do recall there was a case discussed where that happened and it wasnt controversial that the esophageal tube was left in...lots of attendings there too.

 

[Conflicted]

Hmm

Well when i was a paramedic (an eon ago) that is what we were taught. If you miss the first tube leave it in. There was a study done (which i no longer have and would be quite old now) that showed people had a more difficult time with second attempt due to the tube and had a lower success rate.

Having said that, whatever works for you is all that matters. If you dont have a problem why not leave it there. It didnt work for me then so i do not do it now. I see less anatomy and its not my "style"

Good luck on your intern year aredoubleyou, your going to love it.

 

[lushmd]

Isn't there a (significant?) risk of iatrogenic esophageal perforation if the ET tube is left in the esophagus and the pt vomits?

 

[Conflicted]

very true about the risk

I think what I saw the most was the vomit shooting out like putting your thumb over the end of a hose around the ETT. Since the esophagus can expand to accomodate much larger things than an ETT (food) it does so under pressure of vomit as well.

Apparently, this isnt all the time as sevo mentioned.

 

[Noyac]

Noyac, id hazard to guess ive done alot more trauma intubations than you have in the last 10 years. Please justify your comments.

So is this were I am supposed to get in a pissing match with you?

 

[Planktonmd]

Leave it in or take it out ... Just get the darn tube in!
Although it might be a little difficult to mask ventilate with a tube sticking out of the mouth just in case you miss the second time.

 

[Gimlet]

So is this were I am supposed to get in a pissing match with you?

Well, yeah. How else would you compare the size of each other's e-peens?

 

[Conflicted]

Uh No.

Your supposed to evidence what you say, or at least make an attempt to back it up. All you did was fly in the face of experience without a single reason. Its childish.

So is this were I am supposed to get in a pissing match with you?

 

[Noyac]

Uh No.

Your supposed to evidence what you say, or at least make an attempt to back it up. All you did was fly in the face of experience without a single reason. Its childish.

You said never ever.

I said your wrong. Nothing is 100%. Do I need to provide evidence of this?

Or am I supposed to list my trauma intubations here so that you can say you are a better intubater (insert various activities here)? I guess I don't follow your line of reasoning, but then again, WHO CARES!!!!!

I don't know if you have any experience whatsoever. You don't know if I do. Again Who cares!! But your comments give me a good idea of your experience.

Trying to claim that you are more experienced than someone else, on a forum for that matter is CHILDISH.

 

[Conflicted]

Ok

Thanks for the tantrum havent seen one since my 5 y/o went off yesterday. You are being defensive because your insecure, i get it. Let it go.

 

[fakin' the funk]

Might this question be settled by the literature?

 

[jetproppilot]

oh my

As someone who intubates trauma patients on a regular basis I would say to never, EVER follow that advice.

Its hard enough to tube someone with trauma to the face but much harder when there is another tube in the way. Not only is the tube itself an issue for visualization but it elevates the (normally flat) esophagus often pushing the trachea more anterior.

Pull the tube, intubate the patient correctly. There is NO guarentee that aspiration will not occur with a tube in an esophagus which can stretch to accomodate the pressure of the vomit.

I saw Alan Kaye rescue a dude in specials when I was a resident.

Somebody had just tubed the esophagus, same kinda situation, sats falling.

Alan folded the tube-in-the-esophagus to the side, mask ventilated for a short period, then deftly intubated the dying-dude.

Being an inquisitive CA-whatever-I-was, I asked him why he didnt pull the tube out.

"Cuz this was obviously a difficult intubation. That tube told me where not to aim," Alan said with a smirk on his face.

Hard to argue with that.

Not saying how to handle a situation is right or wrong.

But its hard in this business to justify saying definitely dont do it this way.

Remember that, dudes.

Theres more than one way to handle an emergent situation.

And quoting Mil, the right way is the way that worked.

 

[Conflicted]

Well Said

Should never say never

 

[militarymd]

.......

And quoting Mil, the right way is the way that worked.

When I was Active Duty, I was taught that there were only 3 ways of doing things.

1) right way
2) wrong way
3) the Navy way

We were told to pick number 3.

 

[jetproppilot]

When I was Active Duty, I was taught that there were only 3 ways of doing things.

1) right way
2) wrong way
3) the Navy way

We were told to pick number 3.

And thats why you are in private practice now, my friend.

 

[dogbone65]

1) right way
2) wrong way
3) the Navy way

We were told to pick number 3.

LMAO....I haven't heard that in years!!! Good times, good times.