Supraglotic Airways and ICP

[Kiwiology]

OPA with BVM is your initial treatment along with cervical stabilization. The patient needs a Neuro-surgeon not EMS. If you can maintain the airway with BLS measures; you shouldn't waste time with Advance Airway Interventions. Especially, on traumatic patients. Care would be O2, LB/Collar, Reverse Trendenlenberg, V/S, and Reassess; ALS should be done enroute to the ER. Golden Hour... All the best...

You do know the golden hour does not exist?

You do know that an improperly fitted hard collar will cause jugular venous compression, increased ICP and decreased CPP?

You do know that hyperoxic/hyperoxaemic states cause the small precapillary sphinceters/aterioles to constrict?

You do know how difficult OPA and BVM will be for a prolonged period of time?

[Johnboy]

Hyperventilation is in no way what-so-ever indicated for decreasing ICP in todays medicine. It works only transiently, and has more harm then benefits to the situation. The only "safe" way to intubate wether in the field or ED is RSI. If you don't have the equipment in the field, ie, meds, and you MUST protect an airway, I would recommend premedicating with Lidocaine, and Fentanyl prior to perhaps Versed, or Etomidate (which ever you have) Lidocaine to decrease ICP (not proven) and Fentanyl (to decrease catacholamine surge during laryngoscopy, (Proven).

JB

[BushyFromOz]

OPA with BVM is your initial treatment along with cervical stabilization. The patient needs a Neuro-surgeon not EMS. If you can maintain the airway with BLS measures; you shouldn't waste time with Advance Airway Interventions. Especially, on traumatic patients. Care would be O2, LB/Collar, Reverse Trendenlenberg, V/S, and Reassess; ALS should be done enroute to the ER. Golden Hour... All the best...

Is that quoted from a protocol book?

I think if your gonna get a decent canvass of what your options are in managing this patients airway, your gonna have to give more details as to the patients presentation. There is a point where you intervene and theres a point where you can manage without sticking anything in their gob, its a little unclear as to where we are with this pt.

OPA with BVM is your initial treatment along with cervical stabilization. The patient needs a Neuro-surgeon not EMS. If you can maintain the airway with BLS measures; you shouldn't waste time with Advance Airway Interventions. Especially, on traumatic patients. Care would be O2, LB/Collar, Reverse Trendenlenberg, V/S, and Reassess; ALS should be done enroute to the ER. Golden Hour... All the best...

Is that quoted from a protocol book?

I think if your gonna get a decent canvass of what your options are in managing this patiewnts airway, your gonna have to give more details as to the patients presentation. There is a point where you intervene and theres a point where you can manage without sticking anything in their gob, its a little unclear as to where we are with this pt.

Edited April 1, 2011 by BushyFromOz

[usalsfyre]

Hyperventilation is in no way what-so-ever indicated for decreasing ICP in todays medicine. It works only transiently, and has more harm then benefits to the situation. The only "safe" way to intubate wether in the field or ED is RSI. If you don't have the equipment in the field, ie, meds, and you MUST protect an airway, I would recommend premedicating with Lidocaine, and Fentanyl prior to perhaps Versed, or Etomidate (which ever you have) Lidocaine to decrease ICP (not proven) and Fentanyl (to decrease catacholamine surge during laryngoscopy, (Proven).

JB

Maybe not hyperventilation (increased MV) specifically, but controled hypocapenia to an ETCO2 of 28-32 is a commonly used and reccomended by neurosurgeons way of managing the patient with severe ICP increase (i.e. signs of herniation) in the absence of more advanced methods.

[Johnboy]

Usal...

The only thing you are going to do with hyperventilation, or even permissive hypocapnia is possibly cause a secondary brain injury by causing ischemia. Their is NO safer alternative for intubation then RSI. The ONGOING problem with ems systems is that they allow sedated assisted intubation with Versed or Etomidate only, and not a full RSI, this is not safe. Maybe someday they will allow the proper way of doing it (some systems they already do). Hyperventilation is NOT recommended, it causes only a transient decrease in ICP. Current literature states that you will get the most benefit of loweing ICP by raising the head 30 degrees, and even that may reduce cerebral perfusion . Mannitol is the drug of choice, osmotic diuresis usually taken 15 to 30 minutes, and the effect usually lasts 1 to 6 hours.

JB

And ETco2 levels below 30 are just outright dangerous, and is not the common practice today.

[mobey]

Usal...

The only thing you are going to do with hyperventilation, or even permissive hypocapnia is possibly cause a secondary brain injury by causing ischemia. Their is NO safer alternative for intubation then RSI. The ONGOING problem with ems systems is that they allow sedated assisted intubation with Versed or Etomidate only, and not a full RSI, this is not safe. Maybe someday they will allow the proper way of doing it (some systems they already do). Hyperventilation is NOT recommended, it causes only a transient decrease in ICP. Current literature states that you will get the most benefit of loweing ICP by raising the head 30 degrees, and even that may reduce cerebral perfusion . Mannitol is the drug of choice, osmotic diuresis usually taken 15 to 30 minutes, and the effect usually lasts 1 to 6 hours.

JB

And ETco2 levels below 30 are just outright dangerous, and is not the common practice today.

JB: I love your energy and science based critical thinking, wecome to the boards.

You will find that other members here will take you more serious if you can cite references for your claims. Don't bother citing Wiki, or trade magazines. Good published studies, or articles from credible sourses like Medscape will give you alot of clout here. You will also learn alot from tracking down the research, and in some cases..... find that you were wrong all along.

Current literature states that you will get the most benefit of loweing ICP by raising the head 30 degrees,

I am especially interested in studies that support this statement, as I have always done it because everyone else does. I have never really seen evidence that it is indeed a supported treatment.

[DwayneEMTP]

It appeared to me that the OP was really looking for a physiological discussion in regards to his intubation questions...not advice on when to intubate and why a supraglottal device is stupid unless you can't intubate like an adult...

So in response to your question....I have no idea. I love the question but without some refreshing and some research I have no idea.

Some of these folks will be able to argue it with you if we can get em pointed in the right direction..

Dwayne

[usalsfyre]

So I've been meaning to come back to this, have been a little busy.

The only thing you are going to do with hyperventilation, or even permissive hypocapnia is possibly cause a secondary brain injury by causing ischemia.

The Brain Trauma Foundation recommends mild hypocapniea for LIFE-THREATENING increase in ICP. Every source I've looked at also recommends it for such. It is not routine management, nor did I recommend it be. It's for when the patient is herniating in front of you. The studies your talking about are on prolonged hypocapniea, not using as a bridge to more effective therapy.

Their is NO safer alternative for intubation then RSI.

I hesitate to say "safe" and "prehospital RSI" in the same statement. EMS is not really good at RSI if you haven't noticed...

The ONGOING problem with ems systems is that they allow sedated assisted intubation with Versed or Etomidate only, and not a full RSI, this is not safe.

Agreed, but do you know the reasoning? Bet it's not what you think.

Maybe someday they will allow the proper way of doing it (some systems they already do).

Alot of systems do, and a lot of systems kill patients with paralytics too.

Hyperventilation is NOT recommended, it causes only a transient decrease in ICP. Current literature states that you will get the most benefit of loweing ICP by raising the head 30 degrees, and even that may reduce cerebral perfusion.

ANY reduction is what your looking for with imminent herniation. If we can't raise the HOB, can't hyperventilate, how do you suggest treating the death associated with herniation?

Mannitol is the drug of choice, osmotic diuresis usually taken 15 to 30 minutes, and the effect usually lasts 1 to 6 hours.

You do realize osmotic diuresis will make an active bleed worse right? One of the key points to make sure of with Manitol is that the patient is not actively bleeding into their head prior to administration.

And ETco2 levels below 30 are just outright dangerous, and is not the common practice today.

Just going off what our neurosugery group wants (covering a Level I and Level II trauma center that are both Primary Stroke Centers). If 28-32 is their wish, 28-32 is what I'll do.

You strike me as someone who is self-educated and doesn't have a lot of experience in this area. Glad to see your expanding your knowledge though.

[zzyzx]

In regards to keeping the ETCO2 within a certain range when you see clincial signs of brain herniation, it's my understanding that although in healthy patients the ETCO2 will match the actual PaC02, it won't match in sick patients.

Am I correct in what I'm stating here--that you can't really use the ETCO2 as a guide for ventilation? I vaguely remember that there was a thread on this back in the day when VentMedic was active on this site.

Sorry for my lack of references, but it's been a long day and I'm in a lazy mood, and I'm about to pour myself a nice glass of whiskey or two.

[ERDoc]

There are studies that show that laryngoscopy and intubation do cause an increase in ICP, but there is no study showing that it is clinically significant so the use of things such as lidocaine, fentanyl and a defasiculating dose of paralytics is still controversial. The only pre-treatment that I have seen any decent research for has been atropine for bradycardia and that is mostly in the peds population. As for the original question, I haven't been able to find any studies looking at suproglottic airways (after a very brief search) but if laryngoscopy can produce certain affects, why wouldn't a supraglottic airway?