nasal intubations on traumas

[zzyzx]

I'd like to get some opinions on doing nasal intubations on patient's with head injuries. I know that some systems that don't have RSI are pretty aggressive in doing these. I believe Denver is one of those systems. In my system we're allowed to do them on traumas except when we suspect a basilar skull fracture.

Does a nasal intubation create more of a vagal response than an oral intubation? Does it create more of a spike in ICP than an oral intubation?

[Malignant-Hyperthermia]

I dont beieve nasal intubation is something that is routinely done here in EMS, but then again i havn't really looked.

You have piqued my interest though, i am off to read up!

[vs-eh?]

Blind nasal tubes have fallen out of favour here, and are only rarely used. The only time that you are likely to use them on a trauma patient is if they are in trismus and you don't have NMB's available to you.

We have a ghetto PAI here (midazolam and morphine) and our "airway tree" basically outlines that if you have a line, oral intubation is always first with PAI if needed.

Larygoscopy is what causes the cardiovascular/sympathetic effects during intubation, not really passing the tube blindly itself. Nasal intubation would generally have less cardiovascular effects, with the trade off of it being a blind technique with a potentially higher risk of iatrogenic trauma, esophageal intubation, etc...

One of the anesthetist's that educated me basically used a pseudo blind technique (lighted stylet) for the majority of his intubations in large part do to lessened cardiovascular effects.

And I'm sure most are aware that ER's/RT's etc...Generally dislike nasal tubes for a variety of reasons.

If you are worried about increasing ICP with a head injured patient use lidocaine topical/IV plus an analgesic to minimize sympathetic outflow on laryngoscopy (lido has its proponents and doubters). Make your first attempt your best attempt or use an alternate intubation technique which you should have if you have RSI (i.e. lighted stylet).

Oral intubation should always be your first choice.

[Malignant-Hyperthermia]

Nice post vs-eh?

[Ridryder 911]

Part of the other problem more so than Brady and ICP is actually penetrating through the cribiform palate, and entering the brain stem on patients that have trauma induced head injury. One cannot for certain detect a small La Forte fracture, or any fracture that may involve the ethmoid, sphenoid. It does not take much pressure to penetrate the palate.

There are well documented radiology pics showing both pre-hospital and in hospital intubation of the brainstem.. the same reason a NG tube is placed as a OG and goes orally.

Yes, nasal intubation is a routine procedure... I perform it routinely on non-traumatic patients or patients that have a respiratory drive present and does not to be RSI.

R/r 911

[Asysin2leads]

You know, Rid, I'd like to see the rates of penetrating brain trauma from nasal intubation sometimes. I've seen the X-ray photos, but I would be willing to bed that those are the exception rather than the rule.

[vs-eh?]

You know, Rid, I'd like to see the rates of penetrating brain trauma from nasal intubation sometimes. I've seen the X-ray photos, but I would be willing to bed that those are the exception rather than the rule.

EXTREME exception. I have only seen one and I think it was the one that this rule was based on.

Anticoagulants to me would be more of a concern.

[Ridryder 911]

Actually, I was informed it was higher than one would believe. Dr. Shea a neurosurgeon/trauma physician that was very pro-EMS and I believe was Chicago EMS Director for several years used to demonstrate this on cadavers.

His statements was many of them were never published due legality/liability admitted and many was settled and not many wanted to publish such findings. Describing that trauma to facial/head was a direct contraindication of nasal intubation even from the ATLS course. It does make sense pushing a tube past the posterior pharynx, is sometimes difficult. I personally, would not perform it on trauma, rather use alternative measures or retrograde intubation or crich them.

Anticoagulant therapy patients is definitely a concern, an even on non-trauma patients one can soon find out they are on Coumadin after attempting to place a NG or ETT in. But, in the case of trauma, chances are they will be already bleeding.

R/r 911

[tniuqs]

Agreed with most of the dialog here..... but anyone carry Etomidate? TWTG.

Nasals for Head Trauma.... bah humbug just asking for troubles and agree with Rid, OG is way less risky too.

Vs eh: agreed RRT's are limited with the Nasal Tube as its gosh darn hard to bronch them and trying to do a BAL the Bronchial Alveolar Wash becomes a pain, when the do get infected and they usually do, typically the ETT are smaller OD/ID.

Hey in passing, just found a new Cricky device: check it out...... but only in Canada EH? :twisted:

http://www.smiths-medical.com/catalog/cric...dotomy-kit.html

[Shelbmedic]

Tniugs,

I just looked at the web site for the cricothyroidotomy kits these are the same kits we have on our units I work on.