I had a reasonably busy few days at work last week, intubating 3 patients in 4 shifts. All of them went nice and smoothly due to careful planning, setup and communication, followed by techniques such as apnoeic oxygenation with nasal cannula.
But don’t worry, this isn’t another post on intubation. This is a very brief post on how I look after patients after I intubate them.
Ok, so we have the tube in, air is going in and out and we are happy. Now, on with looking after out patient.
- First of all we obviously have to secure the tube. I really only have one option for this, trache tape. You may have many and varied devices or means. Regardless, it is important, especially in the patient with head injury, brain bleed, that sort of thing, to make sure that you don’t cinch things up so tight that you impair drainage by compressing the jugular veins.
- Once the tube is secure I make sure that the analgesia and sedation that I am providing is adequate. This is absolutely vital in any patient that has been RSI’d especially if a long acting neuromuscular blockade is used. In fact, it is absolutely non-negotiable, there is no way that NMBAs can be given without analgesia and sedation.
The method I am currently restricted to is a morphine/midazolam or fentanyl/midazolam infusion. That’s fine for most cases, but I would dearly love to have ketamine as an alternative (for many things). Note that I say infusion. It is my opinion (yes, opinion) that this is the best method to provide adequate steady state analgesia and sedation that can be easily titrated to effect and side-effects. I am aware of many services that use bolus doses only, but this is not something that I am personally very comfortable with as there are inevitable peaks and troughs of sedation and analgesia and it is very easy to under-sedate a patient.
Note that analgesia is the most important aspect with the sedation being the added extra, the cherry on the top.
The degree of sedation can be variable as well. There is not always a need to completely “snow” a patient. Light sedation and analgesia may be adequate in some cases, others may require deeper sedation: again this is on a case by case basis. Heavy sedation can have longer term undesirable effects, so I generally try to aim for the lowest level of sedation required to have a happy, non-tearing/fighting/biting/writhing patient whilst maintaining good perfusion.
- I don’t routinely give long term muscle relaxants. There are a certain subset of patient (traumatic brain injury) in whom my protocol mandates paralytics, but the rest of the time I weigh up whether I really need to give them. There is evidence that NMBAs, especially if their use is prolonged can lead to ongoing muscle weakness. However some patients (such as those who are difficult to ventilate as in ARDS) may have improved outcomes if NMBAs are used, so this has to be weighed up on a case by case basis. NMBAs in the setting of impaired cerebral auto-regulation can avoid spikes in ICP as the patient coughs/gags.
- Positioning. Unless there is some compelling reason why I cannot do so, I position the patient with the head of the stretcher elevated approximately 30-40°. Even if there is suspicion of c-spine injury there is no reason why this cannot be done. Elevating the head of the stretcher achieves a few things. First it allows for a better V/Q matching that you can’t get when the patient is supine which will improve oxygenation and ventilation and reduce complications like absorption atelectasis. Secondly, very importantly, it can significantly reduce the danger of Ventilator Associated Pneumonia (VAP). Finally it also may help with ICP management by allowing efficient venous drainage.
- Whilst we are on VAP, suctioning is very important. It is necessary to not only suction the tube itself, but also the oropharynx. VAP can occur from micro-aspiration around the ETT cuff, so it is important to make sure that there is as little gunk as possible floating around the cords. Use a fresh suction catheter every time you suction the tube (unless you have those flash fully encapsulated numbers. I don’t)
- Oro/nasogastric tubes. I place these on most of my patients, especially if they have been ventilated by face mask prior to intubation. It is very difficult to avoid getting some air in the belly when ventilation occurs with face mask. This is especially true when the person ventilating is inexperienced, and doubly so if ventilation has occurred prior to ambulance arrival. Of course none of my patients are fasted (although only having 6 beers in the half hour prior to crashing the car my constitute fasting for some) so it’s nice to get all that out of the belly as well so it can’t go anywhere else and can’t impinge upon the diaphragm. Personally I find placing gastric tubes far harder than placing any other kind of tubes. Maybe that is just me.
- Tape the eyes. It’s not nice to let the patient’s eyeballs dry out, so I always tape the eyelids down. It also makes sure, in the semi-chaos of the back of an ambulance with swinging giving sets and so on, that the eyes do not get damaged by something falling in them or brushing across them. The method I use is simply a bit of 1″ tape stuck first to the patient’s forehead to render it slightly less sticky, and then I pull gently on the corner of the eye to pull the eyelids shut and tape them down.
- Blankets. A simple thing, but one that is easy to forget. The patient who is sedated (and maybe paralysed) cannot regulate their own temperature effectively. This may be fine in the post arrest patient who we are actively cooling, but it’s not so good in the trauma patient.
- Comfort. I try do some basic nursing care and make the patient comfortable. Try to minimise any noxious stimuli that the patient may receive. Make sure they aren’t lying on broken glass from the car for example. Make sure the sheets aren’t rucked up under them and make sure they are off the spineboard you used to get them out of the car onto the stretcher (which is the only role a spineboard has anyway) The less noxious stimuli the better as it will mean you need less sedation and will end up with a happier patient. By the same token, try to make sure that any fractures are aligned and splinted (including the pelvis)
Ok, so that wasn’t such a brief post. It’s not all that much really: keep your patient pain free, warm, comfortable and ventilating well.
The attentive reader will note that I have not mentioned ventilation at all. This is because that is a topic that deserves a post of it’s own, which I will come to in due course.
That’s about it. I would love to hear from others. Is there anything you do that could help me look after patients? Anything that I do that you think is a bit rubbish? Any tips or tricks for looking after these patients in the back of an ambulance (or helicopter for that matter)? Drop me a line and let me know.