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In many cases of massive GI bleeding, airway control is essential. During endotracheal intubation, suction sometimes just isn't adequate enough to allow to get a good view of the vocal cords. The pool of blood keeps re-accumulating faster than you can suction. You think you see an arytenoid, pointing you in the direction of the trachea, and so you slide the endotracheal tube in.
Unfortunately, when you bag the patient, you realize that you are in the esophagus.
Trick of the Trade:
Leave the esophageal tube in.
Reattempt endotracheal intubation.
"When life gives you lemons, make lemonade."
If the endotracheal tube is in the esophagus, do NOT take it out! You have just created a conduit to remove further bleeding from the field. Take another look with Yankauer suction. Reattempt your intubation with a second tube. Do this as soon as you recognize an esophageal intubation to reduce the patient's risk for oxygen desaturation.
Note:
- Be sure that the esophageal tube is turned away from the providers to avoid being splashed with blood.
- Have an assistant suction the proximal port of the esophageal tube when blood starts pouring out of it.
Saw this procedure conducted by an EMT. Simple and great idea. The patient's explosive vomiting was canalized and intubation was relatively easy-going.
ReplyDeleteThanks for corroborating this trick!
ReplyDeleteCongratulations Dr. Lin!
ReplyDeleteThanks, Bipin!
ReplyDeleteAny time we put a tube in the esophagus (at some point everyone does - or they don't intubate much), we should consider that it is better to leave the esophageal tube in place. Unless the tube is preventing proper placement of the next tube.
ReplyDeleteIt can give us an idea of where the trachea is in relation to the tube. The trachea should be anterior, so if the next tube placed is not anterior to the one in the esophagus, maybe the one we thought was in the esophagus was not in the esophagus (it still might not be in the trachea), or the new tube is not in the trachea.
Directing the esophageal tube into a red bag, or a towel that is rolled up, can be one way to avoid having blood/vomit flying all over the place.
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@Rogue Medic: Excellent point about NOT taking out the initial esophageal tube. The more clues about the anatomy, the better. Ooh, and I do like the idea of a bag/towel around the esophageal tube. I too thought that suctioning alone might miss a little splatter getting on you... Thanks for commenting!
ReplyDeleteA meconium aspirator between the ET and suction tubes can make a great adapter if you're going to be leaving it in the goose want to attach it directly to suction.
ReplyDeleteKudos to Dr. Scott Weingart for bringing this (http://emcrit.org/blogpost/ett-as-suctio/) nifty little contraption to my attention for those REALLY wet airways. Like "the patient just finished drinking his liter of PO contrast and then coded" sort of wet.
Also, congrats on the endowed chair! I just saw the good news on EM Literature of Note. Thanks again for the amazing educational resource you supply with this blog.
DeleteHi Vince: Ah yes, I recall reading about Scott's gem about the ETT being both the tube AND the suction device. I meant to go see if I can find the adapter and meconium aspirator in the ED. You have renewed my motivation!
ReplyDeleteYes, that Ryan on EM Lit of Note is full of surprises! The endowed chair has already been an exciting experience and I don't even official start the position until July!
Leave tube in the goose. Blow up balloon. Hook to suction. NOW place ETT in a better field.
ReplyDeleteHey AJB ACNP: Yes, I think that's the consensus I'm hearing. The tough thing is to find a way to easily connect the suction hose to the ETT. I'm guessing if you take off the 1-inch vent plastic adapter at the end of the ETT, the suction hose may just fit... Thanks for commenting!
ReplyDeleteNice trick - good one to add to the toolbox.
ReplyDelete