Literature Summaries - Integration of Point-of-care Ultrasound During Rapid Sequence Intubation in Trauma Resuscitation
Editor: Betül Gülalp, Prof.
Date: 12 September 2018
DOI: DOI: 10.4103/JETS.JETS_56_17
Appreciate and respect to Dear Authors
For their great contribution in science of Point-of-care Ultrasound performed by Emergency Physicians
Airway and respiratory management play a critical role in trauma resuscitation. Failure to secure the airway or to detect life-threatening respiratory problems can lead to death or disability. Bedside ultrasound (POCUS) plays a vital role in determining respiratory problems such as hemothorax and pneumothorax. The exclusion of esophageal intubation during the studies demonstrated the benefits of POCUS when confirming the placement of an endotracheal tube (ETT). There is limited data on the utility of it in rapid sequence intubation (RSI) during trauma resuscitation. The aim of the study was to investigate the utility of POCUS integration in different phases of rapid sequence intubation (RSI) during trauma resuscitation.
The study was prospective, randomized single-centered study conducted at the Emergency Department of a Level-1 Trauma Center. The primary objective was to study the utility of POCUS in ETT placement and confirmation during RSI in trauma patients.
RSI was considered in three stages:
- Stage 1: Preoxygenation stage
- Stage 2: Tracheal intubation stage
- Stage 3: ETT confirmation stage.
The secondary objectives were (a) time spent for endotracheal tube confirmation by POCUS, (b) identification of tracheal injury, midline vessels, paratracheal hematoma, vocal cord pathologies, pneumothorax, and other potentially fatal conditions which may influence airway management. Patients more than one year of age with any indications for RSI was included. Age <1 year, patients with cardiac arrest on arrival in ED, overt tracheal injury, open thoracic wound, distorted neck anatomy, patients requiring surgical airway, and referred patients from other centers with existing ETT in place were excluded. The study was designed in two phases as training and practice. It consisted of rapid sequence intubation training and protocols during the training phase. In practice, all patients were subjected to resuscitation according to the ATLS guidelines. RSI was assessed as three stages; preoxygenation, intubation and confirmation of intubation.
POCUS during preoxygenation:
Fig 1 "Lung Sliding"
Fig 2. “Barcode sign”
Fig 3. “Stratosphere sign”
Fig 4. Normal longitudinal view of the trachea and cartilage. The hyperechoic line represents the air-mucosa interface and the cartilage is seen as hypoechoic rings
Fig 5. Transverse view at vocal cord level.
Fig 6. Esophagus (arrow) and- The transverse view of thyroid gland level.
Fig 7. Transverse view of the neck just above the suprasternal thyroid at the level of the thyroid gland showing esophageal intubation. (The posterior wall of the esophagus is no longer visible)
Phase I: Preoxygenation phase of RSI (3 min)
Bilaterally the presence of lung sliding excluded pneumothorax.
Phase 2: Tracheal intubation
A postintubation hyperechoic posterior wall image of esophagus transversely confirmed the tracheal intubation.
Phase 3: Confirmation of endotracheal tube placement by POCUS
An intercostal space was imaged longitudinally on the left midclavicular line and lung sliding was evaluated by POCUS;
If lung sliding was present on the left, right root intubation was excluded.
If lung sliding was absent on the the left while present on the right midclavicular line, confirmed the right bronchus intubation.
The data were collected with Excel and analyzed via STATA.
106 patients were enrolled; 53 of them were POCUS performed and 53 of them were clinical examined by 5 points lung auscultation .
The ratio of male to female was 3.8 / 1 in POCUS group and 5.6 /1 other group.
Motor vehicle accident was the most common mechanism of injury.
The mean duration of the procedure (from the initiation of intubation process to confirmation of correct intubation by the left side midclavicular lung sliding) was 37.3 s (±21.92) in the ultrasound group. While, it was 58 sec (±32.04) in the clinical examination group. Esophageal intubation was detected in 8 of the 53 patients by POCUS and the time spent for detection of the displacement of ETE was 18.25 sec. Unfortunately, esophageal intubation was detected in only 2 patients by clinical examination and the time spent for detection of the displacement was 177.5 sec.
Conventionally on bygone, 5-points auscultation had been considered as the method of choice for exclusion of esophageal intubation. This procedure actually takes time and also gastric contents pose a fatal risk for aspiration. Esophageal intubation was detected in only 18.25 seconds in the ultrasound group against 177.5 seconds in the clinical examination group. Dynamic bedside ultrasonography was faster than clinical evaluation. Also POCUS was faster in comparing durations. Literature supports the superiority of POCUS over 5-points auscultation and utilization of EtCO2 in both adult and pediatric patients.
Murat Yazıcı, Resident
Betül Gülalp, Prof.
EMATUS web coordinator. Anyone...Behind the passion and heart...
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