Wednesday, February 3, 2010

Intubation trick, subclavian trick.

Tube trick!

When you intubate a patient, and you're not sure whether or not your tube is in the trachea, and the only stethoscope you have available just *sucks* and you can't hear breath sounds for crap, blow up and deflate the balloon on the endotracheal tube a couple of times, while palpating the trachea (basically, put your hand on the patient's anterior neck). If you can feel the balloon -- or, more likely, the friction of the balloon against the tracheal rings -- you know you're in position.

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Subclavian line tricks!

1. This is revolutionary and yet ridiculous: Curve your needle, the needle you use to find the subclavian; I guess it's a long (2.75", say some of the websites I'm checking) 18 gauge. Point the bevel up (as always), then just put a very soft curve in it. I'm talking a *very* soft curve; you're not hockey-pucking it. Pretend you're bending the needle around, say, a very large (cylindrical) pickle jar. Great! *Now* find your landmarks -- 1/3 of the way into the clavicle from the sternum, and aim for the sternal notch, perpendicular to the long axis of the patient's body, and go. The curve of the needle will keep you fairly shallow, and therefore from dropping the lung.

2. Let's say you're called upon to insert a subclavian, and as you're advancing the guidewire, you meet resistance. The wire continues to feed, but you're just not sure of the positioning: Is the wire feeding down into the chest (yay!) or has it kinked, and now you're feeding into the jugular vein instead? Fear not! Pull the needle you've just inserted the guide wire through but leave the wire in place (so that the wire is the only equipment that remains in the patient). Then, take a flexible angiocath (there should be one over one of the needles -- I think it's the 20-gauge - in your triple lumen kit) and feed the angiocath over the wire. Then -- and this is scary -- pull the wire. Blood should continue to flow out of the angiocath, indicating that you're in a vein. More importantly, though, the angiocath is soft and flexible, and should travel in the direction of least resistance (down, not up). And! And now you can make sure your wire doesn't have any kinks in it. Reinsert the guide wire *backwards* (don't insert the flexible J-bit end, but the other side). Sometimes that J-shape curls up in the vein and it's too big for little people.

Ta-da! Pull the angiocath and proceed as you would normally. You can now be at least somewhat more secure that your line is heading where it needs to be. Plus, you haven't lacerated the subclavian with unnecessary guide-wire mucking.

6 comments:

Anonymous said...

Ballotable ET tube cuff - cute trick but not validated. The only acceptable objective method for confirming tracheal tube placement can be detection of exhaled CO2, preferably by capnography, or by colorimetric detector if you don't have a capnograph,.. anything else is indefensible, unacceptable, and just shitty patient care. Some would rightfully argue that esophageal detector is also near-failsafe objective. When you are intubating a patient NO margin of error is acceptable, relative to confirming intratracheal position of the airway. Your sentence "... not sure whether or not you are in the trachea..." should end with PULL THE TUBE and mask ventilate the patient!

gabbiana said...

Good to know, Anonymous. In this case we had already confirmed placement by end-tidal CO2 (as well as bilateral chest rise and misting in the tube, which, I know, are also imperfect indicators). Still, the ballotable (thanks for reminding me that that word exists) ETT was a neat party trick (if not a legally-defensible one).

I'm curious whether you've ever used ultrasound to check for tube placement. Your comment prompted me to pubmed and thus to this article:

Sustic, Alan. Role of ultrasound in the airway management of critically ill patients. Critical Care Medicine. Focused Applications of Ultrasound in Critical Care Medicine. 35(5) (Suppl):S173-S177, May 2007.
DOI: 10.1097/01.CCM.0000260628.88402.8A

At least in my ED, the ultrasound is typically *right there* during traumas, so why not use it? (Though, to be honest, I can't think of a situation where a capnographer wouldn't be available immediately.)

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