Article, Emergency Medicine

Multiple trauma, resuscitation, and 15 minutes of esophageal intubation: survival without neurologic deficit

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American Journal of Emergency Medicine

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Multiple trauma, resuscitation, and 15 minutes of esophageal intubation: survival without neurologic deficit?

Abstract

Resuscitation of a patient with multiple trauma in pulseless electric activity has a poor outcome. Not only hypovolemia but also hypoxia can lead to cardiac arrest in this population. We report a case that is important for all resuscitation providers. On the one hand, it presents an intriguing chronology with severe trauma, 15 minutes of esophageal intubation, and hypoxic cardiopulmonary resuscitation followed by an astonishing outcome of the patient; on the other hand, it shows how the resuscitation algorithms can save lives in complex circumstances.

Our air rescue service was called to an underground construction site for a 22-year-old patient with multiple traumata after a 13-m fall. Because of the danger and the safety regulations on the scene, the local rescue practitioners treated the patient and brought him to our rescue team on the surface 60 minutes after the trauma and 15 minutes after intubation (Fig.). Our first encounter showed an obviously severely injured patient. To anticipate later diagnostics, he showed open craniofacial injury with pneumencephalon, open arm fractures, blunt chest trauma, Abdominal injury with liver hematoma, traumatic inguinal hernia (ileum), perforated large bowel, and pelvic fracture. We followed the ABCDE approach and saw (A) estimated tracheal intubation; (B) symmetrical rising of the chest, choking, with manual bag to tube ventilation, end-tidal CO2 (etCO2) 0 kPa, oxygen saturation as measured by pulse oximetry (SpO2) showed pulse pletysmography without oxygen value; (C) no electrocardiogram attached, palpable central pulse 100 per minute, large bore venous access; (D) Glasgow Coma Scale 3, pupils equal 5 mm reactive to light, sedation with midazolam and ketamine to facilitate “intubation” 15 minutes earlier; no paralytic agent was given; (E) severely injured patient with a tense abdomen. We immediately attached an electrocardiogram, which now showed a slow broad complex rhythm without palpable pulse, consistent with pulseless electric activity (PEA), and manual chest compression (cardiopulmonary resuscitation [CPR]) was started. One milligram of adrenaline (epinephrine) was given intravenously according to PEA algorithm. Reassessment indicated an absent chest rise despite bag ventilation. On inquiry, we found that etCO2 was 0 kPa since the initial intubation 15 minutes earlier. Under CPR, the tube was removed from the esophagus, and mask ventilation initiated without any difficulty. Oxygen saturation as measured by pulse oximetry climbed to 80%, and the patient regained spontaneous circulation. Cardiopulmonary resuscitation was stopped after 90 seconds in total. One successful attempt of orotracheal

intubation was performed (Cormack and Lehane grade 3), and manual ventilation over the endotracheal tube begun with 100% oxygen. Thereafter, SpO2 reached 100%, and the first etCO2 was 6.8 kPa (measured with the same equipment). Mechanical ventilation was initiated. Circulation was stable without further inotropic support. After helicopter transport to the hospital, the patient received Damage control surgery, was extubated on day 8 after the event, and left the hospital 2 months later without any neurologic deficit.

Unrecognized esophageal intubation is frequent [1], and traumatic PEA resuscitation is often futile [2], so there are 3 messages that we want to address:

Stay with the algorithms, reassess, and think of Reversible causes, even if the situation seems crystal clear [3].
  • Use capnography after endotracheal intubation [4], do not accept technical problems for absent expiratory CO2 [1], “if in doubt take it out.”
  • Use the “silver standard” (laryngeal mask, laryngeal tube, or just mask ventilation), if the gold standard is not successful [4,5].
  • The authors thank the Division of Intensive Care, Hospital of Graubuenden, Chur, Switzerland, for the delivery of the clinical data.

    Philipp Stein, MD

    Institute of Anesthesiology University and University Hospital of Zurich

    Zurich, Switzerland Swiss Air-Ambulance

    REGA (Rettungsflugwacht/Guarde Aerienne)

    Zurich, Switzerland E-mail address: [email protected]

    Roland Albrecht, MD

    Swiss Air-Ambulance REGA (Rettungsflugwacht/Guarde Aerienne)

    Zurich, Switzerland

    Donat R. Spahn, MD

    Institute of Anesthesiology University and University Hospital of Zurich

    Zurich, Switzerland

    http://dx.doi.org/10.1016/j.ajem.2014.01.050

    ? Funding: None.

    0735-6757/(C) 2014

    image of Fig

    Fig. Chronology of the accident and rescue mission. ROSC, Return of spontaneous circulation.

    References

    1. Cook TM, MacDougall-Davis SR. Complications and failure of airway management. Br J Anaesth 2012;109(S1):i68-85.
    2. Martin SK, Shatney CH, Sherck JP, et al. Blunt trauma patients with prehospital pulseless electrical activity : poor ending assured. J Trauma 2002;53: 876-81.
    3. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: electrolyte

      abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asth- ma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2010;81:1400-33.

      Deakin CD, Nolan JP, Soar J, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation 2010;81: 1305-52.

    4. Hasegawa K, Hiraide A, Chang Y, et al. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of- hospital cardiac arrest. JAMA 2013;309:257-66.

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