Tag Archives: Tips

All Updates, ICU, PHARM, Resus, Trauma

GCS in intubated patients

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We use the Glasgow Coma Score to describe conscious level, derived from eye opening, verbal response, and motor response.
One problem is that if your patient is intubated, there can’t be a verbal response. There are some ways round this. Imagine your intubated patient opens eys to a painful stimulus and withdraws his limb from one:

  • Just give him the lowest score (1) for the verbal component – E2M4V1
  • Write ‘V’ (ventilated) or ‘T’ (tube), eg. E2M4VT
  • Make it up, based on what you would expect the V score to be based on the E and M scores.

Weird as it sounds, there is a model for this, demonstrated in the paper abstracted below. The Derived Verbal Score = -0.3756 + Motor Score * (0.5713) + Eye Score * (0.4233).

Don’t worry…if you really want to use this, you don’t have to memorise that equation; there is an online calculator for it here and if you try it you’ll see this patient gets a derived verbal score of 2.3, and therefore a GCS of 7.3! Your decision now whether to round up or down. (In the meantime, I’ve given the patient a V of 1 and called it GCS E2M4VT=7.)
Alternatively, of course, you could try a better validated score that gives more information, the FOUR score, as validated here. The problem is, most people won’t know what you’re talking about.
The conundrum of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores.
Meredith W, Rutledge R, Fakhry SM, Emery S, Kromhout-Schiro S.
BACKGROUND: The Glasgow Coma Scale (GCS), which is the foundation of the Trauma Score, Trauma and Injury Severity Score, and the Acute Physiology and Chronic Health Evaluation scoring systems, requires a verbal response. In some series, up to 50% of injured patients must be excluded from analysis because of lack of a verbal component for the GCS. The present study extends previous work evaluating derivation of the verbal score from the eye and motor components of the GCS.
METHODS: Data were obtained from a state trauma registry for 24,565 unintubated patients. The eye and motor scores were used in a previously published regression model to predict the verbal score: Derived Verbal Score = -0.3756 + Motor Score * (0.5713) + Eye Score * (0.4233). The correlation of the actual and derived verbal and GCS scales were assessed. In addition the ability of the actual and derived GCS to predict patient survival in a logistic regression model were analyzed using the PC SAS system for statistical analysis. The predictive power of the actual and the predicted GCS were compared using the area under the receiver operator characteristic curve and Hosmer-Lemeshow goodness-of-fit testing.
RESULTS: A total of 24,085 patients were available for analysis. The mean actual verbal score was 4.4 +/- 1.3 versus a predicted verbal score of 4.3 +/- 1.2 (r = 0.90, p = 0.0001). The actual GCS was 13.6 + 3.5 versus a predicted GCS of 13.7 +/- 3.4 (r = 0.97, p = 0.0001). The results of the comparison of the prediction of survival in patients based on the actual GCS and the derived GCS show that the mean actual GCS was 13.5 + 3.5 versus 13.7 + 3.4 in the regression predicted model. The area under the receiver operator characteristic curve for predicting survival of the two values was similar at 0.868 for the actual GCS compared with 0.850 for the predicted GCS.
CONCLUSIONS: The previously derived method of calculating the verbal score from the eye and motor scores is an excellent predictor of the actual verbal score. Furthermore, the derived GCS performed better than the actual GCS by several measures. The present study confirms previous work that a very accurate GCS can be derived in the absence of the verbal component.
The conundrum of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores.
J Trauma. 1998 May;44(5):839-44 (if you have full text access to Journal of Trauma the best bit about this article is the discussion on pages 844-5 in which surgeons wrestle with the meaning of the word ‘conundrum’ and the spelling of ‘Glasgow’).

All Updates, ICU, Kids, PHARM, Resus

Paediatric airway gems

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Dr Rich Levitan has made an enormous contribution to the science and practice of emergency airway management, as his bibliography demonstrates. In a new article in Emergency Physicians Monthly entitled ‘Demystifying Pediatric Laryngoscopy’, Rich covers some great tips for optimising laryngoscopic view in kids.
Check this excerpt out for an example:
“During laryngoscopy in infants the epiglottis and uvula are often touching; the epiglottis may be located within an inch of the mouth. Often the epiglottis lies against the posterior pharynx, and it is critical to have a Yankauer to dab the posterior pharynx as the laryngoscope is advanced. Hyperextension of the head pushes the base of tongue and epiglottis backwards against the posterior pharyngeal wall, and makes epiglottis identification more difficult”
Gems like this come thick and fast when you hear or read what Rich has to say. Seven years ago I was left reeling after finishing his ‘Airway Cam Guide to Intubation and Practical Emergency Airway Management‘ which profoundly influenced the way I practice and teach emergency airway skills, including on the Critical Care for Emergency Physicians course.

I’ve finally gotten round to booking a place on one of his courses in March in Baltimore. I’ll let you know how it goes. In the mean time, I’d like to point you toward his training videos as a great educational resource, like this one that demonstrates for novice laryngoscopists the difference between the appearances of trachea and oesophagus, the former having recognisable, defined posterior cartilagenous structures:

Demystifying Pediatric Laryngoscopy
Emergency Physicians Monthly January 19, 2011

All Updates, ICU, PHARM, Resus

Bleeding Tracheostomy

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Adapted from the UK Intensive Care Society’s ‘Standards for the care of adult patients with a temporary tracheostomy‘

Bleeding from an established tracheostomy (ie. ‘late bleeding’, as to opposed to peri-operative bleeding that is more common and often benign) may occur because of erosion of blood vessels in and around the stoma site. This is more likely if there has been infection of the stoma site. Such bleeding may settle with conservative management. More worryingly, however, is the prospect of such bleeding being the result of erosion of a major artery in the root of the neck where there has been pressure from the tracheostomy tube itself or the cuff tube. Most commonly, this erosion occurs into the right brachiocephalic artery (also known as the innominate artery), resulting in a tracheo-innominate artery fistula. This situation may be heralded in the preceding hours by a small, apparently insignificant, sentinel bleed. Bleeding from such a fistula will be massive. THIS IS A LIFE-THREATENING EMERGENCY and so decisions need to be rapidly made.

  1. Call for help– senior medical and nursing staff, other health professionals with tracheostomy care skills (e.g. respiratory therapist, physiotherapist).
  2. Clear airway – blood clots may need to be suctioned.
  3. Replace blood products as required
  4. Bleeding may be temporarily reduced or stopped by applying finger pressure to the root of the neck in the sternal notch, or by inflating the tracheostomy tube cuff (if present) with a 50ml syringe of air. This inflation should be done slowly and steadily to inflate the balloon to a maximum volume without bursting it. Depending on the type and size of the tracheostomy tube this may be anywhere between 10 and 35 ml.
  5. Urgent referral for surgical exploration must now be made, if not already done so. In addition to an ENT or maxillofacial surgeon, it may be necessary to get help from a vascular surgeon. Sometimes, the damage can only be repaired utilising cardio-pulmonary bypass, and so a cardiothoracic surgeon may also be needed to help.
  6. Consider palliation – it is well recognised that fatalities occur in this situation, and that this may be the mode of death for some patients with head and neck cancers
Acute Med, All Updates, ICU, PHARM, Resus

Tracheostomy resources

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The National Tracheostomy Safety Project at www.tracheostomy.org.uk in the UK aims to allow patients with tracheostomies or laryngectomies to be safely cared for in hospitals.
The site contains a wealth of educational resources of use to the critical care practitioner. For example, have you thought about what do with a laryngectomy patient who presents with dyspnoea, or even apnoea? Remember that although applying oxygen to the face & neck is a default emergency action for all patients with a tracheostomy, these patients cannot be intubated and ventilated through the normal oral route since their tracheostomy is an end stoma – it does not communicate with the mouth:

Compare this with the algorithm for other patients with a tracheostomy, in whom attempts to oxygenate and ventilate, including intubation, can be made in an emergency either from the ‘top end’ (mouth) or via the stoma:

There are also a number of multimedia resources and a link to the UK Intensive Care Society’s Tracheostomy Guidelines

All Updates, ICU, PHARM, Resus, Trauma

A tracheal tube in the chest

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Intercostal catheters can kink, obstruct, or get pulled out. These hazards are greater during transport of the patient. Critical care and retrieval medicine doctors in Queensland, Australia (where many people are having a bad time right now) have invented an elegant alternative: using a cuffed tracheal tube in the pleural space instead. It can be attached to a Heimlich valve.
They even used a bit of science to demonstrate its effectiveness, by creating pneumothoraces and haemothoraces in sheep and comparing the tracheal tube with a standard intercostal catheter (ICC).
The method for insertion is simple:

  1. Breach the pleura
  2. Insert a 14 Fr Cook intubating bougie into the thoracic cavity
  3. Railroad a 7.0 mm internal diameter tracheal tube (ETT) into the chest cavity
  4. Inflate the cuff
  5. Retract the tube until resistance is felt.
  6. Remove the ETT connector
  7. Attach a Heimlich valve

The results of the comparison are convincing: ‘The ETT proved faster to insert for both sheep. This was likely because it did not require suturing. Both the ETT and the ICC were comparable in draining blood. It was noted that neither tube was particularly effective when the haemothorax was positioned ‘side-up’. When turned ‘side-down’, both tubes successfully drained blood. Despite having multiple drainage ports, the ICC required more manipulation and was noted to kink. Conversely, the ETT with a single lumen and a Murphy eye, was stiffer and drained a similar amount of blood without the catheter having to be milked.’
Proposed advantages of this method include:

  • More portable equipment
  • Faster insertion
  • Provides kit redundancy
  • Does not require suturing
  • Avoids operator trauma from any sharp edges such as a fractured rib. (No attempt was made to place a finger into the chest cavity in the ETT group).
  • Allows for a smaller incision
  • Less trauma to the insertion site
  • Might also offer a back up, when conventional equipment has been exhausted.

The authors graciously note that both Portex and Cook have developed ICC kits that now go some way in supporting the original idea behind this study. These include flexible introducers (Portex) and guidewire insertion technique (Cook).
Appraisal of the endotracheal tube as an alternative to the intercostal catheter
Emerg Med Australas. 2010 Dec;22(6):573-4

All Updates, ICU, PHARM, Resus, Trauma

Less smelly than chicken drumsticks

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Emergency and orthopaedic doctors Elizabeth and Anthony Bateman from Britain describe their method of making a bone simulator for intraosseous cannulation training:

  • Take up to one Crunchie bar per trainee (leave in wrapper!) – this simulates the cancellous bone that is cannulated.
  • Tightly plaster cast with four layers of polyester cast tape (12.5 cm width matches closely to Crunchie bar length), cutting lengths of the cast tape as needed prior to immersing in water – this simulates the hard cortical bone.
  • Foam padding, or two layers of wool band from the plaster room, can be added to simulate soft tissue.


A quick google reveals it can be a challenge getting Crunchie bars in the United States. Maybe there’s a suitable honeycomb-centred alternative. If not you can resort to ordering them from Amazon.
Intraosseus access simulation: the Crunchie solution
Emerg Med J. 2010 Dec;27(12):961

All Updates, Kids

Newborn mask ventilation

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Seventy doctors and nurses from neonatal units administered positive pressure ventilation to a term newborn manikin using a Neopuff T-piece device. Recordings were made (1) before training, (2) after training in mask handling and (3) 3 weeks later. Leak and obstruction were calculated.
Median (IQR) leak was 71% (32–95%) before training, 10% (5–37%) directly after training and 15% (4–33%) 3 weeks later (p<0.001). When leak was minimal, gas flow obstruction was observed before, directly after training and 3 weeks later in 46%, 42% and 37% of inflations, respectively.
The training provided included the following demonstrated mask technique:

  1. Place the manikin’s head in a neutral position and gently roll the mask upwards onto the face from the tip of the chin.
  2. Hold the mask with the two-point-top hold where the thumb and index finger apply balanced pressure to the top flat portion of the mask where the silicone is thickest.
  3. The stem is not held and the fingers should not encroach onto the skirt of the mask.
  4. The thumb and index finger apply an even pressure on top of the mask.
  5. The third, fourth and fifth fingers perform a chin lift with the same pressure upwards as applied by the thumb and index finger downwards.


In this technique the mask is squeezed onto the face, between the downward thrust of the fingers and upward pull of the chin lift.
Leak and obstruction with mask ventilation during simulated neonatal resuscitation
Arch Dis Child Fetal Neonatal Ed 2010;95:F398-F402
Even with the right technique, adequacy of ventilation can be hard to assess. Principles to bear in mind are:

  • International guidelines recommend that infants with inadequate breathing or bradycardia be given positive pressure ventilation (PPV) via a face mask with a self-inflating bag, flow-inflating bag or T-piece device.
  • Adequacy of ventilation is then judged by assessing the heart rate.
  • However, if the heart rate does not increase, chest wall movements should be assessed to gauge adequacy of ventilation.
  • A human observational study reported a mean VT of 6.5 ml/kg in spontaneous breathing preterm infants in the first minutes of life.
  • When assisted ventilation is required, a peak inflating pressure (PIP) is chosen with the assumption that this will deliver an appropriate VT.
  • However, lung compliance and therefore the PIP required to deliver an appropriate VT vary in the minutes after birth.
  • It is likely that there are even greater differences between infants as the mechanical properties of the lung vary with gestational age and disease states.
  • In addition, many infants breathe during PPV adding to the inconsistency of VT delivered with a set PIP. Therefore, relying on a fixed PIP and subjective assessment of chest wall movement may result in either under- or over-ventilation.
  • Animal studies have shown that PPV with VT >8 ml/kg or inflations with large VTs can damage the lungs.

In an observational study of actual newborn resuscitations in Melbourne, researchers measured inflating pressures and VT delivered using a respiratory function monitor, and calculated face mask leak. After 60 seconds of PPV, resuscitators were asked to estimate VT and face mask leak. These estimates were compared with measurements taken during the previous 30 s.
In 20 infants, the median (IQR) expired tidal volume (VTe) delivered was 8.7 ml/kg (5.3–11.3). VTe and mask leak varied widely during each resuscitation and between resuscitators, who were also poor at estimating VT and mask leak.
Assessment of tidal volume and gas leak during mask ventilation of preterm infants in the delivery room.
Arch Dis Child Fetal Neonatal Ed. 2010 Nov;95(6):F393-7

All Updates, ICU, PHARM, Resus

LMA to stoma ventilation

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Level 1 evidence is great, but for useful tips that can add options to your resuscitation toolbox there are some great finds in journal letters pages.
Try this one: An apneoic patient requires assisted ventilation in your resuscitation room. Bag-mask ventilation is ineffective. You then notice a mature tracheostomy at the same time that you’re told he had a laryngectomy. How would you ventilate him?
The obvious answer is to intubate the stoma with a size 6.0 tracheal tube or a tracheostomy tube if you have one. However prior to that you could bag-‘mask’ ventilate with a size 2 laryngeal mask airway applied to the stoma, holding the cuff in place with pressure through an index finger.

Such a technique is desribed in the context of an elective anaesthesia case in this month’s Anaesthesia. The LMA cuff provided an effective seal around the stoma, thereby allowing leak-free ventilation.
Stoma ventilation using a paediatric facemask is another option.

Tracheostomy ventilation using a laryngeal mask as a ‘bridge to extubation’
Anaesthesia 2010;65(12):1232–1233

All Updates, ICU, Resus, Trauma

Fibrinogen concentrate

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A case report of massive obstetric haemorrhage due to placental abruption describes the successful management of haemorrhage associated with a low fibrinogen level with blood products that included fibrinogen concentrate.

Fibrinogen concentrate can be available more quickly than other clotting products as it is rapidly solubilised from an ampoule in 50 ml water and given as a bolus. To raise the plasma fibrinogen concentration by 1 g/l in a 70-kg person, 1000 ml fresh frozen plasma (6 standard UK units), or 260 ml cryoprecipitate (10 standard UK units) will be required. Administration of adequate doses of fresh frozen plasma or cryoprecipitate to treat hypofibrinogenaemia during obstetric haemorrhage will therefore take a substantial amount of time, even with an efficient blood bank and portering system.
Fibrinogen concentrate use during major obstetric haemorrhage
Anaesthesia 2010;65(12):1229–1230
A previous retrospective study showed its use in a series of surgical and obstetric haemorrhage cases may have been associated with a subsequent decreased need for other blood products.
Fibrinogen concentrate substitution therapy in patients with massive haemorrhage and low plasma fibrinogen concentrations
Br. J. Anaesth. (2008) 101 (6): 769-773 (Full text)

All Updates, ICU, Resus

Left molar approach

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The left molar approach is a technique to improve the view at laryngoscopy using a standard macintosh laryngoscope. It was described by Yamamoto1 as follows:

  • insert the blade from the left corner of the mouth at a point above the left molars;
  • the tip of the blade is directed posteromedially along the groove between the tongue and the tonsil until the epiglottis and glottis come into sight;
  • before elevating the epiglottis, the tip of the blade is kept in the midline of the vallecula and the blade is kept above the left molars;
  • the view provided is framed by the flange, the lingual surface of the blade, and the tongue bulged to right of the blade.


The success of this approach in comparison with alternatives has been reproduced by others2. However although Yamamoto and others demonstrated that this improved the laryngoscopic view, actual intubation may still be difficult because of the limited access to the cords, in part caused by the bulging of the tongue.
Physicians from Turkey described a case3 of an unpredicted difficult airway to demonstrate that the use of the gum elastic bougie can facilitate intubation which had otherwise not been successful via the left molar approach.
The take home message for me is that if I have a grade IV view despite my usual first-pass success optimisation manoeuvres such as positioning, reducing or releasing cricoid pressure, and providing external laryngeal manipulation, it is worth trying the left molar approach in combination with a bougie to gain a view of the glottis and to pass the tube.
1. Left-molar Approach Improves the Laryngeal View in Patients with Difficult Laryngoscopy
Anesthesiology. 2000 Jan;92(1):70-4 Full Text
2. Comparative Study Of Molar Approaches Of Laryngoscopy Using Macintosh Versus Flexitip Blade
The Internet Journal of Anesthesiology 2007 : Volume 12 Number 1
3. The use of the left-molar approach for direct laryngoscopy combined with a gum-elastic bougie
European Journal of Emergency Medicine December 2010 ;17(6):355-356