Complications of a Retrograde Intubation in a Trauma Patient

Abstract

Abstract. The authors report the case of an elder woman involved in a motor vehicle collision (MVC) requiring emergent intubation using the technique of retrograde intubation (RI). Since RI is a blind technique, potential complications arising from its use are numerous and may result in increased morbidity and mortality. Such was the case of this RI that involved incorrect placement of the endotracheal tube (ETT), resulting in suboptimal ventilation and increased morbidity. Additionally, this case illustrates how the failure to detect this error in multiple settings (ambulance, helicopter, emergency department) led to unnecessary and potentially deleterious procedures and significant delay in providing the basics of trauma care, oxygenation and ventilation. Although theoretical complications of RI have been addressed in the past, there have been very few published reports of actual complications. The emergency physician must be aware of difficult airways, options available to establish alternative airways, and methods to confirm appropriate placement of the ETT. The authors also discuss the indications, procedures, and complications involved in performing an RI. Key words: endotracheal intubation; retrograde intubation; airway. ACADEMIC EMERGENCY MEDICINE 2000; 7: 1267-1271 R ETROGRADE intubation (RI) has been used successfully in patients with difficult airways as an alternative method of establishing a definitive airway when more conventional and less-invasive methods are unsuccessful. As opposed to surgical cricothyrotomy, RI is less invasive and requires minimal training.1,2 This case illustrates one of many possible complications associated with RI. CASE REPORTAn 80-year-old woman was the front-seat, restrained passenger of a severe motor vehicle collision (MVC) requiring prolonged extrication. The local emergency medical services (EMS) unit notified the Level 1 trauma center and requested a scene run by the helicopter service. Prior to the helicopter arrival, the patient was extricated and the decision was made by EMS to transport the patient to a nearby community hospital and meet the flight team at the helipad. The patient was showing signs of severe closed head injury with a Glasgow Coma Scale score (GCS) of 5-6. While awaiting the arrival of the helicopter, the patient had two large-bore intravenous catheters placed for fluid resuscitation in the back of the ambulance. A non-emergency medicine (EM)-trained physician staffing the local emergency department (ED) joined the EMS crew in the ambulance and attempts were made to stabilize the airway using rapid-sequence intubations (RSI). The patient proved to have a very difficult airway and could not be intubated by the EMS personnel or the physician using direct-visualization laryngoscopy. The flight crew arrived and determined that since intubation was unsuccessful using direct laryngoscopy, they would perform RI. The procedure was performed by one of the flight nurses. This nurse had four years of experience as a flight nurse and had received training in...

Does the Site of Anterior Tracheal Puncture Affect the Success Rate of Retrograde Intubation? A Prospective, Manikin-Based Study

“…While some authors recommend a greater degree of tension be held on the retrograde wire to increase the odds of ETT passage [8], this tension may result in bleeding, edema, and trauma to the local tissues. Others recommend rotating the tube as it approaches the cords [43], but this evidence is anecdotal at best. A puncture site caudal to the cricothyroid membrane would seem to offer the advantage of a greater distance between the retrograde wire and the impinging structures, as well as a reduction in the acuity of the angle the ETT must negotiate into the trachea.…”

Retrograde tracheal intubation

“…Tracheal tubes made of polyvinyl chloride when compared with armoured and silicon tubes have been shown to exert considerably higher pressure on the point of contact [66]. Application of overzealous pressure has resulted in folding of the tube inside the airway [67].…”

“…The tip of the tube is harnessed either by retrograde guide stitched to it (4) or by a loop of retrograde guide tightened around it (5) and is then pulled down from the pharynx into the larynx. Suction catheters (cooled for added firmness) [66,67] Eschmann TM guide modified by severing the end [72] Guide wire sheath [3] Multi-lumen catheter [14] Airway exchange catheter [73] Custom made guide made by Cook (Cook Critical care, Bloomington, IN, USA) Flexible fibreoptic endoscope [13,25,[79][80][81] Anchor AG + RG Figure 4 In addition to an anterograde guide (AG) over retrograde guide (RG) an anchoring introducer is passed through the tracheal tube into the trachea. retrograde guide is released.…”

The Feasibility of Ultrasound to Assess Subglottic Diameter

“…1 In an emergency department review of 1368 charts, Gill et al 2 found that retrograde tracheal intubation was attempted in 8 patients and was successful in only 4. The usual technique for retrograde intubation is to pass a long guidewire through the cricothyroid membrane and angle it cranially for it to pass through the vocal cords and appear in the oropharynx, after which an endotracheal tube and/or fiberoptic scope is railroaded over the wire.…”