Intratracheal “kinking” and retroflexion of a nasotracheal tube

CORRESPONDENCE

ous coronary dissection: A cluster of cases with this rare finding. Am Heart J 1994;127:1382-1387 5. Bateman AC, Gallagher PJ, Vincenti AC: Sudden death from coronary artery dissection. J Clin Pathol 1995;48:781-784 6. Shaver PJ, Carrig TF, Baker WP: Postparum coronary artery dissection. Br Heart J 1978;40:83-86 7. Ellis C J, Haywood CA, Monro JL: Spontaneous coronary artery dissection in a young woman resulting from an intense gymnasium "work-out." Int J Cardiol 1994;47:193-194 8. Azam MN, Roberts DH, Logan WF: Spontaneous coronary artery dissection associated with oral contraceptive use. Int J Cardiol 1995;48:195-198 9. Fournier JA, Lopez-Pardo F, Fernandez-Cortacero JA, et al: Spontaneous coronary dissection in mitral stenosis. Eur Heart J 1995;16:869-871 10. Masuda T, Akiyama H, Kurosawa T, et al: Long-term follow-up of coronary dissection due to blunt chest trauma with spontaneous healing in a young woman. Intensive Care Med 1996;22: 450-452 11. Ades LC, Waltham RD, Chiodo AA, et al: Myocardial infarction resulting from coronary artery dissection in an adolescent with Ehlers-Danlos syndrome type IV due to a type Ill collagen mutation. Br Heart J 1995;74:112-116 12. Morise AP, Hardin NJ, Bovill G: Coronary artery dissection secondary to coronary arteriography:Presentation of three cases and review of literature. Cathet Cardiovasc Diagn 1981;7:283-296 13. Pasternak RC, Braunwald E, Sobel BE: Acute myocardial infarction in Braunwald E (ed): Heart Disease: A Textbook of Cardiovascular Medicine. Philadelphia WB Saunders, 1988 pp 12221250 14. Basso C, Morgagni GL, Thiene G: Spontaneous coronary artery dissection: A neglected cause of acute myocardial ischemia and sudden death. Heart 1996;75:451-454 15. Corrado D, Thiene G, Cocco P, et al: Non-atherosclerotic coronary artery disease and sudden death in the young. Br Heart J 1992;68:601-607 16. Benham R, Tillinghast S: Thrombolytic therapy in spontaneous coronary artery dissection. Clin Cardiol 1991 ;14:611-614 17. Cripps TR, Morgan JM, Richards AF: Outcome of extensive coronary artery dissection during coronary angioplasty. Br Heart J 1991 ;66:3-6

INTRATRACHEAL "KINKING" AND RETROFLEXION OF A NASOTRACHEAI.TUBE T o t h e E d i t o r : - We report a previously unreported complication of prehospital nasal intubation, and it's description should help raise our awareness for the potential of this complication to occur again, both in oral as well as nasal intubation routes. A Life Flight helicopter was dispatched to the scene of a single-vehicle motor vehicle collision (MVC) versus a tree. En route radio report alerted crewmembers to expect a single young male patient with severe closed head injuries, who had exhibited seizure activity that had stopped after IV lorazepam, and was currently intubated. Prehospital care providers had pronounced the driver of the vehicle at the scene by protocol after blunt traumatic arrest with nonsurvivable injuries. On landing at the scene, the aeromedical crew was met at the side of the road by EMS providers, with the patient being bagged easily with bilateral breath sounds through an 8.0 mm nasotracheal tube. The patient was unresponsive initially for the flight crew with best preflight Glasgow Coma Scale (GCS) of 6 to 7 by EMS, and no history of hemodynamic instability. The patient was carried to the aircraft secured to a backboard with appropriate straps and cervical immobilization devices, and hot-loaded into the aircraft for transport to the St. Vincent Mercy Medical Center level I trauma center. After closing the aircraft

Copyright © 2001 by W.B. Saunders Company 0735-6757/01/1905-0015535.00/0 doi: 10.1053/ajem.2001.24479

455

FIGURE 1.

Initial chest radiograph.

doors, the patient became violently combative, breaking out of some of the straps and disconnecting his IV line in the process. Pink frothy secretions continued to exit his nasotracheal tube during his securing to the backboard, and chemical paralysis and sedation using vecuronium and midazolam allowed for eventual patient control. The patient's oxygen saturation was only in the 80 th percentile following chemical paralysis; and capnography readings through the nasotracheal tube were as high as 58 ram. Bag ventilation resulted in bilateral chest expansion, a confirmatory FEF was positive for a color change, and frothy pink pulmonary secretions continued to exit the tube during ventilation. Despite aggressive bagging the oxygen saturation persisted to be low, and the capnography readings continued to be high. The endotracheal tube position was verified visually during transport using direct laryngoscopy, and the nasotracheal tube was visualized going through the vocal cords. The tube was kept in place and bag ventilation continued for the duration of the 20-minute flight, with small ( < 1 cm) adjustments of the endotracheal tube allowing for more effective ventilation. In the resuscitation bay the oxygen saturation had risen to the 90 th percentile and repeated auscultation of the chest verified bilateral breath sounds with each bagged ventilation. Continued capnography monitoring and colorimetric color change added to the clinical confirmation of nasotracheal tube placement. There were continued advenfitial crackles noted, especially in the left base, and pink frothy pulmonary secretions continued exiting the nasotracheal tube. The patient was placed on a ventilator for controlled ventilation and resuscitation continued. Trauma bay chest radiography initially showed a slightly high intrathoracic placement of the nasotracheal tube (see Fig 1). Approximately 10 minutes into the resuscitation the respiratory therapist was directed to advance the nasotracheal tube, which was done in standard fashion after deflating the pilot balloon. The patient was placed back on the ventilator, and a cross table lateral radiograph of the neck was taken. Shortly after taking this film the patient could not be effectively ventilated with either ambu bag or ventilator, and bradycardia resulted. The prehospital placed nasotracheal tube was removed and the patient was orally intubated without any problem with much better aeration and ventilation. This procedure was per-

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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 19, Number 5 • September 2001

formed by the same aeromedical crewmember that had visualized endotracheal tube placement in the aircraft. Initial inspection of the removed endotracheal tube showed no obstructing clot or foreign matter, but there was some concern that the pilot balloon was asymmetric and may have herniated over the Murphy's eye at the tip of the tube, which had been described previously in the literature. 1,2 It was at this time that the previously exposed lateral neck film was brought into the resuscitation bay after developing. Suprisingly the endotracheal tube was actually bent back on itself in an intratracheal position (see Fig 21), with the distal end of the tube pointing up towards the nasopharynx from which it had been introduced. Closer review of the prior chest film (see Fig 1) showed some blurring of the tip of the endotracheal tube with a small distal bend directed towards the right clavicle. The main body of the tube was unobstructed however, until tube advancement: eventually causing a complete kink and total obstruction of the endotracheal tube. We have subsequently theorized that the distal few centimeters of the nasotracheal tube were actually minimally retroflexed during transport, but the bend still allowed for chest expansion and aeration, a positive end-tidal capnography reading, visualization of the endotracheal tube going through the vocal cords, and exit of pulmonary secretions. There was no hemodynamic instability of the patient during transport, so we propose that a ball-valve effect causing hemodynamically significant auto-PEEP was not present. 3 When the nasotracheal tube was advanced in the trauma bay, the tube curled on itself inside the trachea. This completely occluded the artificial airway and resulted in hemodynamic compromise. Environmental issues may have contributed to the relative ease of this retroflexion, as the endotracheal tube becomes quite flexible during the heat of a summer day. The tube used by the EMS crews, a directed tip Endotrol tube, may have also facilitated the initial

minor retroflexion during the insertion, as it tends to be more flexible than standard endotracheal tubes. Postincident case review has raised the possibility with our flight crews that this could easily happen again in the future. This complication has never previously been considered, nor seen after querying our flight crews, emergency physicians, trauma surgeons, and respiratory therapists: and to our knowledge has not been previously reported in the aeromedical nor emergency medicine literature after computerized MEDLINE search for such a description of this complication. This has been described with the use of specialized double-lumen endotracheal tubes used in thoracic surgery, yet not to our knowledge in the emergency medicine literature. 4 In retrospect, it would have been easier to just replace the endotracheal tube during transport during the placement verifying laryngoscopy. However with chest expansion, bilateral breath sounds, positive capnography, frothy pink pulmonary secretions, and direct visualization of the tube going through the vocal cords the decision to remove a clinically confirmed tube was not done. The hypoxia and hypercapnia were initially contributed to a combination of pulmonary contusion (that existed both clinically and radiographically during the patient's resuscitation course) and possible neurogenic pulmonary edema. This has definitely been an educational case for the flight program, and we hope that radiographic documentation of such a complication in the literature will raise awareness if the clinical scenario repeats itself for aeromedical crews and emergency medicine personnel in the future. After case review and discussion our flight crews have wondered if we have seen this with endotracheal tubes in the past, and we just did not recognize the subtle retroflexion of the endotracheal tube tip for what it really was. The tube will still function for gas exchange, but respiratory therapy will be unable to suction the tube effectively. These tubes are routinely replaced in critical care units to allow for more effective secretion control, even though they may still function for aeration and ventilation. FeED A. SEVERYN,MD Denver Health Medical Center Denver, CO

References 1. Bar-Lavic Y, Gatot A, Tovi F: Intraoperative herniation of a tracheostomy tube cuff. J Laryngol Otol 1995; 109:159-160 2. Grime PD, Tyler C: An obstructed airway: Cuff herniation during nasotracheal anesthesia for a bimaxillary osteotomy. Br J Oral Maxillofac Surg 1991 ; 29:14-15 3. Moore FA, Haenel JB, Moore EE, et al: Auto-PEEP in the multisystern injured patient: An elusive complication. J Trauma 1990; 30:1316-1322 4. Van Dyck MJ, Astiz I: Kinking of a right-sided double-lumen tube in the right upper lobe bronchus. Anestesiology 1994; 40:682

CALCIUM CHANNEL BLOCKER INGESTIONS IN CHILDREN To the E d i t o r : - - T h e report by Belson et al regarding pediatric calcium channel blocker ingestions' provides some useful information about the demographics of this problem. The study, however, suffers from a number of limitations. The authors report on "ingestions" in children, when a more appropriate word might be "exposures." This difference is not trivial: exposure implies that a patient may have taken a drug, whereas ingestion implies that a patient did take a drug. As the authors point out, the actual concentration of the drug in the blood

FIGURE 2.

Cross table lateral neck film.

Copyright © 2001 by W.B. Saunders Company 0735-6757/01/1905-0016535.00/0 doi: 10.1053/ajem.2001.24507