# Airway Management in Head Trauma (Scenerio)



## NPO (Oct 22, 2017)

You arrive on scene of a 2 vehicle MVA involving a car and a prison transport van. The car tboned the van which caused it to roll. You are first on scene arriving with the FD and 2 additional ambulances are en route. 

For the purposes of the scenerio, you will only be responsible for one patient; the prisoner.

You approach the van which is on its side and upon opening the rear door you locate one approximately 50 year old male inmate. The patient is shackled at his hands and feet, but was obviously not restrained by a seatbelt. He is wedged against the bulkhead with his neck at a near 90* angle. You assess his GCS to be 5 (1-1-3). He has snoring respirations, and two swolen eyes with unequal and non-reactive pupils. Rapid trauma assessment reveals an otherwise unremarkable exam except a few superficial lacerations. 

Your nearest Trauma Center is a Level 2, 40 minutes away by ground. The nearest transport helicopter has a 45 minute ETA to scene. 

Upon removal from the van a CCollar is applied, and an OPA resolves the snoring. 

HR: 140
BP: 180/100
RR: 14, regular, improved with OPA, occasional snoring
BGL: 96
SPO2: 96% on 10lpm

I'd like to hear how everyone would treat the patient, with particular attention to airway.


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## Qulevrius (Oct 22, 2017)

I don’t see any particular indication for RSI, due to a <8 RR and unobstructed airway. The OPA should do the trick, keep him on high flow O2 (I would increase to at least 15LPM and monitor saturation), start for the trauma center & request airlift en route to minimize transport time. His neuro and BP are way more alarming, obviously increased ICP so sedate with benzos, give hypertonic bolus & induce hypothermia with icepacks.


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## SpecialK (Oct 22, 2017)

If the major trauma hospital is 40 minutes away by road ambulance, and the patient can leave in said road ambulance without undue delay (less than say, 15 minutes from now) there is no benefit in calling the helicopter unless either the only way to get an RSI Officer is by helicopter (which is not unlikely) or the major trauma hospital is not a major trauma hospital with neurosurgical facilities, and in either case they can meet us en-route.

My management? LMA, gain IV access in case we need it later, call for RSI Officer and start moving +/- meet helicopter en-route.

His very high blood pressure and unequal, unreactive pupils are quite worrying but about that I can do nothing.


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## Qulevrius (Oct 22, 2017)

SpecialK said:


> My management? LMA, gain IV access in case we need it later, call for RSI Officer and start moving +/- meet helicopter en-route.



You don’t want _any_ tube near that crooked airway, unless the pt gets severely hypoxic.


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## SpecialK (Oct 22, 2017)

Qulevrius said:


> You don’t want _any_ tube near that crooked airway, unless the pt gets severely hypoxic.



.... because?


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## TXmed (Oct 22, 2017)

As per your exam my primary concern is airway and less any catastrophic hemmorage. Im gonna choose to perform RSI while im still and not moving for transport that way i have all hands on to assist.

Place NC+NRB at flush rate to begin preoxygenation for atleast 2minutes while i prepare fully. Administer lido + fent. Prepare both suctions immediatly. Position patient in a ramping/HELLP position. I use a bougie on every airway. Ill have an airway assistant to my left prepared to help with guided crc pressure. Ill undo the c-collar and have an assistant hold stabilization. Im cool with using ketamine or etomidate as induction but will want rocuronium as my paralytic. Have ETCO2 on my bvm remove NRB and apply apnic CPAP to raise the spo2 to the highest i can. Remove OPA. Suction then attempt intubation with bougie. Aborting if spo2 drops to 93%-92% to reoxygenate or if SBP reduces below 110. Use high dose fentany and low to moderate dose versed as post intubation sedation.


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## TXmed (Oct 22, 2017)

Qulevrius said:


> You don’t want _any_ tube near that crooked airway, unless the pt gets severely hypoxic.



If you wait until the patient gets hypoxic to do something then youve already lost the battle


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## Qulevrius (Oct 22, 2017)

SpecialK said:


> .... because?



Because per scenario, the pt has a traumatic head/neck injury and the last thing you want to do is to remove the c-collar. Also because with that neuro presentation, the pt stands a pretty good chance of hernia which, when happens, will kill him regardless. And lastly because once you drop a tube, you better be prepared to ventilate and monitor CO2 output very closely - which I’m entirely not sure you have the tools for, unless you’re on a ground CCT with an RT or intensivist as a partner. Not to mention that you’ll be glued to that tube 150% of the time.


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## GMCmedic (Oct 22, 2017)

GCS of 5 and no gag reflex gets a tube while were sitting still.


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## TXmed (Oct 22, 2017)

Qulevrius said:


> Because per scenario, the pt has a traumatic head/neck injury and the last thing you want to do is to remove the c-collar. Also because with that neuro presentation, the pt stands a pretty good chance of hernia which, when happens, will kill him regardless. And lastly because once you drop a tube, you better be prepared to ventilate and monitor CO2 output very closely - which I’m entirely not sure you have the tools for, unless you’re on a ground CCT with an RT or intensivist as a partner. Not to mention that you’ll be glued to that tube 150% of the time.



Most airway experts suggest removing the collar and holding manual during the attempt. There has also been extremely very few instances of an intubation attempt further injuring a spinal patient. If he is going to herniate then he will do it with or without an ET/LMA in his mouth, that makes no difference. Present your LOC neuro assessment clearly to the recieving trauma staff. You can hyperventilate with bvm or vent to an etco2 of no less than 30 for short periods of time, but this patient is not presenting with cushings or uncontrolled seizures so i do not think that is necessary. In fact if you fail to be aggressive with this airway the patient could be hypercapnic for the entirety of the transport thus worsening his condition, if you wait for him to be hypoxic this will greatly worsen his conditon. 

The OP had no mention of blood in the airway, broken teeth, obese, beard etc. The biggest thing making this a difficult airway is the one guy on scene freaking out yelling just load and go. Im all for BLS before ALS and yada yada but if you do not feel confident in your skills to manage this patients airways then you should spend time on a manniken and find some books by george kovacs and levitan. Thats what i did.


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## Qulevrius (Oct 22, 2017)

TXmed said:


> Most airway experts suggest removing the collar and holding manual during the attempt. There has also been extremely very few instances of an intubation attempt further injuring a spinal patient. If he is going to herniate then he will do it with or without an ET/LMA in his mouth, that makes no difference. Present your LOC neuro assessment clearly to the recieving trauma staff. You can hyperventilate with bvm or vent to an etco2 of no less than 30 for short periods of time, but this patient is not presenting with cushings or uncontrolled seizures so i do not think that is necessary. In fact if you fail to be aggressive with this airway the patient could be hypercapnic for the entirety of the transport thus worsening his condition, if you wait for him to be hypoxic this will greatly worsen his conditon.
> 
> The OP had no mention of blood in the airway, broken teeth, obese, beard etc. The biggest thing making this a difficult airway is the one guy on scene freaking out yelling just load and go. Im all for BLS before ALS and yada yada but if you do not feel confident in your skills to manage this patients airways then you should spend time on a manniken and find some books by george kovacs and levitan. Thats what i did.



That’s exactly the rationale. His airway is patent and non obstructed with RR at 14. Monitor SpO2 & capno, but don’t tube ‘just in case’, because once you drop the tube, you won’t see the forest for the trees. And in this case the forest is the IC hypertension which, if left unaddressed, will kill him. You can’t trepanate and you can’t drain CSF, but you can try and address the issue with pharmaceuticals and hypothermia. Because at this particular point, his neck injury definitely is in the higher C’s (otherwise he wouldn’t be breathing at all) and his control centers aren’t affected; but if he herniates, the cerebrum will push the brain stem & it’s game over, tube or not.

Does that make sense ?


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## TXmed (Oct 22, 2017)

Airway management is just one part of a treatment you should be able to see the forrest just fine. He requires an OPA to make his airway somewhat patent and the man still has occasional snoring. Everything you describe could happen either way. Hes not going to neuro icu, the OR or getting an emmergency  drain without a more patent airway (atleast not in any trauma center in texas). Several studies on prehospital intubation report quicker times to CT or to OR.


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## RocketMedic (Oct 22, 2017)

I'd RSI, much as TxMed has suggested.


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## VentMonkey (Oct 22, 2017)

Etomidate—>Succs—>ETI*—>post ETI sedation/ analgesia—>VCV A/C (or ASV) FiO2- 1.0, peep-5, Vt- 6 to 8 ml/ kg IBW, f- 14 to 18 titrated to eucapnea.

*SGA at the ready with the rest falling in line as mentioned above.


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## VFlutter (Oct 22, 2017)

RSI, aggressive analgesia/sedation, and maintain a good MAP. Mildly hyperventilate to an ETC02 of 30 and Mannitol if signs of herniation. At least once he is intubated you can more precisely ventilate and monitor ETC02.  Hypoxia and Hypotension kills TBI patients, I am not going to sit there and wait for him to decompensate before attempting to intubate.


Technically they took Fentanyl out of pre-intubation medications for us but I would give a dose prior to induction. I would probably go with Ketamine for induction, Head Injury patient's usually don't have a sympathetic response so I wouldn't worry too much about hypertension.


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## VentMonkey (Oct 22, 2017)

@NPO, @Qulevrius a rapidly deteriorating level of consciousness can often indicate a extremely valid justification for aggressive prehospital airway management. I don’t know too many EM physicians that would fault EMS for utilizing a “hands on” approach on this one.


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## Qulevrius (Oct 22, 2017)

@VentMonkey you know that it’s purely academic for me. But at the same time, the scenario left me with an impression that the pt didn’t have a rapid deterioration but rather was unresponsive on scene, with a classic case of intracranial hypertension.


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## Colt45 (Oct 22, 2017)

There is going to be major variety in the answers to this. Initially whether or not your agency can do RSI, and the location of the incident. Is this in the country side with plenty of areas to land a bird- or are you in a very populated area and meeting a helicopter isn't really an option with nowhere to land? as far as the scenario goes, after dropping and OPA and seing my sats and RR  REGULAR (key phrase for me in this situation) are within normal limits I would continue assisting ventilation and call for that helicopter to meet me halfway. Where I'm at we can't do RSI  and his GCS is under 8. With obvious cerebral edema or hemmorhage and decorticateposturing. The more pressure builds up on the brain and Spinal cord the more likely this airway we are managing is going to go out the door. More than this guy needs me, he needs a hospital and a surgeon. I'm not wasting time on scene. I'll manage his airway and Spine and get some IV acess started so the flight crew have less to worry about. 

An easier answer exists for this. He needs a tube based purely on the fact that this is a head injury and a higher spine injury. His GCS  is low, and you potentially have a long transport time that gives that swelling a big opportunity to change his RR and work or breathing. Be proactive. Realize that when you get to where your going the first thing that doc is going to order is RSI to guarantee an airway with intracranial swelling and/or hemmorhage. If you do that this guy gets completely focused care on the injury that could kill him quickly.


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## DesertMedic66 (Oct 22, 2017)

Colt45 said:


> There is going to be major variety in the answers to this. Initially whether or not your agency can do RSI, and the location of the incident. Is this in the country side with plenty of areas to land a bird- or are you in a very populated area and meeting a helicopter isn't really an option with nowhere to land? as far as the scenario goes, after dropping and OPA and seing my sats and RR  REGULAR (key phrase for me in this situation) are within normal limits I would continue assisting ventilation and *call for that helicopter to meet me halfway.* Where I'm at we can't do RSI  and his GCS is under 8. With obvious cerebral edema or hemmorhage and *decorticateposturing*. The more pressure builds up on the brain and Spinal cord the more likely this airway we are managing is going to go out the door. More than this guy needs me, he needs a hospital and a surgeon. I'm not wasting time on scene. I'll manage his airway and Spine and get some IV acess started so the flight crew have less to worry about.
> 
> An easier answer exists for this. He needs a tube based purely on the fact that this is a head injury and a higher spine injury. His GCS  is low, and you potentially have a long transport time that gives that swelling a big opportunity to change his RR and work or breathing. Be proactive. Realize that when you get to where your going the first thing that doc is going to order is RSI to guarantee an airway with intracranial swelling and/or hemmorhage. If you do that this guy gets completely focused care on the injury that could kill him quickly.



The only information about the helicopter is that it is 45 minutes away and the level 2 is only 40 minutes away. Meeting the helicopter makes no sense to me. It’s going to take them 45 minutes just to get to your scene which doesn’t include landing time, crew egress, hand over, transferring patient to the airship, and then the take off time. That is if your area is comfortable doing hot loads. 

By the time all of that is completed the patient could already be at the hospital being treated. You also have to include the time it takes for the airship to land at the hospital and then the elevator ride (at least in all the trauma centers I have been to) down to the ED. Also keep in mind that flying ICP patients may actually make the pressure increase in addition to possibly making them hypothermic. 

I also didn’t read where the patient was posturing. Maybe I missed it in the OP.


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## Colt45 (Oct 22, 2017)

DesertMedic66 said:


> The only information about the helicopter is that it is 45 minutes away and the level 2 is only 40 minutes away. Meeting the helicopter makes no sense to me. It’s going to take them 45 minutes just to get to your scene which doesn’t include landing time, crew egress, hand over, transferring patient to the airship, and then the take off time. That is if your area is comfortable doing hot loads.
> 
> By the time all of that is completed the patient could already be at the hospital being treated. You also have to include the time it takes for the airship to land at the hospital and then the elevator ride (at least in all the trauma centers I have been to) down to the ED. Also keep in mind that flying ICP patients may actually make the pressure increase in addition to possibly making them hypothermic.
> 
> I also didn’t read where the patient was posturing. Maybe I missed it in the OP.



Well we hotload in situations like this but I see your point. This is just my opinion. Most of our helicopters fly low ( under 500 ft) with ICP. He was (1-1-3)  GCS which is where I got the posturing from.


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## DesertMedic66 (Oct 22, 2017)

Colt45 said:


> Well we hotload in situations like this but I see your point. This is just my opinion. Most of our helicopters fly low ( under 500 ft) with ICP. He was (1-1-3)  GCS which is where I got the posturing from.


Ahh, I missed the 3 motor score. 

Under 500 ft? I thought the FAA minimum was 500 ft in a non populated area and 1,000 feet in a populated area?


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## VentMonkey (Oct 22, 2017)

DesertMedic66 said:


> Under 500 ft? I thought the FAA minimum was 500 ft in a non populated area and 1,000 feet in a populated area?










Colt45 said:


> Most of our helicopters fly low ( under 500 ft) with ICP.


Remind me to never apply for a HEMS job in your area. We fly as low as reasonably  possible while staying legal, and safe. This sounds like a CFIT catastrophe waiting to happen.


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## VFlutter (Oct 22, 2017)

It is only FAA legal to fly 500ft if you have speakers capable of playing Ride of the Valkyries...

But really most patients, even with free air or increased ICP, do not have issues flying 1000ft.


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## Colt45 (Oct 22, 2017)

Chase said:


> It is only FAA legal to fly 500ft if you have speakers capable of playing Ride of the Valkyries...
> 
> But really most patients, even with free air or increased ICP, do not have issues flying 1000ft.



Haha that's awesome. Yeah I had a flight nurse tell me that literally a few days ago that 500 was what they liked to stay around with ICP if possible. I don't know their exact number though.


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## NPO (Oct 22, 2017)

Thank you everyone for your answers and input. 

In the above scenerio RSI was not available as part of my scope of practice, and would have only been available by helicopter which would have prolonged definitive care. I didn't mention, but can completely eliminate rendezvous with helicopter because the helicopter was coming from the West and the trauma center was east. 

So what ended up happening is I managed the airway BLS but took some extra hands with me in case things deteriorated. The patient was fairly active given his GCS; he would occasionally flex and move a bit, but none of it seemed purposeful. I wasn't confident in my ability to get a more advanced airway (without making things worse with a sympathetic response or aspiration) without PAI, which I didn't have. I aired on the side of caution. 

This scenario was to see how people would treat airway with respect to ICP. I'm not sure what current literature teaches but I was taught to be more reserved on TBI. That said, this is a rather obtunded patient. My new agency DOES carry PAI medications, which is why I was looking to compare notes.


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## TXmed (Oct 22, 2017)

@VentMonkey i think its less to do about elevation and more to do about stimulation (extreme noise, vibration etc.)

Also, i would go pressure control with this guy so i can control his mean airway pressure more accurately. But thats personal preference.

@Qulevrius some of my rationel, is that you have an anotomically difficult'ish airway with the spinal precations and face trauma. You potentially have a situationally difficult airway depending on provider experience. Its best to handle the airway prior to making it a physiollogicaly difficult airway by adding hypoxia,hypercapnea, and further herniation that would come down the road. (When all 3 of those meet thats when you get sentinel events). 

What do the anesthesia people think ? @Remi @E tank 

To the folks with neuro-critical care backgrounds how would your thought process be with mannitol/ hypertonic NS admin with this guy?


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## VentMonkey (Oct 22, 2017)

TXmed said:


> @VentMonkey i think its less to do about elevation and more to do about stimulation (extreme noise, vibration etc.)


An impractical solution given the much safer alternatives, and the realistically minimal changes it would have on the patient’s outcome.


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## RocketMedic (Oct 22, 2017)

Isn't altitude safety in case something goes wrong (like engine failure)? More energy for autorotation? Why not fly at a thousand meters and have some extra room for error?


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## Brandon O (Oct 22, 2017)

TXmed said:


> @VentMonkey Also, i would go pressure control with this guy so i can control his mean airway pressure more accurately. But thats personal preference.
> 
> To the folks with neuro-critical care backgrounds how would your thought process be with mannitol/ hypertonic NS admin with this guy?



Hard to say as we pretty much always have the CT. If he were truly unresponsive with a blown pupil after the initial event I suppose I would consider an empiric slug of hyperosmolar therapy.

Not sure what you mean about using pressure control.

I would say to intubate in the field if you're confident you can do it successfully and without hypotension or hypoxia. Otherwise defer if you think you can maintain without. Would be very wary doing it without drugs.


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## TXmed (Oct 22, 2017)

@Brandon O sorry bout that. I would preffer to use a pressure mode over a volume mode to better controll the mean airway pressure (MAP) as on most transport vents focusing on map gives you better control/understanding of how your ventilation is efficting hemodynamic status and cerebral drainage. Atleast in the out of hospital enviroment. So keep the patient oxygenated to Spo2 > 95%, ETCO2 35-40 (30 if needed for short spells) and decreasing the MAP (generally below 10) to assist in whats mentioned above are my ventilator goals during transport. Then adjusting rise time pressure support to keep patient comfortable and manage sedation so when i arrive the patient isnt snowed unless its needed. 

This is all personal preference for me. Volume mode is just fine just thought i would throw that in to stimulate convo.


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## VentMonkey (Oct 22, 2017)

The advent of PRVC in the transport ventilator setting is in, and of itself, quite the godsend.


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## TXmed (Oct 22, 2017)

@VentMonkey i do not have any hands on experience with PRVC in the transport setting. But thats great if you got it.

@Brandon O i know your settimg is more icu but, would you salt bomb this patient without a foley or labs ?


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## NPO (Oct 23, 2017)

VentMonkey said:


> The advent of PRVC in the transport ventilator setting is in, and of itself, quite the godsend.


Do the Hamiltons have PRVC? Our vent is pretty decent, but does lack any kind of pressure modes other than adjustable pmax.


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## StCEMT (Oct 23, 2017)

If I am playing within my service area, I am probably going to BLS the airway and personally be the one doing it with all the necessary back up equipment handy. I don't have any meds to intubate with. Technically I have Fent and Versed, but not in protocol for this. If I got to choose my preferred way? Probably Ketamine followed by Roc.


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## Akulahawk (Oct 23, 2017)

Here's a little bit of my own thought process as I initially read the scenario. I know the TC is 40 minutes, helicopter is 45 minutes away. I'm not flying this one because by the time the helicopter arrives on scene, I'm going to be about 5-10 minutes out from the hospital _and_ that means the patient is being evaluated by a trauma team about 20 minutes sooner with ground transport vs air. This is a no-brainer thing.


NPO said:


> You assess his GCS to be 5 (1-1-3). He has snoring respirations, and two swolen eyes with unequal and non-reactive pupils.


This instantly makes me think severe TBI.


NPO said:


> Upon removal from the van a CCollar is applied, and an OPA resolves the snoring.


Given the patient is tolerating the OPA, that means his airway reflexes are likely gone or minimal at best, so this guy is getting an ETT. I'm probably not going to RSI unless I cannot open his jaw. The swollen eyes take NTI out of the picture. Why intubate so early? Well, we're not moving so I have a stable place to do it. I want control of his airway and breathing as I suspect he's going to stop breathing on his own. He's also likely to vomit at some point and I want to prevent him from aspirating.


NPO said:


> HR: 140
> BP: 180/100
> RR: 14, regular, improved with OPA, occasional snoring
> BGL: 96
> SPO2: 96% on 10lpm


These vitals tell me he's not herniating yet, but again makes me think severe TBI and to minimize any delay in getting him to a surgeon. The occasional snoring even with the OPA in place tells me the OPA is incorrectly sized, incorrectly placed, or both. Either way this guy's getting an tube. I do _not_ want to have to scramble to intubate when this guy vomits... or loses his respiratory drive.

For those of you that are considering maintaining a BLS airway with this guy, consider that while this guy is breathing on his own (for now), he's occasionally snoring even with an OPA in place. Eventually as his ICP rises he's going to vomit and will aspirate. He will eventually require you to use a BVM. At that point, you'd best have another person in the back with you or you're going to be 100% focused on that BLS airway until you can place an advanced airway and get him on a vent. That means your workload dramatically increases while you're moving and if you have to stop moving to intubate, that's increasing the time to get him to a trauma team.


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## VentMonkey (Oct 23, 2017)

NPO said:


> Do the Hamiltons have PRVC? Our vent is pretty decent, but does lack any kind of pressure modes other than adjustable pmax.


PRVC is actually a VC mode, as the name implies. It monitors and adjusts the airway pressures in the patients lungs based on their efforts then delivers a set Vt accordingly. It requires somewhat less effort from the clinician in monitoring their airway pressures than your standard VCV modes, so it’s more of a “nice to have” mode.

If your vent has AC VC, you could utilize that and monitor their Pip’s and Pplats to make sure you’re where you want them, which is for us, a fairly restricted range. And yeah, the manufacturer programmed PRVC in our vents for us since it’s pretty much the standard in almost every ICU patient we transport and it’s much more practical to try and match their vent settings and parameters to begin with.


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## RocketMedic (Oct 23, 2017)

NPO said:


> Do the Hamiltons have PRVC? Our vent is pretty decent, but does lack any kind of pressure modes other than adjustable pmax.



What do you use?


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## FiremanMike (Oct 23, 2017)

Qulevrius said:


> Because per scenario, the pt has a traumatic head/neck injury and the last thing you want to do is to remove the c-collar. Also because with that neuro presentation, the pt stands a pretty good chance of hernia which, when happens, will kill him regardless. And lastly because once you drop a tube, you better be prepared to ventilate and monitor CO2 output very closely - which I’m entirely not sure you have the tools for, unless you’re on a ground CCT with an RT or intensivist as a partner. Not to mention that you’ll be glued to that tube 150% of the time.



Just a couple of thoughts here..
1. Current literature shows that c-spine injuries have either already occurred prior to arrival or are stable.  On top of that, removing a c-collar and holding manual c-spine during intubation has been common practice for many years now (even before we dispelled the "full c-spine precautions" myth).

2. Waveform capnography is the standard of care and standard equipment on ALS trucks around here, is that a regional thing?  It doesn't take a CCT/RT/Intensivist to bag at 8/min and watch the numbers/waveform..

3. While I don't THINK this is what you meant, you kind of imply that this person is going to die of a herniation, so why bother?  That's not really the mentality I like to see promoted in our field.  If we have a chance to potentially impact or improve morbidity/mortality, we should jump on those opportunities.

As for my management, I'm going to ask my partner to go draw up our crash airway drugs (rocketamine) and RSI as soon as we get into the truck.


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## Qulevrius (Oct 23, 2017)

FiremanMike said:


> Just a couple of thoughts here..
> 1. Current literature shows that c-spine injuries have either already occurred prior to arrival or are stable.  On top of that, removing a c-collar and holding manual c-spine during intubation has been common practice for many years now (even before we dispelled the "full c-spine precautions" myth).
> 
> 2. Waveform capnography is the standard of care and standard equipment on ALS trucks around here, is that a regional thing?  It doesn't take a CCT/RT/Intensivist to bag at 8/min and watch the numbers/waveform..
> ...



1) I’ve been indoctrinated with the ‘once the c-collar is on, it stays on’ approach.

2) I can watch the capno morphology and bag just fine. What I, unfortunately, cannot do, is grow an extra pair of hands for doing anything else. Only CCT trucks carry ventilators.

3) What I was saying is that, IMO, the risk of him herniating is significantly greater than the risk of him hypoxiating and, therefore, should be addressed immediately and aggressively with sedatives, osmotic procedures and body temp control. Because whilst there’s _something_ you can do about his airway if things start getting worse, there’s absolutely nothing you can do if/when the pt herniates.


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## VentMonkey (Oct 23, 2017)

FiremanMike said:


> As for my management, I'm going to ask my partner to go *draw up our crash airway drugs (rocketamine) and RSI* as soon as we get into the truck.


What does your service define as crash airway vs. full on RSI? This sounds more like the latter and not the former. They’re not exactly the same.

Also, @Qulevrius is the kind of EMT I wish I had worked with: extremely well-versed. Unfortunately, he has to keep his lemonade stand open in his county.


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## FiremanMike (Oct 23, 2017)

Qulevrius said:


> 1) I’ve been indoctrinated with the ‘once the c-collar is on, it stays on’ approach.



You should rethink this approach, the standard of care has moved away from the importance of c-spine immobilization



> 2) I can watch the capno morphology and bag just fine. What I, unfortunately, cannot do, is grow an extra pair of hands for doing anything else. Only CCT trucks carry ventilators.



I did not notice the stipulation that you must be alone with this patient for the entirety of EMS care.  If there is truly no way to get another person in the back of the truck, I'd probably wait the 45 minutes for the helicopter.  Intubated or not, transporting this particular patient alone for 40 minutes is just a terrible idea.



> 3) What I was saying is that, IMO, the risk of him herniating is significantly greater than the risk of him hypoxiating and, therefore, should be addressed immediately and aggressively with sedatives, osmotic procedures and body temp control. Because whilst there’s _something_ you can do about his airway if things start getting worse, there’s absolutely nothing you can do if/when the pt herniates.



I'm just not sure you're being realistic or fair about this scenario.  Going back on the stipulation that I MUST be alone on this patient, aggressive pharmacologic therapy, osmotic treatments (of which I'd like to hear more about), and/or induction of hypothermia are all things that are just as risky (if not moreso) than induction of this patient and I am unlikely to initiate these treatments alone.


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## FiremanMike (Oct 23, 2017)

VentMonkey said:


> What does your service define as crash airway vs. full on RSI? This sounds more like the latter and not the former. They’re not exactly the same.
> 
> Also, @Qulevrius is the kind of EMT I wish I had worked with: extremely well-versed. Unfortunately, he has to keep his lemonade stand open in his county.



It's the closest thing we're going to get to crash airway here.  While we do technically have the ability to go straight to our paralytic, it doesn't take that much more time to draw out 100mg of ketamine into the syringe and push it all at once.  Our actual RSI protocol includes a premedication phase of fent/versed, which I would absolutely skip in this case.

You're correct though, I mislabled that a crash airway.  Lets go with "abbreviated RSI protocol"


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## Qulevrius (Oct 23, 2017)

FiremanMike said:


> You should rethink this approach, the standard of care has moved away from the importance of c-spine immobilization
> 
> 
> 
> ...



As I mentioned before, this is purely academic for me. I am a Basic who pretends to be a medic and, for all intent & purpose of this scenario, must stay within the confinements of his county’s scope & protocols. Working out of LACo & OC, most of the pharmacopoeia is N/A. There are no paralytics, the available sedatives are benzos and not barbiturates, RSI is out of the question etc. And yes, it’s just me & my partner in the truck.

As for osmotic procedures - no Mannitol for us, so I have to go with hypertonic saline. The effect is, essentially, the same - the fluid moves along the concentration gradient.

Same goes for hypothermia induction - icepacks to the head, simple yet effective. And I fully agree with you on the transport decision, that’s why my original post said ‘start for the trauma center & request airlift en route’.


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## VentMonkey (Oct 23, 2017)

Personally, I’m not too comfortable with aggressively managing this patient with any form of osmotic diuretic, be it Mannitol or HNS in the prehospital setting.

Sure, there are key factors that may lead us down Cushing’s Triad, but even still I’m again, personally, more of a conservative here and think at least lower-end eucapnea is sufficient. At best, a careful titration of their blood pressure if at all needed with an anti-hypertensive to a reasonable SBP/ MAP absent any acute bradycardia.

With the prevalence of such late-stage game changers as DI, I vote leaving the diuresing to the hospital, moreover, neuro-ICU folks

As @Chase mentions- hypoxia and hypotension are our main combatants.


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## EpiEMS (Oct 23, 2017)

Qulevrius said:


> I am a Basic who pretends to be a medic



FWIW...there is no "scope of practice" for assessment & critical thinking.


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## Qulevrius (Oct 23, 2017)

EpiEMS said:


> FWIW...there is no "scope of practice" for assessment & critical thinking.



I’ve learned the hard way to keep all of it to myself. Because nearly every time I’ve stolen the fire medics’ thunder on scene, it ended up with either dirty looks (best case) or their BC calling in with a complaint.


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## EpiEMS (Oct 23, 2017)

@Qulevrius Fair enough, I'm lucky (most of the time) because I have some medics who aren't averse to talking through patient presentations.


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## Carlos Danger (Oct 23, 2017)

This has been a good discussion. I like the fact that some folks are advocating for a less interventional approach. Not that those who want to RSI are wrong - that's the standard approach that we've all had drilled into our heads - but there is a lot of evidence to support NOT necessarily intubating right away. Just because you have a hammer doesn't mean you need to whack every nail you come across.

@NPO how did the patient do? What was his diagnosis and disposition? Good job, BTW.

One thing to keep in mind is that when you intubate someone like this, it is pretty easy to hurt them. Even a brief episode of hypotension or hypoxemia (neither of which are uncommon) worsens their prognosis significantly. The sympathetic discharge that follows intubation probably isn't as bad, but probably isn't at all helpful to them, either. I flew for a little over 10 years and encountered patients like this (MVC —> TBI) routinely, and intubated them all with extreme prejudice. Knowing what I know now, I like to think I'd be a good bit less aggressive.


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## NPO (Oct 23, 2017)

Remi said:


> @NPO how did the patient do? What was his diagnosis and disposition? Good job, BTW.



He did well. He had virtually no change in condition for the entire transport and apart from a few times  where I had to reposition the airway from his moving, the OPA did very well and he never had any periods of hypoxia. 

That is until the med students RSI'd him at the hospital. They didn't remove the OPA before attempting intubation and effectively created a FBO until the attending realized something was wrong several minutes later. 

I took a more reserved approach with this guy because he had enough reflexes that I wasn't confident that the intubation would be smooth without sedation (which I didn't have) and he was doing good, all things considered.


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## zzyzx (Oct 23, 2017)

Coming to this late...

Why not intubate even if you don't have RSI since you were able to place an OPA with no gag? Bagging this guy w/o an ET tube is likely to cause all kinds of problems for such a long transport. Besides the fact that, as most of the previous posters agree, he needs to have his airway protected due to his GCS and the nature of his injuries, by bagging this guy for 40 minutes w/o a tube you are likely to 1) cause gastric insufflation   2) have no control over the minute ventilation.

This case is a great example of how EtCO2 can be important in managing a severe TBI patient pre hospital.

Most of use don't have vents, and usually the task of BVM ventilation is given to a BLS provider who will often bag at an incorrect rate. Studies have shown that improper BVM ventilation (usually too fast) likely causes poorer outcomes for severe TBI patients. In this case we can reasonable assume that the patient has an isolated head injury, and we can therefore also assume that the EtCO2 will be an accurate guide for BVM ventilations (with ET tube in place)


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## Carlos Danger (Oct 23, 2017)

It is a myth that just because someone will accept an OPA, they will accept an ETT. Laryngeal reflexes are much more sensitive than pharyngeal ones. Laryngoscopy + placing a tube is MUCH more stimulating than placing an OPA. I don't know where that idea came from or how it keeps being perpetuated.


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## VFlutter (Oct 23, 2017)

I assume you mean drug assisted intubation as opposed to RSI? I worked with a physician who loved Etomidate only intubations.....I cleaned up a lot of vomit and usually left in different scrubs then I came in with.


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## zzyzx (Oct 23, 2017)

Remi, you are a nurse anesthetist, so I'll defer to your expertise.

If you have a patient who easily accepts an OPA, why not attempt to intubate? If they gag while you are making the attempt, you can abort the attempt.

Does this not seem reasonable? A guy like this really needs an airway if he's 40 minutes from a hospital, so making the attempt seems reasonable to me. But educate me if I'm wrong.


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## TXmed (Oct 23, 2017)

@Qulevrius couldve fooled me i figured you were in intensive care somewhere.

@FiremanMike @VentMonkey I wouldnt advocate for a crash airway or a "modified RSI" for this patient, nothing tells me he will crash in the next 5 minutes so i would pull out all the stops. Premedicate if you are allowed, do your 7 P's of RSI, No rush necessarily with this patient, doing it right is more important than doing it fast with TBI patients.

@Remi @NPO Thats why i always try to follow the DASH-1A type of thinking. Just because you can get the intubation on first attempt doesnt mean you did not harm the patient or make things worse.

For everyone advocating for RSI, i would suggest listening to EMCRITS Laryngescope as a murder weapon series and reading the DASH-1A concepts. I firmly believe in being aggressive with airway but also not being a retard with a laryngescope either.

@Chase You are far from the first person and far from the last person to describe etomidate only intubation that way.


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## VentMonkey (Oct 23, 2017)

I never advocated for any sort or crash airway, I’m not sure where you got that from.


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## Carlos Danger (Oct 23, 2017)

zzyzx said:


> Remi, you are a nurse anesthetist, so I'll defer to your expertise.
> 
> If you have a patient who easily accepts an OPA, why not attempt to intubate? If they gag while you are making the attempt, you can abort the attempt.
> 
> Does this not seem reasonable? A guy like this really needs an airway if he's 40 minutes from a hospital, so making the attempt seems reasonable to me. But educate me if I'm wrong.



I suppose making a gentle attempt is reasonable as long as you are quick to abort once they start wrenching or clenching. Bad things often follow that.

There's a reason why RSI has become so common in ED's and EMS over the past couple of decades: it makes intubating much easier and safer. Prior to RSI becoming commonplace, intubating across the board had much higher rates of complications and much lower rates of success. In a patient who is breathing and oxygenating well, I just don't see the reason to expose them to the substantial risks that come with literally wrestling an ETT into their trachea. 



zzyzx said:


> A guy like this really needs an airway if he's 40 minutes from a hospital, so making the attempt seems reasonable to me. But educate me if I'm wrong.



Does he really NEED an invasive airway? Right now? Why? Because he's asleep? He is breathing fine. Isn't gas exchange what matters? What does the research say on the topic of outcomes between TBI patients who are intubated in the field vs. those who are not? Did this very patient not do just fine with NPO's non-invasive management? Don't BLS crews all over the country transport patients just like this every day, and they do just fine?  

Like I said before, I'm certainly not going to tell anyone they are wrong for wanting to RSI this guy. It's how I used to practice in the field. It's how we are all trained. It is (arguably) the standard of care. But WHY are we so set on it? WHY do we simply ignore the study upon study that tells us it isn't necessary? Just because it's what our paramedic instructors told us we should do? Because it's what we see the ED docs do? Again, what about all the TBI patients who aren't intubated in the field, and do just fine?

Wanting to intubate is perfectly reasonable, but so it taking a more conservative approach. Aside from dogma, I don't think there is any justification for the idea that an ETT is the only right way to manage a patient who is breathing and oxygenating well.


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## Colt45 (Oct 23, 2017)

Remi said:


> I suppose making a gentle attempt is reasonable as long as you are quick to abort once they start wrenching or clenching. Bad things often follow that.
> 
> There's a reason why RSI has become so common in ED's and EMS over the past couple of decades: it makes intubating much easier and safer. Prior to RSI becoming commonplace, intubating across the board had much higher rates of complications and much lower rates of success. In a patient who is breathing and oxygenating well, I just don't see the reason to expose them to the substantial risks that come with literally wrestling an ETT into their trachea.
> 
> ...



I like this explanation. I think there is multiple ways to handle this patient and there is also plenty of reasons you can back yourself up when explaining why this guy doesn't have a tube yet ( which the ER  doc is going to ask right away while pointing at someone to get intubation equipment). I agree with all your points. I just feel that he is going to get a tube anyway, if you can RSI and speed up that process it's going to save you a lot of grief from E.R. staff. Now with all that being said am I a fan of maintaining a basic airway if it's possible and my patient isn't circling the drain? Sure. Just be sure I have good documentation.


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## luke_31 (Oct 24, 2017)

Remi said:


> It is a myth that just because someone will accept an OPA, they will accept an ETT. Laryngeal reflexes are much more sensitive than pharyngeal ones. Laryngoscopy + placing a tube is MUCH more stimulating than placing an OPA. I don't know where that idea came from or how it keeps being perpetuated.


Very true, I've had a patient or two who has accepted an OPA but when starting to intubate would bite down on the blade I was using the second I hit the valecula.


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## NPO (Oct 24, 2017)

Remi said:


> It is a myth that just because someone will accept an OPA, they will accept an ETT. Laryngeal reflexes are much more sensitive than pharyngeal ones. Laryngoscopy + placing a tube is MUCH more stimulating than placing an OPA. I don't know where that idea came from or how it keeps being perpetuated.


I have met this scenerio face to face before, in a non-TBI patient. She accepted the opa with no problem but when I intubated she gagged and dislodged the tube. Not something I wanted to do in this TBI patient.


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## Brandon O (Oct 24, 2017)

TXmed said:


> @Brandon O sorry bout that. I would preffer to use a pressure mode over a volume mode to better controll the mean airway pressure (MAP) as on most transport vents focusing on map gives you better control/understanding of how your ventilation is efficting hemodynamic status and cerebral drainage. Atleast in the out of hospital enviroment. So keep the patient oxygenated to Spo2 > 95%, ETCO2 35-40 (30 if needed for short spells) and decreasing the MAP (generally below 10) to assist in whats mentioned above are my ventilator goals during transport. Then adjusting rise time pressure support to keep patient comfortable and manage sedation so when i arrive the patient isnt snowed unless its needed.



This is an interesting thought! It does make sense that mean airway pressure should be the respiratory parameter most closely associated with intracranial pressure. Usually in the ICU we can directly follow the latter to see the effects of vent changes, but it's reasonable to do it empirically if you can't. I would just be careful to avoid getting so clever that you compromise oxygenation or ventilation (or cause dyssynchrony).



TXmed said:


> @VentMonkey@Brandon O i know your settimg is more icu but, would you salt bomb this patient without a foley or labs ?



It's all pretty academic since it's hard to imagine the situation. I have empirically used osmolar therapy prior to intracranial pressure monitoring (it can take some time to get in a bolt or EVD). Have not done it prior to imaging. It would probably be reasonable in an austere situation for at least a single bolus if you have very high suspicion (this scenario might qualify; even better if they blew a pupil in front of you).

I would avoid mannitol without a Foley. Hypertonic without a central line is not the best idea, but I know some places think it's reasonable with a good IV.

I suppose you could do an IO, although many places consider hypertonic fluids contraindicated via IO.

I have also bolused sedation for this purpose, although I would probably only use propofol which most prehospital services don't carry.



VentMonkey said:


> PRVC is actually a VC mode, as the name implies. It monitors and adjusts the airway pressures in the patients lungs based on their efforts then delivers a set Vt accordingly. It requires somewhat less effort from the clinician in monitoring their airway pressures than your standard VCV modes, so it’s more of a “nice to have” mode.



To be pedantic, I would describe PRVC as a pressure mode -- just one that tries to regulate its resulting volumes. If I showed you the scalars of a PRVC breath you would describe it as a pressure control breath. You wouldn't know it was PRVC unless you knew whether I was fiddling with the inspiratory pressure or the vent was doing it automatically.

Maybe they should have called it VRPC


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## VentMonkey (Oct 24, 2017)

Brandon O said:


> To be pedantic, I would describe PRVC as a pressure mode -- just one that tries to regulate its resulting volumes. If I showed you the scalars of a PRVC breath you would describe it as a pressure control breath. You wouldn't know it was PRVC unless you knew whether I was fiddling with the inspiratory pressure or the vent was doing it automatically.
> 
> Maybe they should have called it VRPC


Maybe, but PRVC just rolls off of the tongue a whole lot easier. Either way, I find it is almost a continuous difference of opinions with what’s called what, and where it fits in when discussing ventilator management and strategies, be it in the respiratory therapy world, or prehospital one. Maybe at the mid-level and intensivist level it’s a tad clearer with better defined guidelines and terminology?

Granted, in the prehospital setting we’re way short on the know how, so perhaps much gets watered down in CC classes and courses to fit the general paramedic populations. I mean who could really learn Vent management in 1-2 days? Thanks for clarifying though.


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## Brandon O (Oct 24, 2017)

VentMonkey said:


> Maybe, but PRVC just rolls off of the tongue a whole lot easier. Either way, I find it is almost a continuous difference of opinions with what’s called what, and where it fits in when discussing ventilator management and strategies, be it in the respiratory therapy world, or prehospital one. Maybe at the mid-level and intensivist level it’s a tad clearer with better defined guidelines and terminology?
> 
> Granted, in the prehospital setting we’re way short on the know how, so perhaps much gets watered down in CC classes and courses to fit the general paramedic populations. I mean who could really learn Vent management in 1-2 days? Thanks for clarifying though.



If you're thinking that the higher you get, the more people agree, I have some sad news for you.


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## FiremanMike (Oct 24, 2017)

Remi said:


> Does he really NEED an invasive airway? Right now? Why? Because he's asleep? He is breathing fine. Isn't gas exchange what matters? What does the research say on the topic of outcomes between TBI patients who are intubated in the field vs. those who are not? Did this very patient not do just fine with NPO's non-invasive management? Don't BLS crews all over the country transport patients just like this every day, and they do just fine?
> 
> Like I said before, I'm certainly not going to tell anyone they are wrong for wanting to RSI this guy. It's how I used to practice in the field. It's how we are all trained. It is (arguably) the standard of care. But WHY are we so set on it? WHY do we simply ignore the study upon study that tells us it isn't necessary? Just because it's what our paramedic instructors told us we should do? Because it's what we see the ED docs do? Again, what about all the TBI patients who aren't intubated in the field, and do just fine?
> 
> Wanting to intubate is perfectly reasonable, but so it taking a more conservative approach. Aside from dogma, I don't think there is any justification for the idea that an ETT is the only right way to manage a patient who is breathing and oxygenating well.



If I'm being honest, I guess my only real articulable argument for intubating now is that I'd rather do it now while he's oxgenating well and I'm the one making the plans.  While it is certainly reasonable and prudent to simply pre-plan the eventual crash intubation, the vast majority of providers will feel that increased stress if/when the patient does crash and will function at a level below their best.

I have grown into the "less is more" approach the older I get, but this patient potential crash just makes me nervous.


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## Carlos Danger (Oct 25, 2017)

Brandon O said:


> To be pedantic, I would describe PRVC as a pressure mode -- just one that tries to regulate its resulting volumes.



I think of it as a pressure mode. It's just a pressure mode that targets a set volume instead of a set pressure. What makes it cool is that it manipulates flow rates to try to reach the target volume with the lowest pressure possible. At least that is my understanding of how it works.


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## Brandon O (Oct 25, 2017)

Remi said:


> I think of it as a pressure mode. It's just a pressure mode that targets a set volume instead of a set pressure. What makes it cool is that it manipulates flow rates to try to reach the target volume with the lowest pressure possible. At least that is my understanding of how it works.



I would say it manipulates inspiratory pressure to reach target volume. All pressure control manipulates flow (to reach the target pressure); variable flow based upon patient demand is a hallmark of pressure modes.


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## VentMonkey (Oct 25, 2017)

I really should pony up the money for RT school; it’s my most realistically practical option.


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## NPO (Oct 25, 2017)

VentMonkey said:


> I really should pony up the money for RT school; it’s my most realistically practical option.


I think that would be great, but I'd hate to see your aptitude wasted somewhere you couldn't stretch your wings.

Where do you think you'd like to work as an RT?
Do many local (to you) hospitals allow the RTs to operate with relative autonomy?


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## VentMonkey (Oct 25, 2017)

NPO said:


> I think that would be great, but I'd hate to see your aptitude wasted somewhere you couldn't stretch your wings.
> 
> Where do you think you'd like to work as an RT?
> Do many local (to you) hospitals allow the RTs to operate with relative autonomy?


Hey thanks, man! Honestly I don’t know at this point. I just know I have no desire to (currently) teach, no desire to be a nurse, and I definitely know where my heart is with regard to EMS management.

I like the vent, and all things airway related. I figure it’s a good segue to an aging paramedics body (I could use the vent as a walker through the hospital, lulz).

I’m still overall having too much fun and enjoying what I do, but dealing with high-acuity NICU/ PICU kiddos has its appeal, autonomy or not. Even being part of a specialty NICU/ PICU transport team wouldn’t be so bad, especially as I age.


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## NPO (Oct 25, 2017)

VentMonkey said:


> I’m still overall having too much fun and enjoying what I do, but dealing with high-acuity NICU/ PICU kiddps has its appeal, autonomy or not. Even being part of a specialty NICU/ PICU transport team wouldn’t be so bad, especially as I age.



This is where I think you'd be best used. I know you've expressed interest in fixed wing transport before, and I know of several specialty pediatric transport teams where RTs are quite valuable. Combined with your prehospital and critical care experience, I think you'd be well suited for SCT.


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## Qulevrius (Oct 25, 2017)

VentMonkey said:


> I’m still overall having too much fun and enjoying what I do, but dealing with high-acuity NICU/ PICU kiddos has its appeal, autonomy or not. Even being part of a specialty NICU/ PICU transport team wouldn’t be so bad, especially as I age.



If you decide to go through with this, ping me. The wife used to be a NICU/PICU transport coordinator & transport CCRN for a few years, and she still has friends with REACH Air.


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## Carlos Danger (Oct 26, 2017)

Brandon O said:


> I would say it manipulates inspiratory pressure to reach target volume. All pressure control manipulates flow (to reach the target pressure); *variable flow based upon patient demand is a hallmark of pressure modes*.



This is probably true of all modern ICU vents and even some newer transport vents (neither of which I'm very familiar with anymore) but the "basic" PCV mode uses a flow pattern that decelerates in a linear fashion until the target pressure is reached. Just like volume modes, the vent doesn't vary anything beyond what the operator sets.

PRVC was actually a proprietary term (I forget which manufacturer) and I think it was the first commonly-used mode that would not only change flow rates to meet patient demand by sensing changes in airway resistance at different points of the inspiration cycle, but would also adjust the flow rates at different points to achieve the set vT at the lowest airway pressure possible. Or again, at least that's how I've always understood it.

Of course that's nothing compared to what the newest ICU vents can do, but for us old-timers who don't specialize in ICU ventilation using modern vents and whose original transport ventilator delivered only 100% oxygen and required calculating the flow rate, e-time, and i-time in order to get the tidal volume and respiratory rate you wanted, PRVC was like magic when it first became commonplace. All you have to do is set tidal volume and rate, and the vent will select the appropriate flow and ensure the lowest possible pressure? Sign me up!


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## Carlos Danger (Oct 26, 2017)

VentMonkey said:


> Hey thanks, man! Honestly I don’t know at this point. I just know I have no desire to (currently) teach, no desire to be a nurse, and I definitely know where my heart is with regard to EMS management.
> 
> I like the vent, and all things airway related. I figure it’s a good segue to an aging paramedics body (I could use the vent as a walker through the hospital, lulz).
> 
> I’m still overall having too much fun and enjoying what I do, but dealing with high-acuity NICU/ PICU kiddos has its appeal, autonomy or not. Even being part of a specialty NICU/ PICU transport team wouldn’t be so bad, especially as I age.



If you could get into specialty transport as an RRT you might love it for the most part, but I guarantee you'll miss those scene flights. 

I too came close to going to school for respiratory therapy, for the same exact reasons that it interests you. At the last minute I decided to enroll in the Excelsior nursing program instead, primarily because it would be easier for me to keep flying FT while going to school.

Unfortunately, after working with many RRT's in the ICU and HEMS, my impression is that the RT field seems to have a problem with career satisfaction. I think that, similar to EMS, many people get into it thinking that the day-to-day is going to be quite different than what it usually turns out being. I haven't known many who were really happy doing what they were doing, aside from the ones that I flew with. I'm sure many do like what they do, but you just have to make sure it's what you want to do.


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## VFlutter (Oct 26, 2017)

Remi said:


> Unfortunately, after working with many RRT's in the ICU and HEMS, my impression is that the RT field seems to have a problem with career satisfaction. I think that, similar to EMS, many people get into it thinking that the day-to-day is going to be quite different than what it usually turns out being. I haven't known many who were really happy doing what they were doing, aside from the ones that I flew with. I'm sure many do like what they do, but you just have to make sure it's what you want to do.



This is my experience as well, primarily working with RRTs in the ICU. There is very little autonomy, limited career growth, and monotonous daily work.


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## FiremanMike (Oct 26, 2017)

Chase said:


> This is my experience as well, primarily working with RRTs in the ICU. There is very little autonomy, limited career growth, and monotonous daily work.



I've heard the same about perfusionists, which sucks because that would be such a cool job..


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## Bullets (Oct 26, 2017)

VentMonkey said:


> Hey thanks, man! Honestly I don’t know at this point. I just know I have no desire to (currently) teach, no desire to be a nurse, and I definitely know where my heart is with regard to EMS management.
> 
> I like the vent, and all things airway related. I figure it’s a good segue to an aging paramedics body (I could use the vent as a walker through the hospital, lulz).
> 
> I’m still overall having too much fun and enjoying what I do, but dealing with high-acuity NICU/ PICU kiddos has its appeal, autonomy or not. Even being part of a specialty NICU/ PICU transport team wouldn’t be so bad, especially as I age.



RN?  Perhaps a masters in nursing and become a CRNA? or an NP? NPs are PhDs now, at least in my hospital NPs operate with relative autonomy, primarily in Paeds, Trauma, TICU and NSICU. Or even PA. If you have a bachelors its pretty much the same to a MSN or PA in my area


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## Brandon O (Oct 27, 2017)

Remi said:


> This is probably true of all modern ICU vents and even some newer transport vents (neither of which I'm very familiar with anymore) but the "basic" PCV mode uses a flow pattern that decelerates in a linear fashion until the target pressure is reached. Just like volume modes, the vent doesn't vary anything beyond what the operator sets.



I guess I can't speak to all of the older models, but I don't think it's possible to have pressure control without a variable flow.

Here's why: the basic premise of pressure control is that you reach a target pressure and then hold it for a set time. (At least, by convention this is how it works; you could have another universe where it works differently, but this is what people mean when they say "pressure control" these days.) Flow doesn't decelerate until you reach the target pressure; flow decelerates _because_ you've reached the target pressure.

Flow starts out very high in an effort to quickly reach the set pressure (how high is determined by rise time, the only control you have on this), then once you get there, it takes much less flow to maintain that pressure.



 

But airway pressure depends on the compliance in the airway, and in a patient with any spontaneous work of breathing, compliance depends on their effort. If they do nothing, compliance will be low; if they inspire vigorously, compliance will be high. And they can do both of those things during the same breath if they want.

The vent doesn't know what the patient is doing, but it knows the airway pressure, so if it wants to reach and maintain the target pressure, it has to adjust flow in order to match the patient's attempts to change it.

I don't think it's possible to do this without a variable flow. If the vent cannot adjust flow, it cannot reach the goal pressure; flow is the independent variable here. I suppose you could have a fixed flow (like volume control), and just inspire linearly until you peg the pressure limit, but this would only work in a patient with zero effort (fixed compliance), and would also make it impossible to set your inspiratory time (since the minimum inspiratory time would become determined by flow). Is that how older vents did it?



> PRVC was actually a proprietary term (I forget which manufacturer) and I think it was the first commonly-used mode that would not only change flow rates to meet patient demand by sensing changes in airway resistance at different points of the inspiration cycle, but would also adjust the flow rates at different points to achieve the set vT at the lowest airway pressure possible. Or again, at least that's how I've always understood it.



I would say the added variable in PRVC is not flow, but volume. The individual breaths look exactly the same as pressure control breaths. The difference is a BREATH TO BREATH variation in the set pressure.

You give one PC breath at 25 cmH2O. The resulting volume is 350. Your goal was 400.
The next PC breath is therefore at 27 cmH2O. The resulting volume is 370. Still too low.
The next PC breath is 29 cmH2O. The resulting volume is 400. Great, we'll keep this inspiratory pressure until compliance changes.


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## TXmed (Oct 27, 2017)

How well does PRVC work with a patkent with lung etiology. Asthma/COPD or pulmonary contusion ?


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## Brandon O (Oct 27, 2017)

TXmed said:


> How well does PRVC work with a patkent with lung etiology. Asthma/COPD or pulmonary contusion ?



Works fine. The only time I think it's a poor choice is when patient factors (such as dyssynchrony) create inconsistent compliance; this tends to confuse the vent and result in weird volumes. Or when you really want to tightly control all of your variables, and -- let's say -- directly control the exact minute ventilation to manipulate your acid-base status. Easier done when the vent's not acting like Clippy from Word and trying to be helpful.


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## E tank (Oct 27, 2017)

FiremanMike said:


> I've heard the same about perfusionists, which sucks because that would be such a cool job..



Every single perfusionist I've ever met, all pretty smart guys, wouldn't trade their jobs for the world. They do way better than RT's in the accounts receivable department, to be sure.


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## EpiEMS (Oct 27, 2017)

E tank said:


> They do way better than RT's in the accounts receivable department, to be sure.



RTs (not the lower-level one, the technician role) median annual wage is $58k. Cardiac techs broadly look to be at $55k, but I see anecdotal evidence for perfusionists being at ~2x RTs...


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## VFlutter (Oct 27, 2017)

EpiEMS said:


> RTs (not the lower-level one, the technician role) median annual wage is $58k. Cardiac techs broadly look to be at $55k, but I see anecdotal evidence for perfusionists being at ~2x RTs...



Cardiac Tech is not a Perfusionist.... 

Most of the ones I know make around $100-120K. More along the lines of CRNA than RT 
http://www1.salary.com/perfusionist-Salaries.html


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## EpiEMS (Oct 27, 2017)

Chase said:


> Cardiac Tech is not a Perfusionist....



Yes, understood - probably some unhelpful context on my part. U.S. DOL didn't break out (or even identify) perfusionists, so I figured it'd be worthwhile to add a similar - cardiology focused - tech.


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## VFlutter (Oct 27, 2017)

EpiEMS said:


> Yes, understood - probably some unhelpful context on my part. U.S. DOL didn't break out (or even identify) perfusionists, so I figured it'd be worthwhile to add a similar - cardiology focused - tech.



It’s really not a bad gig. Some places you can still get a bachelors degree and go make $100k+.

I think I’d enjoy it but not really a great career move for me personally. Thinking about becoming a RN ECMO specialist


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## TXmed (Oct 27, 2017)

Chase said:


> It’s really not a bad gig. Some places you can still get a bachelors degree and go make $100k+.
> 
> I think I’d enjoy it but not really a great career move for me personally. Thinking about becoming a RN ECMO specialist



I worked with someone who did that part time, made good money especially if you do traveling


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## bizzy522 (Nov 12, 2017)

Im way late to this party.. Id say Just place an I-Gel and hit the road. This is a time sensitive call, we are 40 minutes away from a Trauma Center. The best thing for this patient is an quick ride to the trauma doc (hopefully within the Golden Hour). We can protect his airway by dropping and I-Gel. We can administer a paralytic to control ventilations if we fear herniation. Other then that keep the patient warm and dont allow a period of hypoxia or hypotension.


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## Tigger (Nov 12, 2017)

bizzy522 said:


> Im way late to this party.. Id say Just place an I-Gel and hit the road. This is a time sensitive call, we are 40 minutes away from a Trauma Center. The best thing for this patient is an quick ride to the trauma doc (hopefully within the Golden Hour). We can protect his airway by dropping and I-Gel. We can administer a paralytic to control ventilations if we fear herniation. Other then that keep the patient warm and dont allow a period of hypoxia or hypotension.


I don't necessarily disagree, but the whole golden hour thing is kind of bunk. Obviously this patient needs to be transported quickly, but not at the expense of proper care (which may or may not be airway management).


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## grumpy1 (Dec 11, 2017)

I'm coming in to this very late and I didn't read many responses so I am going to type and see what the group thinks......

Given the scenario, pt needs to be intubated via RSI but lets hold the Etomidate, why..... because it works on the adrenal cortex and could HYPOTHETICALLY reduce the amount of epi/norepi helping the sympathetic nervous system.  RSI the pt with Ketamine, Succ and Fentanyl........after confirmation and checking the BP use Versed (midazolam), and fentanyl for sedation with maybe ROC as necessary.  Standard Vent settings 6mL/kg, 5 PEEP, 10 PS, Fi02 80% (ween to ETC02 40).

Meds in addition to sedation, TXA.  Watch the BP because we don't want in to get too low (Monroe-Kelly doctrine).

If you have an aircraft service worth anything an auto-launch should've already been accomplished given to mechanism alone with a van in the crash.  Even though this pt has an obvious HI rotor wing transport is not contraindicated.  Pt with a pneumocephalic would only be at risk for further damage because blood doesn't expand at altitude, only air. 

My $0.02.


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## E tank (Dec 11, 2017)

grumpy1 said:


> I'm coming in to this very late and I didn't read many responses so I am going to type and see what the group thinks......
> 
> Given the scenario, pt needs to be intubated via RSI but lets hold the Etomidate, why..... because it works on the adrenal cortex and could HYPOTHETICALLY reduce the amount of epi/norepi helping the sympathetic nervous system.



It reduces serum cortisol levels for a day...might be an issue in sepsis patients, probably not in this scenario. If it isn't chosen, this isn't the reason not to choose it.


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## VFlutter (Dec 11, 2017)

Also, these patients usually have already had a significant catecholamine surge and are catecholamine depleted by the time we arrive.


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## grumpy1 (Dec 11, 2017)

E tank said:


> It reduces serum cortisol levels for a day...might be an issue in sepsis patients, probably not in this scenario. If it isn't chosen, this isn't the reason not to choose it.



It was an outside the box thought and its always good to bounce those off others at times, good observation on the time.


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## medicsb (Dec 12, 2017)

Ketamine could also produce hypotension, though unlikely in this scenario.  A single dose of etomidate is likely to have negligible effects.  I'd use etomidate.


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