# Scenario-ish: To intubate or not to intubate?



## Handsome Robb (Dec 20, 2014)

Ran this call recently,  I wanted some opinions and thoughts about how you would handle this. 

Backstory: 1430 in the afternoon, heavy traffic conditions. We were 4 blocks north and the other unit was 2 blocks south when the call dropped, came out as a priority 2 (still lights and sirens response but able to divert) traffic collision given to the first unit then upgraded to a priority 1 extrication and we were added as a second unit, P1, at that point. First unit arrived on scene and requested we continue, we arrived 30 seconds later. T-bone accident to the passenger side door at >50mph. My pt was the passenger, unrestrained, 25-30 inches of intrusion into his seat which displaced his seat into the driver's seat. His window and passenger side windshield severely spidered. 

When I got to him he was unresponsive, GCS 4 (1/1/2) (you could argue 3 but he did display a little bit of decerabrate posturing but not very obvious.) but was breathing adequately with a patent airway, no signs of cyanosis. No real outward signs of trauma besides a few lacs and a busted ankle.  At this point it was only the two units on scene and fire was fighting traffic so we decided not to wait for them due to his status. I peeled the door back as best I could and climbed in next to him with my partner in the back seat maintaining manual c-spine. I placed a collar and with the help of one crew member from the other unit and a bystander holding the foot of the board for us we extricated him out the driver's side door onto a board right as fire arrived. Trauma naked, c-spine and to the ambulance. 

Once in the ambulance vitals were:  
162/70
Sinus with inverted p's and t's in II with a rate from 40-90 bpm
respirations were beginning to shallow at a rate of 22 and slightly irregular,
SpO2 of 86%, 
GCS now a "solid" 3
CBG 106 mg/dL

I dropped an OPA which he tolerated and began bag assisting with ETCO2 in place targeting 30mmhg. Had a good EtCO2 wave form and great compliance and chest rise, only required a little suctioning, lung sounds were clear and equal bilaterally. With the bag assisting his SpO2 was now 97-99%. 

This is where the question is. I had a 13 minute scene time including the 5ish minutes it took us to extricate him from the car and a 7 minute transport time to a Level II TC, no Level I available. 

Do you intubate? If yes do you use drugs? If so which drugs and why? What if you don't have the ability to RSI?

I'll tell you what I did after some respond.


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## Tigger (Dec 20, 2014)

Given the timing I think you present a reasonable case.

Even if you could RSI, by the time everything is setup you would be getting close to the hospital anyway.


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## emschick1985 (Dec 20, 2014)

Handsome Robb said:


> Ran this call recently,  I wanted some opinions and thoughts about how you would handle this.
> 
> Backstory: 1430 in the afternoon, heavy traffic conditions. We were 4 blocks north and the other unit was 2 blocks south when the call dropped, came out as a priority 2 (still lights and sirens response but able to divert) traffic collision given to the first unit then upgraded to a priority 1 extrication and we were added as a second unit, P1, at that point. First unit arrived on scene and requested we continue, we arrived 30 seconds later. T-bone accident to the passenger side door at >50mph. My pt was the passenger, unrestrained, 25-30 inches of intrusion into his seat which displaced his seat into the driver's seat. His window and passenger side windshield severely spidered.
> 
> ...


I think you did great, vitals show the bagging was effective at the time. RSI and intubation would have delayed transport time, I think you did a great job.


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## teedubbyaw (Dec 20, 2014)

Agreed with tigger. Given those specific issues, I'd have kept with the bvm/opa.


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## Handsome Robb (Dec 20, 2014)

Well thanks, I appreciate it. I'm just wondering other's thoughts. Like I said, would you? Which drugs? Why?


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## chaz90 (Dec 20, 2014)

With the time to the trauma center I don't think I would have rushed an RSI. With effective bagging and a 7 minute transport time I'd call it a day right there. For where I am though, I'd be intubating this patient and flying them out to the Level I. The local level IIIs wouldn't (and shouldn't!) have much to do with this patient. 

If he tolerated the BVM and an OPA I'd likely consider intubating without drugs. Any signs of trismus or gag reflex though and I'd RSI with Lidocaine+Etomidate+Succinylcholine.


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## Akulahawk (Dec 20, 2014)

Given the transport time to the L2 trauma center, I'd stick with BVM because it's clearly effective. The OPA isn't causing a response, so I might consider intubation, and certainly alert the ED that this patient will likely need to be intubated on arrival so they can prepare ahead of time. If everything else is going good and I have the time or the extra hands available, I might give the tube a go...


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## emschick1985 (Dec 20, 2014)

We don't have RSI capability at our service yet. I really wish we did because I have had several situations where it was very much needed.


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## Tigger (Dec 20, 2014)

It's possible that this patient would not need to be RSIed as well. I guess if you had extra hands in back it would have been conceivable to try and intubate the patient, but if you were alone that seems like less than a poor idea.

The priority here is getting the patient to a trauma center, right?


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## PotatoMedic (Dec 20, 2014)

Superglotic at most with a transport time that short.  That is my opinion.


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## DesertMedic66 (Dec 20, 2014)

With that transport time I would have stuck with the BVM/OPA as long as ventilations were still efficient. 

If the transport time was longer I would probably have intubated him. He is tolerating the OPA just fine so he may take the tube without issue. We don't have any RSI meds in my area so I would go without them.


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## Tigger (Dec 20, 2014)

FireWA1 said:


> Superglotic at most with a transport time that short.  That is my opinion.


This is a good point. If you are alone in back you could quickly place one and then not have to deal with a one handed mask seal.


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## Burritomedic1127 (Dec 20, 2014)

Tigger said:


> This is a good point. If you are alone in back you could quickly place one and then not have to deal with a one handed mask seal.


A great idea

Since the pt tolerated the OPA no prob, a quick King Lt some endtidal and you have a more "secure" airway than bagging. Along with the fact of not adding time away from the trauma center with intubating


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## medicsb (Dec 21, 2014)

My general approach is to start planning the intubation as soon as it is determined that the pt. might need to be intubated.  How far into planning you get will depend on resources.  When I was still on the street I worked where we had to call for orders to RSI, which meant if possible one of us would go to the ambulance to call for orders and set up the equipment and draw meds.  Once the patient was loaded into the ambulance, we'd proceed.  

Sounds like you had limited personnel, but you or your partner could go to the ambulance to set-up as soon as the patient is extricated in order to expedite the process.   

For this pt. you could probably go with ETI without meds, but I don't think I'd knock you for pushing etomidate and succs (or whatever you carry).


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## Tigger (Dec 21, 2014)

medicsb said:


> My general approach is to start planning the intubation as soon as it is determined that the pt. might need to be intubated.  How far into planning you get will depend on resources.  When I was still on the street I worked where we had to call for orders to RSI, which meant if possible one of us would go to the ambulance to call for orders and set up the equipment and draw meds.  Once the patient was loaded into the ambulance, we'd proceed.
> 
> Sounds like you had limited personnel, but you or your partner could go to the ambulance to set-up as soon as the patient is extricated in order to expedite the process.
> 
> For this pt. you could probably go with ETI without meds, but I don't think I'd knock you for pushing etomidate and succs (or whatever you carry).


No doubt a plan for additional airway compromise is always warranted, which I'm sure Robb had. Sometimes you just don't get to that point based on timing, which is likely here. I'm sure you were prepared to intubate if you were not able to bag him @Handsome Rob ?


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## Carlos Danger (Dec 21, 2014)

Good call Robb. I don't think I'd have done anything different, other than perhaps drop an LMA instead of masking, just to make it easier on myself. As someone else said, with such a short transport you were likely at the ED before you would have had the tube secured, and the patient was able to be intubated in an environment with a lot more resources available. Even if the transport had been 10 or 15 minutes long, I'd say what you did would still be very appropriate.

What meds would I have used if I'd have tubed this guy? A large dose of etomidate quickly followed by some sux would work just fine. I'd prefer propofol over etomidate, but most of us don't have that in the field....etomidate is just fine; so is ketamine if it's all you have, though it'd be my last choice. If I had time, I'd cut the dose of etomidate in half, and give some lidocaine, fentanyl, esmolol, and glycopyrrolate (or a small dose of atropine) first.

As far as intubating without meds.....I would avoid that if at all possible. This guy's ICP is already approaching lethal levels, and the sympathetic surge that results from airway instrumentation without sedation is only going to make that worse. Some profound sedation and/or sympathetic blockade is highly desirable in this guy.

If you don't have RSI and he really _needs_ to be tubed, then of course you just do what you can do, recognizing that airway takes priority. Maybe you could at least spray the airway and give some fentanyl or whatever beta blocker it is that you carry? Anyone have protocols for that, absent the ability to RSI?


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## SandpitMedic (Dec 21, 2014)

Etomidate 20-40mg dependent on weight. Drop that tube en route; if I had 7 estimated minutes I could do that. This guy requires a secure airway. So I can do it in the field with sedation meds to reduce sympathetic response as noted earlier, sooner, and achieve the secure advanced airway. S/s of increasing ICP/multisystem trauma with airway compromise = buying plastic. Anything goes south and there is always the BLS/ILS airway options to fall back on.

I've ran similar calls like this, and while I am not afraid to bag someone in, I am pretty aggressive on airways.


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## zzyzx (Dec 21, 2014)

I don't think you did anything terribly wrong, but i will have to disagree with you and the other posters and say that this guy needed intubation. All the talk in recent years about going from paramedics intubating should not distract you from situations where a patient needs an advanced airway immediately, and this guy needs a tube. He has no gag and is completely unresponsive, so why not just drop a tube? It should take you about one minute. And if you have trouble, just put in a King, which again should only take one minute. What was the very first thing they did when you arrive in the ER? Im sure they intubated. There are many downsides to BVM ventilations, including gastric insufflation, the fact that it is not an easy procedure, and requires 2 people. What if the guy had vomited after getting bagged for a few minutes? Again I'm not saying you handled the call badly but i do think this guy is like the poster child for that patient who needs a tube.


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## DesertMedic66 (Dec 21, 2014)

Remi said:


> Good call Robb. I don't think I'd have done anything different, other than perhaps drop an LMA instead of masking, just to make it easier on myself. As someone else said, with such a short transport you were likely at the ED before you would have had the tube secured, and the patient was able to be intubated in an environment with a lot more resources available. Even if the transport had been 10 or 15 minutes long, I'd say what you did would still be very appropriate.
> 
> What meds would I have used if I'd have tubed this guy? A large dose of etomidate quickly followed by some sux would work just fine. I'd prefer propofol over etomidate, but most of us don't have that in the field....etomidate is just fine; so is ketamine if it's all you have, though it'd be my last choice. If I had time, I'd cut the dose of etomidate in half, and give some lidocaine, fentanyl, esmolol, and glycopyrrolate (or a small dose of atropine) first.
> 
> ...


The county I did my medic internship at has protocols for 1.5mg/kg lido IVP for tube placement when there is suspected ICP.


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## NomadicMedic (Dec 21, 2014)

Gotta say, after reading the scenario I was torn. I don't know if I would have intubated him or not. It might have simply depended on how lucky I was feeling that day… However, I've become a lot less cavalier about taking someone's airway. If BLS airway maneuvers were getting it done and you only had seven minutes to the hospital, good on you. 

Putting a tube in the trachea is not what makes you a good paramedic, delivering a viable patient to the emergency department is. 

...and to the person who said, "I'm sure the first thing that happened when they got to the emergency department is he bought a tube". I'm sure he did. And it's always, ALWAYS easier to do tube a trauma patient when the bed is adjustable to the optimum height, there's lots of lights, you're not bouncing down the road and you've got plenty of other people, a glidescope and the trauma doc standing by.


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## STXmedic (Dec 21, 2014)

@Remi Just to pick your brain, what is your rationale behind Etomidate over Ketamine here? Not arguing- genuinely curious.


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## Carlos Danger (Dec 21, 2014)

SandpitMedic said:


> S/s of increasing ICP/multisystem trauma with airway compromise = buying plastic.






zzyzx said:


> I don't think you did anything terribly wrong, but i will have to disagree with you and the other posters and say that this guy needed intubation.
> 
> It should take you about one minute.



This is dinosaur thinking, guys. The idea that these patients benefit from early prehospital intubation has been soundly disproven by research, and should (and is, slowly) go the way of backboards.

This patient needed airway management, not necessarily intubation. Aggressive does not always equal appropriate.

Edit: I'm not saying that intubating patients like this is necessarily wrong.....I'm saying that it's definitely not the definition of progressive care.



STXmedic said:


> @Remi Just to pick your brain, what is your rationale behind Etomidate over Ketamine here? Not arguing- genuinely curious.



Well, it's just my own experience and bias, I guess. I know that ketamine has been shown safe in increased ICP states, but in a patient like this, I'm more comfortable using an agent that I know reduces ICP, maintains CBF, and raises the seizure threshold.

If they were hypotensive, ketamine would probably be my first choice, but with hypertension and signs of herniation, I guess I'm just not sold on it.


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## STXmedic (Dec 21, 2014)

Thanks. I guess being relatively new to ketamine, and being accustomed to my wife telling me about her numerous patients who actually receive ketamine blouses for IICP in the NSICU, I'm not having to fight that old stigma. I hadn't considered etomidate's effect on seizure activity, though.


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## medicsb (Dec 21, 2014)

Tigger said:


> What meds would I have used if I'd have tubed this guy? A large dose of etomidate quickly followed by some sux would work just fine. I'd prefer propofol over etomidate, but most of us don't have that in the field....etomidate is just fine; so is ketamine if it's all you have, though it'd be my last choice. If I had time, I'd cut the dose of etomidate in half, and give some lidocaine, fentanyl, esmolol, and glycopyrrolate (or a small dose of atropine) first.



Lidocaine?  Esmolol?  Glycopyrrolate?  WHHHYYYYY?  None of that stuff has any evidence of improved outcomes and just takes up time.  The patient is also hemodynamically unstable (HR 40s-90s).  Keep the beta-blockers far away.  Keep anything that could decrease HR or blood pressure far away.  This pt. was in an MVC, we do not know if the CNS is the only system involved; they still have significant potential for internal bleeding.    



Remi said:


> This is dinosaur thinking, guys. The idea that these patients benefit from early prehospital intubation has been soundly disproven by research, and should (and is, slowly) go the way of backboards.



Except it has not _really_ been disproved.  Afterall, the best airway study to date demonstrated improved functional outcomes. But then again that study is hard to extrapolate to the US where training and experience in most places are so much less than Australian MICA Paramedics.  It's probably more realistic to say that poorly trained and/or inexperienced intubators (i.e. the overwhelming majority of US paramedics) are associated with poor outcomes.


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## CANMAN (Dec 21, 2014)

Given your situation, resources on hand, location, and time to the trauma center I think the care you provided was completely appropriate and glad to see provider's making the smart choice. With the being said, held to the protocols within my system (which is an RSI system and Paramedic/Nurse team) I would be looking for a new job if I didn't intubate a trauma scene patient with a GCS of 3.

My question would be if the car really had over two feet of intrusion to the seat/patient compartment how the hell were you able to peel the door back and rapidly extricate? Given the details and damage to the seat one would think the door, rocker channel, etc would be mangled...?


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## SandpitMedic (Dec 21, 2014)

I wasn't the one who said "He's buying a tube on arrival" or something to that, and the ER tube is cake in comparison. But, I feel like I want to comment on that.

While I am not cavalier with my airway, I am aggressive. I am always cognizant of my patient's ability to tolerate a tube, and of their probable projected clinical course. I.e: Should I tube this 69 year old COPD'er she may never come off of the vent. CPAP is an option to avoid a 3 month ICU admission vs. a 3 day observation in MedTele. Of course, with a patient like this- trauma/brain injury... The ET tube is the only definitive choice AND it is what this patient requires.

I trained, practiced, and prepared for that, be it a difficult or an "easy" tube. I'm a paramedic. That is why intubation is in my scope. And if it is warranted and indicated, barring other contraindications, I will almost always do it. I've had patients that go downhill with less invasive and patients that improve with less invasive. But a trauma patient with no gag and posturing is getting it.

Suffice it to say, there is also nothing wrong with going the route of Robb. He wasn't "wrong" It's okay not to tube... Due to time, adequate BLS, equipment malfunction, contraindications, etc.

So long as you are acting in your patients best interest you did the right thing.

You won't get every tube, and you don't always need to. There is always the BLS/ILS option. Additionally, and fortunately I have the option of direct and video laryngoscopy, that helps also.

And who is "missing" all these tubes... It's almost 2015.... Continuous waveform capnography anyone?  You have to try to not know you're not in...


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## teedubbyaw (Dec 21, 2014)

Next person to say cavalier gets slapped.


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## DesertMedic66 (Dec 21, 2014)

teedubbyaw said:


> Next person to say cavalier gets slapped.


Cavalier


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## triemal04 (Dec 21, 2014)

Based only on the available information, it really only depends on one thing.

Are you (and this isn't meant in a personal way, but something that to many people don't really understand and think about) truly competant at intubation and equipped to do so?  Which includes everything that comes before, and after the act of placing a tube in the trachea.

If the answer is yes, then he should have been intubated.  If the answer is no, (and there's no shame in that) then he shouldn't have been, and what you did was fine.


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## Carlos Danger (Dec 22, 2014)

medicsb said:


> Lidocaine?  Esmolol?  Glycopyrrolate?  WHHHYYYYY?  None of that stuff has any evidence of improved outcomes and just takes up time.  *The patient is also hemodynamically unstable (HR 40s-90s)*.  Keep the beta-blockers far away.  Keep anything that could decrease HR or blood pressure far away.  This pt. was in an MVC, we do not know if the CNS is the only system involved; they still have significant potential for internal bleeding.



We don't know for sure that the CNS is the only system involved, but we know for sure that it _is_ involved that that preventing further injury to it is a high priority. I think there is plenty of evidence that prevention of secondary injury due to hypertension or hypotension is beneficial.

The goal of these drugs is to _improve_ hemodynamic stability by reducing anesthetic requirements while also blunting the ICP increase that follows laryngoscopy and intubation. Even if other injuries do exist, I don't see how pursuit of more stable hemodynamics would be harmful.

A perfect induction and intubation in a patient like this means zero change in MAP and ICP, so getting as close to that as possible is the idea.

Lidocaine reduces anesthetic requirements, meaning you can use less sedation. It also may prevent ectopy, and it blunts ICP increases. Yes, I know that last one is controversial. I still use it on most intubations, whether emergent or not. 

Glyco prevents bradycardia in the face of spikes in ICP, esmolol, sux, and opioids. I have actually begun using glyco as a routine pre-medication for most of my anesthetics. 

Esmolol also reduces anesthetic requirements, and prevents spikes in BP. A small dose is not going to cause hypotension, but it will go a long ways towards preventing the hypertension that results from airway instrumentation. I give a lot of esmolol to sick patients. 

You can use fentanyl as a sympatholytic, but to do that reliably requires pretty high doses (>3 mcg/kg), which in combination with other anesthetics can contribute to undesirable decreases in MAP.

Etomidate --> sux --> tube is a perfectly acceptable strategy if those drugs are all you have, or if they are all you know how to use, or if the patient is crashing. There is plenty to be said for the K.I.S.S principle in the field or in a crisis. But Robb asked what we'd _like _to use, and given the chance I like to try doing a little better than the very basics. 



medicsb said:


> Except it has not _really_ been disproved.  Afterall, the best airway study to date demonstrated improved functional outcomes. *But then again that study is hard to extrapolate to the US where training and experience in most places are so much less than Australian MICA Paramedics.  It's probably more realistic to say that poorly trained and/or inexperienced intubators (i.e. the overwhelming majority of US paramedics) are associated with poor outcomes.*



The vast majority of studies on intubation by American paramedics show high rates of complications and worsened or unimproved outcomes. Does it have to be that way, or will it always be that way? Of course not, and I hope not. But it's been like that for decades and the trend does not appear to be changing, at least not from what I can see.


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## medicsb (Dec 22, 2014)

Remi said:


> We don't know for sure that the CNS is the only system involved, but we know for sure that it _is_ involved that that preventing further injury to it is a high priority. I think there is plenty of evidence that prevention of secondary injury due to hypertension or hypotension is beneficial.
> 
> The goal of these drugs is to _improve_ hemodynamic stability by reducing anesthetic requirements while also blunting the ICP increase that follows laryngoscopy and intubation. Even if other injuries do exist, I don't see how pursuit of more stable hemodynamics would be harmful.



But, in light of the fact that injuries were sustained in an MVC, you cannot proceed as if the CNS is the only affected organ system.  In the prehospital setting and in the ED, you plan as if other organ systems are affected.  They are a multi-system trauma until proven otherwise.  In this pt., I would argue that one should proceed as if they did have ongoing, uncontrolled bleeding - consider them hypovolemic even if they are not showing outward signs of shock or compensation thereof.  I certainly do not have the time to mull over research on the use of some extravagant RSI cocktail, but just a brief skimming of results on pubmed of the different agents suggest seems to show retrospective studies on patients for which the diagnosis has already been made in which the outcomes are based on surrogate outcomes (hemodynamic parameters versus actual patient outcome).  In EM/EMS/CCM, etc., we already have learned in the past that improvement in surrogate end-points do not always equal improvement in outcomes.      




> A perfect induction and intubation in a patient like this means zero change in MAP and ICP, so getting as close to that as possible is the idea.





> Lidocaine reduces anesthetic requirements, meaning you can use less sedation. It also may prevent ectopy, and it blunts ICP increases. Yes, I know that last one is controversial. I still use it on most intubations, whether emergent or not.




If the patient makes it to the OR without already being intubated, chances are you know a lot more about them than the person intubating in the field or the ED.  Regardless, prevention of ectopy - who cares?  We don't even care about ectopy in patients having an MI, why care if they are under anesthesia (I facepalmed everytime I saw an anesthesia provider push lidocaine just because the patient threw a few PVCs).  Less anesthetic requirement is good given the effects it can have on hemodynamics, but its not like lidocaine doesn't have its own potential problems.  At this time, there are no data demonstrating improvement in patient centered outcomes.  You are most likely treating the monitor and yourself more than anything.  Keep the lido in the drug box.



> Glyco prevents bradycardia in the face of spikes in ICP, esmolol, sux, and opioids. I have actually begun using glyco as a routine pre-medication for most of my anesthetics.




Sounds like you're more likely to be treating the effects of meds you're giving than the patient.  Worried about bradycardia?  Hold the esmolol.  



> Esmolol also reduces anesthetic requirements, and prevents spikes in BP. A small dose is not going to cause hypotension, but it will go a long ways towards preventing the hypertension that results from airway instrumentation. I give a lot of esmolol to sick patients.




Any patient centered outcome data in traumatic brain injury or in a head injured patient that also has other injuries? A small dose in the patient in compensated shock may turn it to decompensated when you blunt their physiologic compensatory mechanism (i.e. incr. inotropy and HR).  The otherwise healthy patient without concomitant injury may do just fine, but the scenario does not provide you with that patient.  Hypotension is far more devastating to the head injured patient, so why add an agent that is more likely to decrease BP than anything else?  



> You can use fentanyl as a sympatholytic, but to do that reliably requires pretty high doses (>3 mcg/kg), which in combination with other anesthetics can contribute to undesirable decreases in MAP.




You provided all the reasons why it probably is not necessary in the scenario provided.



> Etomidate --> sux --> tube is a perfectly acceptable strategy if those drugs are all you have, or if they are all you know how to use, or if the patient is crashing. There is plenty to be said for the K.I.S.S principle in the field or in a crisis. But Robb asked what we'd _like _to use, and given the chance I like to try doing a little better than the very basics.




Sometimes the very basics are what's best.  I would say that etomidate and succs is probably no worse than the cocktail suggested and may be better.


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## RocketMedic (Dec 22, 2014)

I'd say that this patient needed a tube. With that being said, not necessarily an EMS tube if you really are only seven minutes out.


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## Akulahawk (Dec 22, 2014)

Pretty much what RM above said. This patient needs a tube/definitive airway control. EMS doesn't have to be _this_ patient's intubationist though. I do agree with the idea of using a bridge device like an LMA though. They can be about as fast to deploy as a King Tube and if you have the right kind, you can intubate through it or you can use a bougie and drop a tube that way. When you're just 7 minutes out and the patient looks pretty much like crap and getting worse, sometimes it's just best to "think" like an EMT and scoop & run and do your ALS stuff, whatever you can, while en-route. If I have a couple of extra bodies, I'll grab 'em and put 'em to work... and if I have time to drop a tube, then I'll do it. Sometimes it's just better to use a BLS airway for now and take definitive airway control later. I think this is just on of those cases. Besides, with a decent report, it should be obvious to the ED that they may be the ones to intubate and they'll be ready & waiting to do it upon arrival. 

Something else to remember is that if you have a vent, you might be able to set that up to be "the bag" for you so all someone has to do is maintain a good seal. Just a thought and hopefully EMS vents can be used in that way.


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## RocketMedic (Dec 22, 2014)

A king plus a vent could be a great thing. With that being said, a hit hard enough to cause dysrhythmias probably devastated cerebral perfusion, so I wouldn't be super-optimistic as to mortality. This guy needs a neurosurgeon and Doc Brown's Delorean.


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## RocketMedic (Dec 22, 2014)

Also depends a lot on the patient to be tubed. Robb's better at tubes than I am, but I think we all agree that a mallapatti one is a way easier tube than a superobese 4+.


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## Carlos Danger (Dec 22, 2014)

medicsb said:


> Sometimes the very basics are what's best.



Yep, sometimes KISS is best, as I already said. And sometimes it's not.

Look, maybe you are unfamiliar with glyco and esmolol as adjuncts to intubation, but they are commonly used drugs that help to stabilize hemodynamics. Small-moderate doses of esmolol do not cause hypotension or bradycardia, especially in the face of SNS discharge. 

All it amounts to is giving normal induction meds, along with a couple adjuncts that allow you to use smaller doses of hemodynamically compromising drugs and to blunt the negative physiologic response to the procedure. Nothing overly complicated about it.

I'll give you that there's no research that shows my "cocktail" is better than etomidate + sux, but there is plenty of research that tells us how bad hypotension and hypertension is for these patients, and I can assure you that you'll see much less dramatic swings in MAP when you use these adjuncts properly. So take that equation for whatever it's worth to you.


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## SeeNoMore (Dec 22, 2014)

I would intubate en route, RSI meds as needed.


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## systemet (Dec 23, 2014)

The patient's oxygenating well, appears to be ventilating ok, and is 7 minutes from a trauma center with real doctors. You've got to draw up your ket, sux, and 1:100 epi, prep your tube, get out a bougie, prep a King or LMA, grab out the cric kit, fire an end-tidal on the bagger, and maybe setup the vent. You can do this in 7 minutes, but when they're sat'ing high, and not seizing, I'd hold off and keep with the BVM/OPA. I'm a fairly good paramedic, but the EM guys are a lot better at this than me.

Put the patient a little further away, make them difficult to bag, hypoxic, give them some chest wall injuries, or change the nature of the receiving facility and this decision changes.

I wouldn't put a King or LMA in this patient without drugs. They may be a 3, but they've postured, have hemodynamics but are altered, and probably have a significant closed head injury. I agree that there may be other occult injuries.

If I was going to tube them, I'd go with a half-dose of ketamine, and sux. I don't have lidocaine any more.  I've read a few of the studies, and agree that there's no positive outcome data, but I like the physiological argument that increasing ICP is bad, and premedication with lido decreases ICP spikes in bolted patients getting deep suction in the ICU. If I had access to it, I would give it. I don't see a massive downside.

Regarding glyco'/atropine and esmolol, I wouldn't give either. I understand that these things might be used in the neuro ICU or OR once the patient's been thoroughly irradiated, but I'd be concerned about other injuries that might not have delcared themselves. I don't carry esmolol on my ambulance, and am not comfortable with using it for premedication. I do use metoprolol occasionally for rate control.


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## SeeNoMore (Dec 23, 2014)

I am surprised how many folks would opt not to intubate this patient. That being said I am used to working with a partner, if I was alone in the back drawing up meds and maintaining the airway would be more challenging. Though I would intubate this patient, I would not question a medic who chose to maintain the airway with a BVM or other device. It just goes against the stereotype of Paramedics being quick to intubate. I guess EMTlife (hopefully) represents a more thoughtful community of providers given everyone here has interest in the exchange of ideas outside of the workplace at a minimum.


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## RocketMedic (Dec 23, 2014)

It's not that he doesn't need to be intubated, it's a realization that intubation is not the be-all of his care.


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## Nova1300 (Dec 23, 2014)

Difficult call when that close to the hospital.  Head injuries with a GCS less than 8 are almost always intubated.  If you guys are interested in a bit more reading on the topic, search the Brain Trauma Foundations TBI guidelines.  

I agree with Remi.  Those adjuncts, when used by skilled practitioners can really keep your hemodynamic swings in check when inducing a head injury.  Especially short acting drugs like esmolol.  

Again it is a hard call to make.  Could that 10 minutes of mild hyperventilation enroute to the hospital be the one thing that keeps the patient from herniating until definitive therapy?  

Looking further down the road, I will tell you that many of these folks have aspiration events after severe TBI and fluff out ARDS on hospital day number 3-4.  Did they aspirate on impact, or was it the ventilation with an unsecured airway?  Really tough to tell.  I'm not sure there is a good answer in the prehospital setting.


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## SeeNoMore (Dec 23, 2014)

RocketMedic said:


> It's not that he doesn't need to be intubated, it's a realization that intubation is not the be-all of his care.



Fair enough. I still feel intubation would be a good option prehospitally. Not the only option, but the one I would choose.


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## PotatoMedic (Dec 23, 2014)

Nova1300 said:


> Again it is a hard call to make.  Could that 10 minutes of mild hyperventilation enroute to the hospital be the one thing that keeps the patient from herniating until definitive therapy?



I believe PHTLS no longer reccomends hyperventilation of TBI's.


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## SeeNoMore (Dec 24, 2014)

Controlled hyperventilation with a target of Pc02 26-30 is still the standard of care for pt's presenting with evidence of elevated ICP.


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## Akulahawk (Dec 24, 2014)

SeeNoMore said:


> Controlled hyperventilation with a target of Pc02 26-30 is still the standard of care for pt's presenting with evidence of elevated ICP.


Which is why it's good to get grumpy if all you have to detect EtCO2 with is a colorimetric device and not something spiffy that shows you the waveform and some numbers.


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## SeeNoMore (Dec 24, 2014)

Do any US ALS services lack waveform Etc02? I thought that was the standard everywhere.[/QUOTE]


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## Brandon O (Dec 24, 2014)

SeeNoMore said:


> Controlled hyperventilation with a target of Pc02 26-30 is still the standard of care for pt's presenting with evidence of elevated ICP.



Most authorities are now suggesting this should be done only as a "rescue" intervention in the setting of active herniation, with the idea of temporizing until other interventions are available. In other words, when they blow a pupil and you're 5 minutes down the road from a guy with a big saw.

If there's nobody to catch what you're throwing it's probably worse than useless. I don't know if this scenario really qualifies. I would probably keep that gun in the holster for a bit.


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## SeeNoMore (Dec 24, 2014)

True Brandon O , what I should have said was pt's presenting with signs of herniation/acutely elevated ICP and diminishing condition. As you point out the issue is still being debated. For the time being it's part of my practice.

Just to be clear, I am not saying this pt would have been hyperventilated, just intubated. And I do agree that hyperventilation is at best a temporary measure for severely ill patients.


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## Akulahawk (Dec 24, 2014)

SeeNoMore said:


> Do any US ALS services lack waveform Etc02? I thought that was the standard everywhere.


I would certainly hope that all ALS services in the US have waveform EtCO2. Quite frankly, I hope I never have to work for a service that doesn't...


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## RocketMedic (Dec 24, 2014)

Lots still don't. "Our paramedics know how to place tubes." Which is an admission of both miserliness and stupidity. Quite effective at weeding out bad employers.


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## Akulahawk (Dec 25, 2014)

RocketMedic said:


> Lots still don't. "Our paramedics know how to place tubes." Which is an admission of both miserliness and stupidity. Quite effective at weeding out bad employers.


That was my suspicion and also is exactly correct... Great way to weed out the bad places to work. Those would only use EtCO2 if their EMS Director made them and they'd only do that kicking and screaming.


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## SandpitMedic (Dec 25, 2014)

If I don't use the EtCO2 waveform when I intubate, AND transmit it to my chart... It is an automatic 3 day suspension, and immediate termination the 2nd time!


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## Shishkabob (Dec 27, 2014)

Tigger said:


> Given the timing I think you present a reasonable case.
> 
> Even if you could RSI, by the time everything is setup you would be getting close to the hospital anyway.



I've never accepted that reasoning.  7 minutes to set up for an RSI for 7 minutes to transport... where they still have to set-up and do an RSI.  You're now looking at >14 minutes.  He needs an airway, he's going to get an airway ASAP, why prolong the inevitable and let the clinical course suffer?  Not saying I'd have tubed in this situation, but the "Well you can get there quickly" line shouldn't be the sole determining factor. 


Shoot, the two are not even mutually exclusive.  Nothing says you can't intubate while headed towards the hospital and accomplish both tasks.


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## DesertMedic66 (Dec 27, 2014)

Linuss said:


> I've never accepted that reasoning.  7 minutes to set up for an RSI for 7 minutes to transport... where they still have to set-up and do an RSI.  You're now looking at >14 minutes.  He needs an airway, he's going to get an airway ASAP, why prolong the inevitable and let the clinical course suffer?  Not saying I'd have tubed in this situation, but the "Well you can get there quickly" line shouldn't be the sole determining factor.
> 
> 
> Shoot, the two are not even mutually exclusive.  Nothing says you can't intubate while headed towards the hospital and accomplish both tasks.


Do hospitals not prep for patients when you do a call in? Ours will usually have everything laid out and meds drawn up. As soon as we move the patient over they get a quick set of vitals and then go to work.


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## Tigger (Dec 27, 2014)

Linuss said:


> I've never accepted that reasoning.  7 minutes to set up for an RSI for 7 minutes to transport... where they still have to set-up and do an RSI.  You're now looking at >14 minutes.  He needs an airway, he's going to get an airway ASAP, why prolong the inevitable and let the clinical course suffer?  Not saying I'd have tubed in this situation, but the "Well you can get there quickly" line shouldn't be the sole determining factor.
> 
> 
> Shoot, the two are not even mutually exclusive.  Nothing says you can't intubate while headed towards the hospital and accomplish both tasks.


I'm not sure RSI is an advisable procedure to do alone while moving, but to each his own.


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## Carlos Danger (Dec 27, 2014)

Lots of posters here have said that the right thing to do in this scenario would be to intubate in the field.

For those who take that position, how do you square your opinion with the many studies that show that these patients actually do worse when intubated in the field?

Like this one from earlier this year: Is prehospital endotracheal intubation associated with improved outcomes in isolated severe head injury? A matched cohort analysis.


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## triemal04 (Dec 27, 2014)

Remi said:


> Lots of posters here have said that the right thing to do in this scenario would be to intubate in the field.
> 
> For those who take that position, how do you square your opinion with the many studies that show that these patients actually do worse when intubated in the field?
> 
> Like this one from earlier this year: Is prehospital endotracheal intubation associated with improved outcomes in isolated severe head injury? A matched cohort analysis.


I'm absolutely not going to discount the results of that retrospective analysis; nobody should.  But I would ask that you explain something to me:  How is that people can, on the one hand, go off on the poor quality of prehospital medical care in southern Cali, specifically LA, and talk about how it is worthless and needs a complete overhaul, and yet on the other hand, hold up a study that (most likely; I only have access to the abstract) was done in LA as a reason for all prehospital providers to do something?

Something just doesn't add up.

There are similar analysis's from systems that are the polar opposite of LA that have come up with entirely different results.  

Should those results be ignored because they don't match what people want to hear or do?

Should we pick and choose what "study" or analysis to believe in?  Should we only read abstracts and only learn what the stated conclusion is?

Or should we really look at the data that's presented?

Prehospital intubation can be done, and done properly.  And when it is, it can be beneficial.  The problem is that not every system is set up to really perform intubation properly.  That is the take away message from all studies like this is what I said earlier: 





> Are you (and this isn't meant in a personal way, but something that to many people don't really understand and think about) truly competant at intubation and equipped to do so? Which includes everything that comes before, and after the act of placing a tube in the trachea.
> 
> If the answer is yes, then he should have been intubated. If the answer is no, (and there's no shame in that) then he shouldn't have been, and what you did was fine.



People, and systems, need to know what their limitations are, and if a study done in a specific area applies directly to them.  Problem being, most don't understand this.


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## luke_31 (Dec 27, 2014)

From research I did towards my degree one of the things that I found was that the trauma severity on these patients was significant enough that the mortality rate was relatively unaffected by the prehospital intubation.  That is to say I found that most of the patients that were intubated in the prehospital setting probably we're not going to survive regardless of who and where did the intubation.  Multiple meta-studies showed that the typical trauma patient intubated in the prehospital setting had significant comorbidity factors in relation to the traumatic injuries that it was hard to say for certain that it was the paramedics who intubated these patients that caused the patients to die more frequently. The hardest part of looking at these studies I found was the people doing the study acknowledged that there was a possibility that the injuries alone would kill the patient. A good example of this is the mortality rate of patients intubated in a cardiac arrest of medical nature. Looking at the rate of cardiac arrest saves versus deaths you could infer that it was the intubation that caused the increase in mortality, reality speaking we are trying to bring back someone who is clinically dead a heroic task to begin with.


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## Carlos Danger (Dec 28, 2014)

triemal04 said:


> How is that people can, on the one hand, go off on the poor quality of prehospital medical care in southern Cali, specifically LA, and talk about how it is worthless and needs a complete overhaul, and yet on the other hand, hold up a study that (most likely; I only have access to the abstract) was done in LA as a reason for all prehospital providers to do something?



The study was indeed done in LA.

Are you saying that studies done in LA are impertinent because standards there are significantly different than the rest of the country? Are paramedics in SoCal not trained to the same national standards as other places in the US?

FWIW, the findings here were not unlike the those from the San Diego trial whose results were published in 2002.



triemal04 said:


> There are similar analysis's from systems that are the polar opposite of LA that have come up with entirely different results.
> 
> Should those results be ignored because they don't match what people want to hear or do?
> 
> Should we pick and choose what "study" or analysis to believe in?



No on is picking and choosing here. There are some studies that show mildly improved outcomes with intubation (I would not say "the polar opposite"), but those tend to be in select systems with much higher standards than normal, and therefore can't really be extrapolated to the majority of EMS agencies. One example that comes to mind is a retrospective analysis done in Seattle a few years ago.

Even the Bernard study done in Australia, which is the only prospective, randomized trial done on prehospital intubation of TBI's, showed only moderate rates of improvement in neuro status at 6 months with prehospital intubation as compared to those intubated in the hospital. There was no difference in mortality, ICU, or hospital stay, and there was something like a 5-fold increase in cardiac arrest among those intubated prehospital. Overall, the trial did show RSI to be an statistical success, but hardly the clinical game changer that it's proponents want it to be. And at any rate I don't think those results can even be extrapolated to the US, given the large difference in the way paramedics are trained there. 

Overall, the aggregate of the data shows success rates that are lower, complication rates that are higher, and outcomes that are generally worsened when patients are intubated in the field as compared to in the hospital.


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## triemal04 (Dec 28, 2014)

Remi said:


> The study was indeed done in LA.
> 
> Are you saying that studies done in LA are impertinent because standards there are significantly different than the rest of the country? Are paramedics in SoCal not trained to the same national standards as other places in the US?
> 
> FWIW, the findings here were not unlike the those from the San Diego trial whose results were published in 2002.


Well...actually...





triemal04 said:


> I'm absolutely not going to discount the results of that retrospective analysis; nobody should.


What I am suggesting, in fact demanding, is that what any self-respecting individual should do, is look at more than what the conclusion in an abstract says, and look at how the data used was obtained, which includes looking at the services involved.  Questions should be asked, like "Is that service the same as the rest of the country?  Is it the same as mine?  How comparable is it?  Is that a service that should be emulated?  Have other services come up with different results?  If so, why?  How did they differ?"

What national standards do you speak of?  Do you mean national registry?  Does Cali/LA require that?  Is this the same national registry that doesn't require any live intubations to become a paramedic?  Seriously, what kind of answer was that?

A co-worker worked in San Diego during the trial you mentioned; I'll just leave it out there that they weren't exactly a high-speed system either, and there were some inherent...flaws...in how that study was run within the department.



> No on is picking and choosing here. There are some studies that show mildly improved outcomes with intubation (I would not say "the polar opposite"), but those tend to be in select systems with much higher standards than normal, and therefore can't really be extrapolated to the majority of EMS agencies. One example that comes to mind is a retrospective analysis done in Seattle a few years ago.


Of course they can be applied to other EMS systems!  That is the true take home for studies like this.  It doesn't matter where you work; Australia, King County, LA, the real conclusion for all these airways studies is very simple: *IF *prehospital providers are really taught how to intubate, they can do so safely, effectively, and in a way that is beneficial.  And prehospital providers in fact* CAN* be taught to do so.  *IF *they don't learn, it's a bad idea.  Every department that intubates should be considering this, and thinking about which applies to them, and if the latter, if they can change to the former, or if it's worth changing to the former.  Not everyone can, or really should.

All the data has really ever showed is that if you aren't really ready to intubate, don't do it.

Edit:  I'm in a hurry, more tommorow.


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## SandpitMedic (Dec 28, 2014)

Remi, forgive me, what is it that you do exactly? Are you a Medic, RN, etc? And are you in a hospital (floor/ER) or in the field?


Triemal raises a great counter-argument, better than I could raise, and I side with him.

Essentially, given the proper training and tools, Paramedics can effectively perform field intubations that are beneficial to patient outcomes.

There are many who are beyond help, and even though we perform advanced procedures, they truly were never going to make it anyway. Blaming us or intubation or the Epi dose is really just a farce. The studies, one you mentioned from 2002, are outdated.. We're talking 13 years ago; there have been great advancements in field technologies and training that should render "goosing the tube" obsolete... So while there are difficult airways and no one is perfect, I would rather see that phrase along with "missed" tubes go the way of backboards, as you put it, rather than intubation as a whole.

Like I said, EtCO2.....KingVision.....Bougies.....better stethoscopes.... Better understanding.....

Granted they aren't utilized by all agency's... I'd like to see it made into the legislation or CASS or regulatory body standards to have all of those tools mandatory. 

There's no reason to miss a tube _*and not know it*_ in 2015. Period.

And has been established: this patient of the topic requires advanced airway stat.


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## Carlos Danger (Dec 28, 2014)

triemal04 said:


> Well...actually...
> What I am suggesting, in fact demanding, is that what any self-respecting individual should do, is look at more than what the conclusion in an abstract says, and look at how the data used was obtained, which includes looking at the services involved.



Not sure what you are getting at here. Are you implying that those who think that prehospital intubation remains unproven are simply ignorant of what the research is really saying, because all we read is the abstracts?

That would be an extremely bold assumption that is insulting to a lot of very smart people who spend plenty of time reading and considering the research.



triemal04 said:


> What national standards do you speak of?  Do you mean national registry?



What I mean is that the paramedics working in southern California are trained to the same minimum national standards as they are everywhere else in the US.

If there were a significant difference in training among paramedics in SoCal vs. the rest of the country, then you could argue that studies done there can't be generalized to places where the paramedics are more highly trained, which is why research done in Australia can't be extrapolated to countries where the paramedics have much less training than they do in Aus. This is the same reason we don't expect paramedics to perform as well as ED doctors, or EMT-B's to perform as well as EMT-P's.

But it's not like that..... a run-of-the-mill paramedic from SoCal has essentially the same education as a run-of-the-mill paramedic in Ohio or Utah or Arizona or North Carolina. So you cannot discount research done in SoCal just because think the paramedics there are weak.



triemal04 said:


> *If* prehospital providers are really taught how to intubate, they can do so safely, effectively, and in a way that is beneficial.  And prehospital providers in fact* CAN* be taught to do so.



This brings us back to my original question: *on what basis do you make this claim?* What research can you cite that shows it results in positive outcomes, that isn't overwhelmed by other research showing poorer or equal outcomes?





SandpitMedic said:


> Essentially, given the proper training and tools, Paramedics can effectively perform field intubations that are beneficial to patient outcomes.


Maybe, maybe not. It certainly seems logical. But lots of things in medicine that seem perfectly logical are never proven until eventually, we find that we were actually dead wrong about what seemed perfectly obvious. Consider MAST pants, using IVF to achieve normotension in bleeding trauma patients, and backboards. It wasn't all that long ago that these things were deemed so obviously beneficial that no one even questioned them, and later we found that we were actually harming patients with these interventions.

So again, what is the basis for this position?



SandpitMedic said:


> There are many who are beyond help, and even though we perform advanced procedures, they truly were never going to make it anyway. Blaming us or intubation or the Epi dose is really just a farce.



Um, no.....those factors are controlled for in any study that is decent enough to make it through the peer-review process.



SandpitMedic said:


> The studies, one you mentioned from 2002, are outdated.. We're talking 13 years ago; there have been great advancements in field technologies and training that should render "goosing the tube" obsolete...



It's not outdated if studies being published 12 years later are showing very similar results.



SandpitMedic said:


> Like I said, EtCO2.....KingVision.....Bougies.....better stethoscopes.... Better understanding.....



If these things make such a difference, then why are the results of the study done in LA and published earlier this year (the one that I linked to a few posts back) essentially the same as the results of the study from San Diego that was published in 2002? And why did the study done in Australia show such modest differences in outcomes, even in light of the fact that the paramedics there are so much more rigorously trained than the ones in the US?



SandpitMedic said:


> There's no reason to miss a tube _*and not know it*_ in 2015. Period.



I agree, but that statement misses the point completely.

The problem in both San Diego and LA studies (as well as others) really isn't tube placement. The problem is that the patients simply don't do as well, after the fact. This points to factors surrounding the intubation that can negatively impact outcomes, such as poor hemodynamic control, hypoxemia, poor ventilation practices, etc.



SandpitMedic said:


> And has been established: this patient of the topic requires advanced airway stat.



No, this patient requires care that can be counted on to give them the best chance of achieving an optimal outcome.

The bottom line is that no one has yet proven that intubation in the field will provide that chance.


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## SandpitMedic (Dec 28, 2014)

You addressed a lot of things.... 

However, you did not advise of your role in medicine.

Do tell...


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## STXmedic (Dec 28, 2014)

SandpitMedic said:


> You addressed a lot of things....
> 
> However, you did not advise of your role in medicine.
> 
> Do tell...


I'm familiar with what Remi does, but I'm not sure how it matters. He/She is providing relevant information and valid arguments. It shouldn't matter if he's a field provider or an in-hospital provider (a hint: it's both, and he focuses a lot on airway management).


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## NomadicMedic (Dec 28, 2014)




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## SandpitMedic (Dec 28, 2014)

The dynamic in which we work is the focus of this entire debate.

I say it does matter what he does if he is going lambast paramedics and make statements insinuating we: a.) should have advanced airways stripped from our scope, and b.) are too ignorant to learn how/when to do it correctly.

He does offer some valid points, and to that end I'm not taking it personal. However, I think if our environments differ so will our perspectives.

All of us have the common denominator of trying to do what is in our patients best interest, Remi included. It's not personal, I am just of a different mindset.

There is also the possibility that he is exactly right, but then the opposite must be possible as well.


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## Carlos Danger (Dec 28, 2014)

SandpitMedic said:


> The dynamic in which we work is the focus of this entire debate.
> 
> I say it does matter what he does



The dynamic we work in has nothing to do with any of this. The outcomes of our interventions are the topic of debate here.

I'm not sure why my credentials are germane to this discussion; my position is either supportable and valid, or it isn't. I could be a layperson with an interest in clinical research, an EMT-B who has done his homework, or a fellowship trained EM/EMS physician....it really doesn't matter.

What I do is no secret though, and you seem really interested, so I don't mind summarizing my resume: Began my career in the military right out of high school. Been a civilian paramedic since 1997 and an RN since 2004. I spent most of my career working as a flight paramedic and flight nurse. Also did ICU in tertiary hospitals, and ground CCT. I will be done with grad school in about 5 weeks and about a week later, God willing, I'll be a CRNA. I have always had an interest in prehospital airway management, especially in TBI patients, and have stayed on top of the research (for the most part) for about the past 5 years or so.



SandpitMedic said:


> if he is going *lambast paramedics* and make statements insinuating we: a.) should have advanced airways stripped from our scope, and b.) are too ignorant to learn how/when to do it correctly.



Please do not put words in my mouth, especially insulting ones. I never "lambasted" paramedics, I never said intubation should be take out of paramedics' scope, and I never ever said anything to the effect that paramedics are too ignorant to learn to intubate. If I thought that I wouldn't still be involved in EMS and I wouldn't bother with this forum.

Unfortunately, there are always people who take this discussion personally. I don't understand why, but I do understand that it's a big part of the reason why we don't see our patient care (as measured by actual outcomes) improving in this area. It's also a big part of the reason why more physicians and other advanced providers don't bother engaging more in these discussions....many of us just don't want to hear what they have to say. Not that they all agree with my position, of course.

It's not at all about "taking skills away" from paramedics. It's all about finding the safest way to effectively manage airways and improve outcomes. Paramedics need to know how to manage airways, including how to intubate. We also need to understand that despite how many of us were trained, intubation is simply not always in the patients best interest, even if we are pretty good at it.

There is plenty of room for intelligent, civil debate in this area. The science is not "settled" by any means....though IMO, it's quite clear that we should be doing certain things differently.

All I did was ask for the folks who say "this patient needs to be intubated now!" to _objectively_ justify their position. Sorry if you find that offensive.


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## SandpitMedic (Dec 29, 2014)

Field intubations - yes. So says every EMS medical director in the United States and the Western world as far as I know.

You provide excellent points for debate Remi, and it is correct to question all of the things we do as providers to ensure we provide the highest standard of care through evidence based medicine .

Although, I will continue to intubate patients that present as TBI with a GCS of 3. That is until your research provides explicit concrete proof that by doing so I am essentially signing said patients' death certificate.

We have not proved either way as of yet,  despite our own strong opinions. I appreciate your perspective.

I have nothing left to add.


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## triemal04 (Dec 29, 2014)

I'm sorry, I think your status as a newly minted CRNA is going to your head a bit.  I'd like to say otherwise, but some of your conclsuions and what, what one can only think, you are intentionally ignoring is driving me in that direction.  I would hope that's not really the case.
*


Remi said:



			Not sure what you are getting at here. Are you implying that those who think that prehospital intubation remains unproven are simply ignorant of what the research is really saying, because all we read is the abstracts?

That would be an extremely bold assumption that is insulting to a lot of very smart people who spend plenty of time reading and considering the research.
		
Click to expand...

*Not at all, it's not in the least bit insulting; anyone who actually takes the time to read a full study and really think about the research will ask questions raised by the data and consider the source of the data.  They might even consider all those things I previously mentioned.  Someone who does that would understand that results may differ when a similar process is tested by different people/groups with different abilities.  My comment does not apply to people like that.  People who only read an abstract won't do any of the above though, and they may feel a bit insulted, but someone who actually thinks about it won't, and shouldn't be insulted. 



> *What I mean is that the paramedics working in southern California are trained to the same minimum national standards as they are everywhere else in the US.*



Really?  Are they?  I think many would beg to differ.  I think many services that incorporate extra training and education into their new hire process and constant ongoing training and education would differ.  Departments that have real standards and track their own success/failure rates might dispute that.  While we are judged off our minimums, as it should be, the hubris involved in believing that nobody exceeds those minimums is astounding.  But, I suppose if you actually think that there are no differences between any paramedics and any services throughout the country, that's your prerogative...

*



			If there were a significant difference in training among paramedics in SoCal vs. the rest of the country, then you could argue that studies done there can't be generalized to places where the paramedics are more highly trained, which is why research done in Australia can't be extrapolated to countries where the paramedics have much less training than they do in Aus. This is the same reason we don't expect paramedics to perform as well as ED doctors, or EMT-B's to perform as well as EMT-P's.

But it's not like that..... a run-of-the-mill paramedic from SoCal has essentially the same education as a run-of-the-mill paramedic in Ohio or Utah or Arizona or North Carolina. So you cannot discount research done in SoCal just because think the paramedics there are weak.
		
Click to expand...

*So you really do believe that a paramedic is a paramedic and LAFD provides the same level of care as...say...Sussex County?  Down in Pecos?  Or your own previous flight service?  I'm sorry, this is an inherently flawed assumption, and if you're willing to admit it, you know it.

*



			What research can you cite that shows it results in positive outcomes, that isn't overwhelmed by other research showing poorer or equal outcomes?
		
Click to expand...

*This. 
http://www.trauma.org/index.php/community/blog_post/section_research/1169/ (benefit and commentary)
http://www.ncbi.nlm.nih.gov/pubmed/12534484 (beneficial in the short-term, unclear on long-term)
http://www.sciencedirect.com/science/article/pii/S0300957212002705 (benefit)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4091894/ (read the entire study please)
http://www.researchgate.net/publica..._severe_head_injury_in_children_a_reappraisal  (no real benefit...and yet, no real harm)
http://www.ncbi.nlm.nih.gov/pubmed/21841511  (no benefit...and no harm once everything was adjusted)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4153828/  (this one requires reading the entire thing and some real thinking)
All of the above shows that, yes, when prehospital intubation is performed by *competent* providers, it can be beneficial, and at the worst, isn't harmful.

http://cjem-online.ca/v8/n2/p116  Now this is a Candian review of a Wang study that points out many of the questions that are raised by these studies, and things that should be considered when reading them.  Read the commentary and take it to heart. 

I'm sorry, but you *are *picking and choosing what you want to believe and not thinking beyond what is the stated conclusion of a study.  You're even doing the same with some of the responses here.

Whether you want to admit it or not, there are other providers, both in and out of the hospital who can effectively manage the airway through intubation.  Whether you want to admit it or not, there are some paramedic services (not all) that can intubate effectively.

So sorry.


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## RocketMedic (Dec 29, 2014)

Honestly, I am skeptical of many surveys that claim intubated patients do worse than non intubated patients. Generally speaking, patients intubated prehospitally or even on the ed are already far more seriously ill or injured than a control group that isn't intubated despite broadly similar circumstances.


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## CANMAN (Dec 29, 2014)

triemal04 said:


> I'm sorry, I think your status as a newly minted CRNA is going to your head a bit.  I'd like to say otherwise, but some of your conclsuions and what, what one can only think, you are intentionally ignoring is driving me in that direction.  I would hope that's not really the case.
> 
> So you really do believe that a paramedic is a paramedic and LAFD provides the same level of care as...say...Sussex County?  Down in Pecos?  Or your own previous flight service?  I'm sorry, this is an inherently flawed assumption, and if you're willing to admit it, you know it.



Man the borderline poo slinging in this thread is comical! Although Remi I also agree that you bring up some valid points I have to agree with the point above. All services are not created equal in my opinion. We may all be trained to the same National standard, however MANY employer's go above and beyond to provide some awesome initial and recurrent training. I don't know about the rest of the RSI provider's on the forum but at my service we have quarterly skills checkoffs and required number of live tubes. We all have different experience levels, and follow our individual protocols. Again my medical director who is credentialed in Anesthesia and Critical Care Medicine would have an MI if I transported a trauma scene run patient and a GCS of 3 without a more secured airway, so I am held to that by protocol, regardless of my own opinions, if I want to maintain a job. I also believe that an RSI can be easily setup and performed in less then 7 minutes, and if transporting by ground have no problem with intubating enroute.


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## Carlos Danger (Dec 29, 2014)

triemal04 said:


> I'm sorry, I think your status as a newly minted CRNA is going to your head a bit.



Another ad hominem against a person you don't even know, just because you disagree with their point of view on a contentious topic. Very professional. 

And so many in EMS wonder why the rest of healthcare views paramedics the way that they do. Dr. Bledsoe had it so right.




triemal04 said:


> we are judged off our minimums, as it should be,



Exactly. Remember that those are *your* words......and consider how it impacts this debate.



triemal04 said:


> But, I suppose if *you actually think that there are no differences between any paramedics and any services throughout the country*



Nope, I never said that. In fact, I stated the exact opposite. Maybe re-read my post a little closer.



triemal04 said:


> This.
> http://www.trauma.org/index.php/community/blog_post/section_research/1169/ (benefit and commentary)
> http://www.ncbi.nlm.nih.gov/pubmed/12534484 (beneficial in the short-term, unclear on long-term)
> http://www.sciencedirect.com/science/article/pii/S0300957212002705 (benefit)
> ...



What? Really? Not a convincing list by any means.

Remember, you need to read a lot deeper than the abstract. If you did, you'd know that only *ONE* of those studies shows improved outcomes in TBI patients who are intubated prehospital. The rest show, at best, no harm. I can probably think of a hundred things that we could do to patients that cause no harm....but bring no benefit, either. Does that mean we should be doing them, especially when they are potentially risky? Using your logic, yes we should.

The study that does show benefit is the Australian study done by Bernard, et al that I already referred to in a previous post. The benefits were minimal and questionable. In fact, the benefits were so far removed from the intubation (GOSe at _six months_??) that it's difficult to even attribute such an outcome measure to the intubation, given the long period of time and all of the other clinical interventions that occurred between the intubation and when the outcome was measured.

But hey, it _was _a large, well done study, and technically it did show an improvement in outcomes.....so I'll give it to you. We'll ignore the dramatic increase in prehospital cardiac arrests, we'll ignore the fact that all variables (Pa02, PC02, SBP, etc.) measured on ED arrival were no better at all in the patients who were intubated, and we'll ignore that prehospital intubation did not reduce mortality or the need for surgical intervention or the amount of time spent in the ICU or the hospital. We'll just focus on the mild improvement in GOSe six months later and score this one as a win for the folks who think that the more plastic we shove down people's throats, the better care we are providing. No problem. 

(guess what: none of that analysis was in the conclusions section of the abstract!)

However.....there is still a huge obstacle you have to overcome if you expect to use this study as evidence that paramedics in the US should be intubating everyone with a TBI: This study was done in Australia, where the paramedics have _far _more training than American paramedics do. 

You can't say that the outcomes achieved by someone whose paramedic training took 5 years is going to be the same as someone whose training took 10 months. If that were the case, we could just get rid of ED docs and replace them with paramedics.  

I suggest that you seriously consider taking a course on evaluating research. 




CANMAN said:


> All services are not created equal in my opinion



Of course not. That's the _whole point. _

Again, you cannot take a study done using above-average clinicians and extrapolate it to thousands of run-of-the-mill paramedics who barely have any airway experience. 

You guys are so busy being offended and trying to poke holes in my reasoning that you aren't even considering what I'm presenting.


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## SandpitMedic (Dec 29, 2014)

Dr. Bledsoe *is* my medical director! And I would be fired if I did not intubate that patient. 

He wrote the books, lest you forget. (Most of them anyway.)

No one is making passive shots at you, we are pretty much all in agreement that your side of the coin on this is tainted due to your perspective and occupation.

We do hear you though, but disagree.


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## triemal04 (Dec 29, 2014)

Remi said:


> Another ad hominem against a person you don't even know, just because you disagree with their point of view on a contentious topic. Very professional.



Let's all just take a deep breath for a little bit.  That was not, nor have I previously made, any sort of personal attack towards you.  What I'm suggesting, and is a valid suggestion, is that your new position is skewing your thinking.  It's not an insult, just something you should consider; I only bring it up due to some of your comments here, some of which I pointed out.  There's nothing personal about it.  Getting upset over nothing is counter-productive, ok?




> Nope, I never said that. In fact, I stated the exact opposite. Maybe re-read my post a little closer.


I'm sorry, what you have been implying very clearly, is that you don't see a difference between various paramedic level services within the US.  If you did see and understand the difference you'd realize that the results of one study done in one particular area might not be representative of another particular area.  It's part of why results of similar studies may differ, and why, when someone is considering implementing changes based on a study, they need to consider if they work in a similar setting and with similar resources.  



> Remember, you need to read a lot deeper than the abstract. If you did, you'd know that only *ONE* of those studies shows improved outcomes in TBI patients who are intubated prehospital. The rest show, at best, no harm. I can probably think of a hundred things that we could do to patients that cause no harm....but bring no benefit, either. Does that mean we should be doing them, especially when they are potentially risky? Using your logic, yes we should.



Let's continue to be calm, ok?  I very clearly noted that several of the studies I linked showed only no harm, or only a small possible benefit.  That's not a revelation, it's just counter to your arguement and other studies that show perhospital intubation is directly harmful.  

Now, I'm glad that you are well familiar with Dr. Bernard's study; more people should be.  Have you taken the time to read through the rest?  If you take the time and think through it as I asked, there is a lot of food for thought in there.  If we all remain calm, I'd be happy to discuss it.




> However.....there is still a huge obstacle you have to overcome if you expect to use this study as evidence that paramedics in the US should be intubating everyone with a TBI: This study was done in Australia, where the paramedics have _far _more training than American paramedics do.


This is true; however, it would appear that there are select places within the US that have found a way to overcome that with their own internal training.  Again, please read through everything I listed. 



> Again, you cannot take a study done using above-average clinicians and extrapolate it to thousands of run-of-the-mill paramedics who barely have any airway experience.


I don't believe anyone, least of all myself, has suggested that all paramedics are capable of performing select skills at the same level as various high-performing systems.  In fact, everything that I've said has been the opposite.  The vast majority of departments in the US should not be intubating anyone.  Yet, there are some services that have the abilities to do so in a safe, and competent manner.  Should departments like that change what they do because under-performing systems don't operate as efficiently?  I say no.  Just as under-performing systems shouldn't immedietly change what they do because a better service is...well...better.  (of course this isn't to say that they shouldn't try and effect wholesale change on their system to improve by emulating a better service; just that they shouldn't increase their skillset because someone else does it better)




> You guys are so busy being offended and trying to poke holes in my reasoning that you aren't even considering what I'm presenting.


I don't know that anyone is getting offended; I'm not.  By the tone of this post, you seem to be, and I have to ask why?  You posted a study from LA to bolster your claim that all prehospital intubation is detrimental.  There are flaws within that arguement that have been pointed out.  We can either continue on this road, or not, it's up to you.


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## Carlos Danger (Dec 29, 2014)

triemal04 said:


> That was not, nor have I previously made, any sort of personal attack towards you.  What I'm suggesting, and is a valid suggestion, is that your new position is skewing your thinking.



If you had simply suggested that my anesthetic experience may negatively impact my ability to objectively consider all of the variables in play here, that would have been one thing. It would have been false - considering that I have spent far more of my career intubating people in ambulances and helicopters than in the OR, and also considering that many of the greatest contributors to EMS research have been physicians and others who never even worked prehospital - but it would have been a fair question.   

Instead, what you actually wrote was _"I'm sorry, I think your status as a newly minted CRNA *is going to your head* a bit."_ That means something very different than saying my position is "skewing my thinking", and it is insulting. I've also been accused of not actually having read the research that I refer to, of wanting to take intubation out of the paramedic scope, and of saying that paramedics are ignorant. None of which even approaches the truth.

I don't get personally offended by anything that some anonymous, random stranger who knows nothing about me says on some random internet forum. But the reality is, this kind of personal reaction to questioning or criticism of certain practices is very common among the EMS community, and fair or not, it does contribute to the perception that others in healthcare have of the professionalism of the EMS community, not unlike the way that the "Race the Reaper" t-shirts and the FB posts that say, in all seriousness, "I'm a hire levil of car then nerses r becuz I kin intibate" do. I'm just sayin'. 



triemal04 said:


> I'm sorry, what you have been implying very clearly, is that you don't see a difference between various paramedic level services within the US.  If you did see and understand the difference you'd realize that the results of one study done in one particular area might not be representative of another particular area.


No, I am very well aware of the fact that there are big differences in EMS systems and the level/quality of care that they provide. I'm the one who keeps pointing out that you can't extrapolate the results of studies done in Australian EMS systems to EMS systems in the US. Also, in my reply to your first reply to my first post on this topic (if you can follow that), I wrote _"There are some studies that show mildly improved outcomes with intubation (I would not say "the polar opposite"), but those tend to be in select systems with much higher standards than normal, and therefore can't really be extrapolated to the majority of EMS agencies." _I then referred to a study done in Seattle that showed improved outcomes. So clearly I recognize that there are differences from place to place, and I also recognize that the research is not homogenous. 

The EMS systems in LA and SD are not nearly as different from the rest of the American EMS systems as the Australian EMS systems are. They are large, busy systems whose paramedics meet the same minimum national training standards as every other paramedic everywhere in the US, whereas the Australian paramedics have far higher educational standards. So it's not a double standard to say that you can't extrapolate from Australian EMS to American EMS, but you can extrapolate from SoCal to the rest of the US. 

As you wrote yourself in your last post, "we are judged by our minimums". What that means that as a whole EMS profession, we have to answer to the results of large studies, even if we feel those studies are not representative of the quality of care provided by other agencies. So even if you think paramedics in SoCAl suck, you have to answer for their performance, because that is where most of the studies are done.

How do you answer for it? By countering with other studies that show different outcomes. But unfortunately, there just isn't much of that. There are a few. But they tend to be in "elite" systems that are just as different from mainstream as the weaker systems are. 

I have read A LOT of research on EMS airway management (not just in TBI) over the years. What I can tell you is that the majority of it is negative. I'm not happy about that; it just is what it is. 

I am working on an a lit review and evidence table for my blog that aggregates and compares all of the studies done on American EMS systems and their outcomes with intubating TBI's, but it is slow going since I don't have a lot of free time, and what little I do have tends to get gobbled up on EMTLife.



triemal04 said:


> I very clearly noted that several of the studies I linked showed only no harm, or only a small possible benefit.  That's not a revelation, it's just counter to your arguement and other studies that show perhospital intubation is directly harmful. Now, I'm glad that you are well familiar with Dr. Bernard's study; more people should be.  Have you taken the time to read through the rest?  If you take the time and think through it as I asked, there is a lot of food for thought in there.



First, everyone needs to understand that the point of doing or evaluating research should be to try to find out the truth, not to try to find evidence that supports what you already think is true. We should go into reading each article with an open mind, having no idea what we'll learn, and analyze it objectively.

With that in mind, I do not have a vendetta against prehospital intubation. I am not out to find proof to support my preconceived ideas. I am perfectly, 100% open to any research that shows that intubating TBI patients (or any other patients) actually helps make them better. In fact I would welcome it. I love managing airways, and I like doing things for patients that help them in the long run. The research I have read, as well as my personal clinical experience, is the _source_ of my opinion, not something that I use as a club to try to beat others into seeing things my way.

I agree, there is plenty of food for thought in those papers. But the Bernard study is the only one that actually shows an improvement in _clinical outcomes_ in TBI patients. I do not see where the others show a benefit. If I am missing something, please point out specifically which study and specifically what outcome was improved.

My overall point in challenging ya'll to provide evidence of your position was not to argue that paramedics should not be intubating TBI patients.....it was to make the point that for something so many people feel so strongly about, it's actually quite difficult to justify objectively. You can make good arguments for it, but the objective data is either not there or in most cases is not strong.


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## SandpitMedic (Dec 29, 2014)

On an aside... From the aside...

My job is *emergency medicine.
*
While I take note of the probable continuation of care and treatment, my job is to consider the best approach or combination of approaches to mitigate life threatening circumstances as they arise or become imminent. Not to worry about what the CRNA in the OR or the ICU doctor thinks, notwithstanding this person is getting intubated the moment we walk into the ER if I choose not to.  I have to worry about the here and now within my scope of practice to prolong the patient's life.

With Robb's patient:

Do I BLS this trauma patient with a TBI, GCS3, and no gag... Increasing the probability of aspiration after trying to one man BVM this guy and pumping loads of air into his stomach for 10 minutes? Does this person have a high likelyhood of survival with a normal quality of life as it is? Are there other factors to consider such as internal hemmorage or pneumothorax? How about the likelyhood of vomiting even without a BVM to the face?

Or do I go for the secure airway via ETT as trained....and be able to move on from the airway?

It's common sense. It's basic ALS emergency medicine for this patient, so long as you are competent and capable. It's also an _objective logical reason._

Sorry I'm not sorry. You paramedic the way you want to if you disagree. I get this went off on a wild debate about the topic. But I'm sticking to intubation en route.


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## triemal04 (Dec 29, 2014)

Remi said:


> Instead, what you actually wrote was "I'm sorry, I think your status as a newly minted CRNA is going to your head a bit." That means something very different than saying my position is "skewing my thinking", and it is insulting.


Not really.  I wrote both those things because, based on your comments in this thread, what you choose to ignore, and how those comments are coming across to me, that is how it appears.  I have no doubt that you don't want to consider that and I don't say it to be insulting and in all honesty I don't care, it's just as a simple statement of what my perception is; if you choose to see it another way, that would be on you.



> But the reality is, this kind of personal reaction to questioning or criticism of certain practices is very common among the EMS community, and fair or not, it does contribute to the perception that others in healthcare have of the professionalism of the EMS community, not unlike the way that the "Race the Reaper" t-shirts and the FB posts that say, in all seriousness, "I'm a hire levil of car then nerses r becuz I kin intibate" do. I'm just sayin'.


Nor does the content of your previous post.  You can't really talk professionalism and keeping things impersonal with that type of response.  Want this to be professional?  Let's move on then.



> I've also been accused of not actually having read the research that I refer to


Yes, by me.  Because based on your comments it appears to me that, with many, you are not considering anything else other than the abstract.  If that isn't so, and you are considering all, or as many as possible, aspects of the data, as I said before, then you shouldn't be bothered by that as it doesn't apply to you.  But, that isn't what I see from your posts, sorry.   



> f wanting to take intubation out of the paramedic scope, and of saying that paramedics are ignorant.


Not by me.  So let's move on.



> Also, in my reply to your first reply to my first post on this topic (if you can follow that), I wrote "There are some studies that show mildly improved outcomes with intubation (I would not say "the polar opposite"), but those tend to be in select systems with much higher standards than normal, and therefore can't really be extrapolated to the majority of EMS agencies." I then referred to a study done in Seattle that showed improved outcomes. So clearly I recognize that there are differences from place to place, and I also recognize that the research is not homogenous.



And yet you also have said this: 
_Are you saying that studies done in LA are impertinent because standards there are significantly different than the rest of the country? Are paramedics in SoCal not trained to the same national standards as other places in the US?

What I mean is that the paramedics working in southern California are trained to the same minimum national standards as they are everywhere else in the US.

If there were a significant difference in training among paramedics in SoCal vs. the rest of the country, then you could argue that studies done there can't be generalized to places where the paramedics are more highly trained,

a run-of-the-mill paramedic from SoCal has essentially the same education as a run-of-the-mill paramedic in Ohio or Utah or Arizona or North Carolina. So you cannot discount research done in SoCal just because think the paramedics there are weak._

There's a bit of a discrepancy here, and again, the hubris involved in thinking that no place ever exceeds the minimum is astounding.  If you can explain that, great.



> As you wrote yourself in your last post, "we are judged by our minimums". What that means that as a whole EMS profession, we have to answer to the results of large studies, even if we feel those studies are not representative of the quality of care provided by other agencies. So even if you think paramedics in SoCAl suck, you have to answer for their performance, because that is where most of the studies are done.
> 
> How do you answer for it? By countering with other studies that show different outcomes. But unfortunately, there just isn't much of that. There are a few. But they tend to be in "elite" systems that are just as different from mainstream as the weaker systems are.


Of course we do; I brought that up because it's true.  Just as I said previously about your study from LA:  _I'm absolutely not going to discount the results of that retrospective analysis; nobody should._ 

And now we apparently come to the crux of the problem.  Do me this favor:  stop, go back and re-read everything I posted in this thread.  Seriously, do that for me.  Now, based on all that, what part of what I have previously said is not in line with this statement:  _I don't believe anyone, least of all myself, has suggested that all paramedics are capable of performing select skills at the same level as various high-performing systems. In fact, everything that I've said has been the opposite. The vast majority of departments in the US should not be intubating anyone. Yet, there are some services that have the abilities to do so in a safe, and competent manner. Should departments like that change what they do because under-performing systems don't operate as efficiently? I say no._  And:  _The problem is that not every system is set up to really perform intubation properly._

What part of that do you have a problem with and disagree with? 

In all honesty, you can say that you're just trying to challenge people, but when you're argueing out of both sides of your mouth...c'mon...


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## RocketMedic (Dec 30, 2014)

Acadian as a whole practices in a manner very, very, sickeningly similar to California. 
Most places work basically the same.

For what it's worth, many places emphasize all the wrong things....very short scene times, universal protocols, c-spine, etc- and don't do much about the important stuff.


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## WiserOne (Jan 1, 2015)

Just adding my two cents...... The patients condition upon your arrival was not such for his lack of intubation. You managed the patient well and if time permitted very well COULD have intubated. Given the time circumstances, I would have not intubated. 

Add ten minutes to transport time and I would have tried dropping a superglotic or intubated sans sedation.


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## SeeNoMore (Jan 4, 2015)

Honestly I am less concerned with whether or not someone would choose to intubate this patient, and more concerned with whether the provider (generally speaking not the OP)  had a clear confident approach to airway management. It's fine to evaluate a patient and choose BLS airway management, especially with short transport times.  It's also fine to move to intubation with a clear organized plan including what you are going to do if you are not successful in placing an ETT. I have seen providers get rushed and move to intubation before they had covered their BLS airway bases and had a plan B, C etc. I think part of this is the culture of "get the toooobe".


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## SandpitMedic (Jan 8, 2015)

And then there was this....

Intubate.

http://www.emergency-live.com/en/he...i-increases-rate-favorable-neurologic-outcome

And this...

http://www.emergency-live.com/en/health-and-safety/prehospital-airway-management-best-articles-2014


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## Carlos Danger (Jan 8, 2015)

SandpitMedic said:


> And then there was this....
> 
> Intubate.
> 
> ...



No new information there. 

Those links both refer to the same paper, the Bernard study that was done in Australia and published 4 years ago that was already referred to several times in this thread.


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## Carlos Danger (Jan 8, 2015)

I am slowly working on a lit review on this topic. It's slow going because I have a lot of studying to do right now, and I'm also working full time. I may not have it done until late next month.

I've identified about 15 or so studies done on American EMS systems and published between 2000 and now that look at outcomes of TBI patients who are intubated vs. not intubated, as well as a handful more that look at related but technically separate concepts such as RSI vs. non-RSI intubation in this population.

As I said I won't be done for a while, but what I can tell you preliminarily is that there is no data that I have found that shows that patients intubated by American paramedics do better than those who are not intubated.

There _are_ studies that show improvements in those intubated with RSI vs. non-RSI, there are studies that show improvements with intubation + HEMS transport, and there are studies in the European literature that show improvements in outcome using physician-staffed teams. There is also the Bernard study that keeps coming up that was done in Australia which shows mildly improved functional outcomes measured _six months_ later, but no difference in survival or any of the other outcomes that are of primary interest to EMS.

The reality is that there is *nothing* in the recent *American* literature that supports routine intubation of TBI patients. In fact most studies show significantly worse outcomes, even after adjusting for injury severity (as best as can be done in retrospective studies, anyway).

If anyone can find find a study that says otherwise, please refer me to it. I've spent hours searching PubMed and references sourced from related papers, but it is certainly possible that I've missed something.

You can argue about this if you want, but you aren't disagreeing with me, you are disagreeing with the aggregate of published medical literature over the past 14 years.


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## Posterior (Feb 3, 2015)

I have a hard time calling a airway "patent" when they have a GCS of 3-4. 
I'm not saying I disagree with your decision, but personally I would have pulled the trigger and RSI'd. 
I'm only concerned about what would happen enroute, gastric distention, vomit, so-on.


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## DrParasite (Feb 4, 2015)

PHTLS says that there is no need to intubate trauma patients if a BVM and OPA are working well.  

That being said, I would think that intubation was indicated in the OP's case.  Provided, however, it didn't delay transport to a trauma center.

IIRC, intubation isn't what causes worse outcomes, but rather the delay in transport while a paramedic attempts to intubate.  So if you take a look, and can drop the tube successfully in less than a minute, and be on your way to the trauma center, good.  I think the argument could be made that intubating (or BAID, which I'm getting more fond of now that I have moved down south) is better to maintain an airway in a moving ambulance, vs being the sole provider with a BVM attempting to maintain a seal while going down the road.   

But when you prep for an RSI, you're spending precious time that should be spent going go the trauma center.

BTW, I don't think California paramedics are any worse trained than anyone else.  However, CA paramedics are less experienced at intubating, because they don't do it frequently on real people.  This is a problem with any all ALS systems (compared to tiered EMS systems), because providers just don't do it enough.  California is further hampered because they have so many paramedics (every firefighter, ambulance operator, tow truck driver, and fast food worker is a paramedic looking for a new job), so on a sick calls, you might have 2 to 6 paramedics on a scene, and only one can actually get the tube.  Some haven't intubated a real person in the last 12 months.  Compare that to my old stomping ground of NJ, when there are paramedics who intubate 2 people a week, and you see who is more experienced at intubations.  It isn't about training, it is about using the skills in real patients.  To over simplify, anesthesiologists are really good at intubations; psychiatrists, not so much.  both are MDs, but one intubates more often.


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## systemet (Feb 4, 2015)

> IRC, intubation isn't what causes worse outcomes, but rather the delay in transport while a paramedic attempts to intubate.



For all the pressure to transport rapidly, there's not a much data supporting rapid transport in blunt head injuries. 

The arguments against prehospital intubation generally focus on:

(1) Paramedics are less skilled at intubation than physicians and are more likely to expose patients to additional secondary insults, e.g. hypoxia, hypotension, hypercapnia, through prolonged or repeated intubation attempts.

(2) Paramedics are more likely to inadvertently hyperventilate patients once intubated, resulting in a reduction in cerebral blood flow.

Without going to the effort of looking up the primary research, it's clear that this depends on the paramedic and their experience / exposure to intubation, the equipment available to them, and the system in general. Some systems / paramedics are capable of intubating people very safely, and there's some evidence to support the practice, e.g. the Bernard et al. study, above.  Others are not. Confounding this, is the likelihood that prehospital intubations represent a high risk group of airways that may be intrinsically more challenging, due to environmental factors, or an increased incidence of difficult airways within the group. This is reflected in some studies involving physicians as well as paramedics.


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## Brandon O (Feb 4, 2015)

"Paramedics intuating TBI in the field" does seem to be a profoundly heterogeneous group.


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## systemet (Feb 5, 2015)

Brandon O said:


> "Paramedics intuating TBI in the field" does seem to be a profoundly heterogeneous group.



Agreed.  I think that you and I see that, but that the physicians, as a group, generally don't.  There's not a lot of distinction made between someone who graduates from a six month program, and someone who graduates from a 3 year program, or between the person who does tubes on simman, versus the person who gets 50 OR tubes before touching a prehospital patient.

There also seems to be a lack of appreciation that while the TBI group may be very susceptible to poor airway management, many of the other groups of patients that we intubate may have much less risk if there's a period of transient hypoxia, hypotension or hypercapnia.


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## SeeNoMore (Feb 5, 2015)

And really why should Physicans or anyone else have to learn these distinctions? We all have the same cert. It our own fault (as a professoin) that we do not promote a better standard of education andcare. I understand the hesitancy to see complex procedures in the hands of providers who represent such a range of quality.


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## medicaltransient (Feb 5, 2015)

I like the comments with Etomidate only. Has anyone seen the research that says King tubes LMA and comdi tubes occlude the IJ and are harmful to cerebral circulation. Has anyone read the research that sux should never be used in prehospital environment and better outcomes are coming from Vec and Roc as the first and only nmba durring RSI. I will look for the research when I wake up and post it. Goodnight guys!


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## Carlos Danger (Feb 5, 2015)

I think most physicians and others who look at this recognize that there is a broad range of skill levels among paramedics, and also that this is both a challenging population (TBI patients) to manage in the first place, and a challenging environment (the field) to do it in. We _are _asking a lot here. We take these clinicians (paramedics), give them a fraction of the training that EM docs and anesthesia folks get, and then put them in an especially challenging environment with the most challenging types of patients, and expect them to produce outcomes similar or better than the hospital intubations? Most of us appreciate this, I think.

But still, there is a fair amount of research on this, and it is is pretty consistent on the lack of difference in outcomes. It's not just in CA, either. The Bernard study that keeps coming up was a really decent RCT done in Australia - with paramedics who are generally considered much better trained than most American paramedics - and it showed no improvement in survival with prehospital intubation.

The reason could have something to do with factors that are beyond anyone's control. It could be that very early post-insult, these patients are even more exquisitely prone to the secondary injury that can result from intubation than they are an hour later. It could have more to do with post-intubation management during transport than it does with the intubation itself. Maybe it's related to hyperoxemia from the 100% oxygen that is almost universally used in the field post-intubation. Could it be the drugs - is something different being used for intubation in the ED's than what is being used in the field? There are probably confounders and bias that exist in these studies (they are almost all retrospective) that haven't been considered.


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## SandpitMedic (Feb 5, 2015)

Remi said:


> I think most physicians and others who look at this recognize that there is a broad range of skill levels among paramedics, and also that this is both a challenging population (TBI patients) to manage in the first place, and a challenging environment (the field) to do it in. We _are _asking a lot here. We take these clinicians (paramedics), give them a fraction of the training that EM docs and anesthesia folks get, and then put them in an especially challenging environment with the most challenging types of patients, and expect them to produce outcomes similar or better than the hospital intubations? Most of us appreciate this, I think.
> 
> But still, there is a fair amount of research on this, and it is is pretty consistent on the lack of difference in outcomes. It's not just in CA, either. The Bernard study that keeps coming up was a really decent RCT done in Australia - with paramedics who are generally considered much better trained than most American paramedics - and it showed no improvement in survival with prehospital intubation.
> 
> The reason could have something to do with factors that are beyond anyone's control. It could be that very early post-insult, these patients are even more exquisitely prone to the secondary injury that can result from intubation than they are an hour later. It could have more to do with post-intubation management during transport than it does with the intubation itself. Maybe it's related to hyperoxemia from the 100% oxygen that is almost universally used in the field post-intubation. Could it be the drugs - is something different being used for intubation in the ED's than what is being used in the field? There are probably confounders and bias that exist in these studies (they are almost all retrospective) that haven't been considered.


 Spot on post.


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## systemet (Feb 6, 2015)

SeeNoMore said:


> And really why should Physicans or anyone else have to learn these distinctions?



I would argue that if a physician is going to be involved in the oversight and direction of prehospital care, then they should know the level of skill and training of *their* providers.  Not a group of paramedics in San Diego, King County, or Victoria, Australia. The fact that the group is heterogenous means that what works in one setting may not work in another. This falls under system design and CQI/QA.



> We all have the same cert. It our own fault (as a professoin) that we do not promote a better standard of education andcare.



But we don't. The guys in Victoria, Australia don't have the same cert as the guys in San Diego. And is it reasonable to say that the paramedic at King County has the same cert as the paramedic in San Diego? Yes, they're both paramedics in the US, they may both be NREMTPs, but is their initial training, ongoing training, skill exposure and continuing education even remotely similar?

What about a Critical Care Paramedic in Ontario (4 years), an ambulance-nurse in Sweden (5 years), etc? The world doesn't end at the borders of the US, yet the findings from these studies are often extended to systems that are completely different.



> I understand the hesitancy to see complex procedures in the hands of providers who represent such a range of quality.



So do I, but I think there's a paucity of research in this area (1 RCT on RSI; 1 RCT on pediatric intubation showing equipoise). I don't think that this question has been settled.

The Victoria study suggests that prehospital RSI can be performed safely (nonsignificant mortality difference), and results in improved neurological outcome (*which is the outcome that really matters). This is a study that excluded patients that were flown. Granted, there's limitations:

* These paramedics were highly trained, worked in a system with strong QI/QA, and underwent a more rigorous training program than *most* (but not all) US paramedics. We don't know if these results are generalizable to other systems.

* The confidence interval for the odds ratio is 1.00-1.64, making it hard to know how large the benefit is. The authors themselves note that a one patient difference in either group takes the p-value from 0.46 to 0.6

So, we don't know the full extent of the benefit, there's a 1 in 20 chance it's spurious, and it's not clear whether you can reproduce this elsewhere.


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## systemet (Feb 6, 2015)

Remi said:


> The Bernard study that keeps coming up was a really decent RCT done in Australia - with paramedics who are generally considered much better trained than most American paramedics - and it showed no improvement in survival with prehospital intubation.



True, but disability at 6 months was significantly improved, which is probably more important.


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## Carlos Danger (Feb 6, 2015)

systemet said:


> True, but disability at 6 months was significantly improved, which is probably more important.



Functional outcome was _statistically_ improved at six months, but was clinically a very minor improvement.

More importantly, when you consider the length of time that elapsed between the intervention in question (intubation) and the outcome measurement, as well as the innumerable other clinical interventions that a TBI patient would undergo during that interval, all the way from ED resuscitation to ICU care to rehabilitation, as well as all the other individual factors that could potentially affect eventual outcome - none of which were even attempted to be controlled for by this study - I think it is really hard to definitively credit the prehospital intubation with the improved outcome.


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## systemet (Feb 6, 2015)

Remi said:


> Functional outcome was _statistically_ improved at six months, but was clinically a very minor improvement.



11 more patients that were able to live independently, travel locally, and buy their own groceries in the prehospital intubation group.
_
www.tbi-impact.org/cde/mod_templates/12_F_01_*GOSE*.pdf
_
I'm not saying being GOSe 5 is a great way to live, but it's a lot better than being a 4.

Granted, you look at the confidence intervals, and run the study again, and there's a 5% chance that that number is 0 (or negative) instead of 11.



> More importantly, when you consider the length of time that elapsed between the intervention in question (intubation) and the outcome measurement, as well as the innumerable other clinical interventions that a TBI patient would undergo during that interval, all the way from ED resuscitation to ICU care to rehabilitation, as well as all the other individual factors that could potentially affect eventual outcome - none of which were even attempted to be controlled for by this study - I think it is really hard to definitively credit the prehospital intubation with the improved outcome.



This is why you randomise, though. You're right, you can't control these factors (or at least it's difficult to do so), but you also can't assume they're collectively working in the same direction in the pre-hospital intubation group. Their findings would be strengthened if this was a multi-center trial, or if someone else can reproduce them.


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## systemet (Feb 6, 2015)

Also, once you hit the ICU, you're intubated, they may be aware this was a prehospital intubation when they go through the chart, but they're almost blinded. It's hard to think that they're going to really modify their care based on where that ET tube was put in. Even more so, in the rehab environment, where they probably aren't aware.


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## Carlos Danger (Feb 6, 2015)

The overall difference in GOSe was actually _not_ statistically significant - I was mistaken.



> The median GOSe was higher in the paramedic intubation group compared with hospital intubation (5 vs. 3), however, *this did not reach statistical significance (P = 0.28)*.
> 
> The median 6-month extended Glasgow Outcome Coma scores were higher in the paramedic intubation group, *although this finding did not reach statistical significance*. More patients in the paramedic intubation group had cardiac arrest prior to hospital arrival, but the overall mortality rate at hospital discharge was similar in both groups.



I'm skeptical, that's all.

All we are talking about here is performing an intubation roughly 30 minutes earlier (in the field) than it would otherwise have been performed anyway (in the ED). Doing so had no impact on any of the measured physiologic parameters (BP, sp02, pH, Hgb) that are known to be of importance in TBI, or on the early clinical course (ICU days). 

It just seems implausible to me that you can do an intervention a little earlier than you would have done it anyway, and even though you find no evidence that changing the timing of the intervention made any difference during the most important phase of the clinical course, still attribute a difference found 6 months later to the change in timing of your intervention.


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## systemet (Feb 6, 2015)

Remi said:


> The overall difference in GOSe was actually _not_ statistically significant - I was mistaken.




Yep, but the proportion of patients in the GOSe 5-8 group versus the GOSe 1-4 group was statistically significant (p=0.046): _"The proportion of patients with favorable outcome (GOSe, 5–8) was 80 of 157 patients (51%) in the paramedic intubation group compared with 56 of 142 patients (39%) in the hospital intubation group (risk ratio, 1.28; 95% conﬁdence interval, 1.00–1.64; P = 0.046)"_

One plausible mechanism is that properly performed intubation / ventilation is protective against episodes of hypoxia and hypercapnia that are devastating to the prognosis of TBI.


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## Carlos Danger (Feb 6, 2015)

systemet said:


> One plausible mechanism is that properly performed intubation / ventilation is protective against episodes of hypoxia and hypercapnia that are devastating to the prognosis of TBI.



That's always the assumption, but blood gases on arrival were the same between the groups in this study. Other studies looking at this topic have found similar blood gases, as well.


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## systemet (Feb 6, 2015)

Remi said:


> That's always the assumption, but blood gases on arrival were the same between the groups in this study. Other studies looking at this topic have found similar blood gases, as well.



If you look at the methods, they didn't draw an ABG until after placing an art line and capturing the airway:

_"In the hospital emergency department, patients who were not intubated underwent immediate RSI by a physician prior to chest x-ray and computed tomography head scan. In these patients, arterial blood gases were performed only after intubation and insertion of an arterial cannula."_

Granted, there was no significant difference between arrival SpO2. There was a tendency towards lower body temperature and tachycardia in the prehospital group.

Inadvertent hyperventilation was postulated as a source of excess mortality during San Diego RSI trial, although the majority of the providers didn't have access to ETCO2 to direct their practice.

http://www.ncbi.nlm.nih.gov/pubmed/15284540
http://www.ncbi.nlm.nih.gov/pubmed/12634522


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## Carlos Danger (Feb 6, 2015)

systemet said:


> If you look at the methods, they didn't draw an ABG until after placing an art line and capturing the airway:
> 
> _"In the hospital emergency department, patients who were not intubated underwent immediate RSI by a physician prior to chest x-ray and computed tomography head scan. In these patients, arterial blood gases were performed only after intubation and insertion of an arterial cannula."_



True, but presumably the non-intubated patients were were exchanging air well during transport, otherwise the paramedic in attendance would have intervened. 



systemet said:


> Inadvertent hyperventilation was postulated as a source of excess mortality during San Diego RSI trial, although the majority of the providers didn't have access to ETCO2 to direct their practice.
> 
> http://www.ncbi.nlm.nih.gov/pubmed/15284540
> http://www.ncbi.nlm.nih.gov/pubmed/12634522



I don't doubt that at all. I think a likely reason why some studies have shown better outcomes among intubated patients than others probably has a lot to do with better post-intubation care. Most of the lit that I've seen that looks at HEMS transport of these patients shows good outcomes. I think the those providers are more familiar with and thus more skilled at proper ventilation. Better sedation might play a roll too.


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## systemet (Feb 6, 2015)

Remi said:


> True, but presumably the non-intubated patients were were exchanging air well during transport, otherwise the paramedic in attendance would have intervened.



_"Of the 152 patients allocated to hospital intubation, 144(95%) arrived at the emergency department without intubation. In 5 patients, there was a decrease in conscious state and loss of airway reﬂexes during transport to hospital, and intubation was undertaken without supplemental drug therapy. In 2 patients, cardiac arrest occurred duringtransportand intubation wasundertaken during cardiopulmonary resuscitation without supplemental drug therapy. In 1 patient, a medical helicopter became available after randomization and the patient was successfully intubated for the ﬂight using RSI_

They also did an intention-to-treat analysis.



> I don't doubt that at all. I think a likely reason why some studies have shown better outcomes among intubated patients than others probably has a lot to do with better post-intubation care. Most of the lit that I've seen that looks at HEMS transport of these patients shows good outcomes. I think the those providers are more familiar with and thus more skilled at proper ventilation. Better sedation might play a roll too.



I agree completely.


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## Brandon O (Feb 6, 2015)

Just want to say, fellas, that this has been one of the best EBM discussions I've seen on this forum.


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## NomadicMedic (Feb 6, 2015)

Brandon O said:


> Just want to say, fellas, that this has been one of the best EBM discussions I've seen on this forum.



Second.


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