# Intubation and Spontaneous Respirations



## LACoGurneyjockey (Jun 10, 2014)

Came across a scenario on a call earlier today that neither I nor my partner could come up with a clear answer to. 
We got called to a single vehicle rollover at highway speeds. One patient DOA, one pinned in. He's got a strong radial pulse at 120 and labored, snoring respirations at 30/min, GCS of 5. 
After he was extricated, packaged and loaded my partner went for the intubation. Tube went in fine, but when I went to confirm lung sounds the patient appeared to still be breathing on his own. I'd get lung sounds with the patients inspiration as well as with FD bagging. 
My question, can this patient continue to breath spontaneously if the tube was in the trachea? Does his continuing to breath mean the tube was in the stomach?
Maybe 3-5 minutes later we started getting resistance with the BVM. The tube was found to be in the esophagus and we pulled it. 
My partner visually confirmed placement thru the cords, and my partner and I both confirmed lung sounds immediately after the intubation. While getting the tube holder in place FD managed to jostle the patient quite a bit. Our thinking was this is when we lost the tube. 
Any thoughts? The patient had spontaneous respirations from prior to intubation throughout until he was finally RSI'd by the flight crew. 
Of note, in Kern County our only drug to assist with intubation is versed at 1mg, which was given.


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## STXmedic (Jun 10, 2014)

Why would placing a tube in the trachea immediately take away their ability to breathe? All it is is an open airway. And 1mg of Versed? Seriously?


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## LACoGurneyjockey (Jun 10, 2014)

I know I know, but not everyone gets to be an RSI badass in Texas... For being just outside of So Cal I can't complain. 
So basically, if a patient was breathing inadequately before you tube them, they're going to continue to breath inadequately with the bag just improving volume?


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## STXmedic (Jun 10, 2014)

I don't even have RSI at the moment. I'm just referring to the near worthlessly low dose.

It depends on why they're breathing inadequately. If it's an airway issue, you may actually make their breathing easier. If something else is causing the respiratory compromise, the ET tube will just provide you with an adequate airway. It shouldn't directly affect their breathing, though.


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## Handsome Robb (Jun 10, 2014)

Search "SIMV". Not all agencies carry vents capable of SIMV in the 911 setting though.


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## LACoGurneyjockey (Jun 10, 2014)

Ventilators cost money, right? Yeah, we don't carry those. 
He was apneic until being extricated and an OPA got him breathing on his own. Followed up with the trauma center and apparently he had a brain bleed, cervical fracture (they didn't say which), and multiple breaks on his right arm. So I'm guessing his position in the vehicle was the airway issue, but I guess a C3 fracture or the bleed could definitely have contributed.


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## Handsome Robb (Jun 10, 2014)

I'd be surprised if he had a fx in the C3-5 region and still had a respiratory drive due to the phrenic nerve exiting the spinal column, which is what controls your diaphragm. Also sounds like he may have been displaying an abnormal respiratory pattern, biots or cheyne-stokes both could fit what you're describing unless his rate become regular after correcting the airway obstruction. 

Not to monday morning QB but why no OPA or at least an NPA in the car during extrication? Patient like that I'm gonna be in the car with them while fire cuts the car apart around us.


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## VFlutter (Jun 10, 2014)

We had a doc that liked to put intubated patients on a T piece for weans. It is definitely possible to have adequate representations with an ETT, just tiresome without some pressure support.


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## socalmedic (Jun 10, 2014)

yes, the patient can spontaneously breathe though the tube and BVM, there is a one way flutter valve in the bvm that allows the patient to breathe even when you are not actively bagging. so I would say yes it is possible that the patient was breathing in addition to your (the FD) ventilation with BVM.

I would say that while your partner saw the tube pass the chords it was pulled before the cuff was inflated leaving only the distal tip in the trachea and the cuff outside the trachea. one of the movements that you described re-positioned the tip from the trachea to the esophagus. It is hard to pull the cuff through the larynx if properly inflated which is why I say that it was probably only a marginal placement at best.

was waveform capnography used? if so what did the wave look like? if not, why wasn't it?


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## medicsb (Jun 10, 2014)

Yes, as you now know, it is totally possible for a patient to breath with an ETT in place.  I've seen patient 30+ minutes into cardiac arrest still breath through an ETT (yeah, seriously, it was bizarre), and plenty of RSI patients who resumed spontaneous respiration after the succs wore off.  I used to do one of two things: squeeze the bag when they breath in or allow them to breath and give them a moderate to large squeeze a few times a minute between respirations.


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## rmena (Jun 10, 2014)

Davis County Utah does has a special deputy sheriff paramedic position that does RSI. I think they are the only system in Utah that isn't a CC unit that does RSI.


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## Handsome Robb (Jun 10, 2014)

I thought about applying to Davis County when my shoulder gets better. Wanna talk to someone who knows the system first though.


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## Carlos Danger (Jun 10, 2014)

LACoGurneyjockey said:


> Came across a scenario on a call earlier today that neither I nor my partner could come up with a clear answer to.
> We got called to a single vehicle rollover at highway speeds. One patient DOA, one pinned in. He's got a strong radial pulse at 120 and labored, snoring respirations at 30/min, GCS of 5.
> After he was extricated, packaged and loaded my partner went for the intubation. Tube went in fine, but when I went to confirm lung sounds the patient appeared to still be breathing on his own. I'd get lung sounds with the patients inspiration as well as with FD bagging.
> My question, can this patient continue to breath spontaneously if the tube was in the trachea? Does his continuing to breath mean the tube was in the stomach?
> ...



What most likely happened is that your partner tubed the goose, and the "good" breath sounds you heard were from the patients spontaneous respirations.


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## LACoGurneyjockey (Jun 10, 2014)

His respirations went from apneic in the car initially, to rapid, shallow, and labored after we started to lift the car off him.
No real interventions in the car because he flipped a convertible mustang and was pinned between the car and the road, with both pillars almost entirely collapsed. And Monday morning QB away, I wouldn't post here if I didn't want to take something away from it...
All we have for ETCO2 is colorimetric which was used


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## teedubbyaw (Jun 10, 2014)

He was apneic? Wait, I thought he had snoring resps on arrival? 

It sounds like you were listening to him breath, and not necessarily the manual breaths. Plus, depending on where you're listening, that sound can transmission and be heard as respirations, even if the tube is placed in the esophagus. 

Do you guys not have capnography? 3-5 minutes and just finding out the tube is incorrectly placed is completely unacceptable.


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## rmena (Jun 10, 2014)

So was the thinking then that you were going to have a delayed transport/extrication time? was their blood/vomitus/other airway complications or you just wanted a more definitive airway?


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## rmena (Jun 10, 2014)

the reason I ask is that I know there is quite a bit of grey area with intubation and the rule of thumb of sub 8 intubate on glassgow is a very sloppy rule


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## rmena (Jun 10, 2014)

To clarify, I totally agree with the decision in this case I am just a newer medic trying to figure out when it is appropriate to intubate and when it isn't necessary.


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## rmena (Jun 10, 2014)

Add to this list of indications they taught in class for ET intubation as opposed to King/LMA

1. Code
2. oral secretions in unconscious patient (i.e. blood, vomit, water)
3. long transport times to eliminate risk of filling stomach with air and aspirating a pt
4. swelling secondary to burns, acute epiglotitis/croup (like completely closed airway)
5. le forte II/III fractures to protect the airway and allow for better ventillation

Sorry, I know you guys think I am probably a moron but our medic class/preceptors pushed BLS airways to the max so intubation was kinda left sparse.


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## medicsb (Jun 10, 2014)

Indications and method to intubate, realistically, is going to vary depending on your training and experience.  An EM physician may intubate patients that you would not, an experienced anesthesiologist or CRNA will intubate some patients that an EM physician would not, and an otolaryngologist may be more comfortable securing an airway under certain circumstances than some anesthesiologists or CRNAs.

It will be better for you to simplify the indications according to difficult airway course teaching (not unique to them, but its where I first learned it):
1. Impaired protection or maintenance of the airway (e.g. the comatose patient)
2. Impaired respiration (e.g. the CHF'r, COPD exacerbation, etc.)
3. Anticipated course of disease/care   (e.g. airway burns, expanding neck hematoma, the fatiguing respiratory patient, etc.)

You need to get to know your skill level.  Being that you're out on your own, you should already have a pretty good idea.  You also need to consider if you have back up (i.e. an experienced partner) and what do they feel comfortable with.  If you only tubed a handful of patients during training, I would not make riskier attempts.  If you do not have an experienced partner who can take over, I would not make riskier attempts (do not consider a partner experienced if he or she has 20 years experience but only intubating 1-2 patients per year for those 20 years).  

Ultimately, good BVM technique (with an airway adjunct) or use of a supraglottic device may be your best choice.  



rmena said:


> Add to this list of indications they taught in class for ET intubation as opposed to King/LMA
> 
> 1. Code
> 2. oral secretions in unconscious patient (i.e. blood, vomit, water)
> ...


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## rmena (Jun 10, 2014)

I like how that's broken down. makes more sense that way.


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## kindofafireguy (Jun 10, 2014)

My current system pushes advanced airway management for anyone with anticipated clinical need. A person who has a GCS of 5 is someone who has serious potential for losing control of their airway. RSI would be utilized in this case.


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## LACoGurneyjockey (Jun 11, 2014)

Let me clarify. He was apneic on arrival, with shallow, snoring respirations during extrication which improved slightly after OPA placement. 
With the airship, ETA to a level 2 trauma center was roughly 50-60 minutes from our arrival on scene, plus snoring labored respirations and a GCS of 5 were our indications for ET. 

Teletubby, we have colorimetric ETCO2, unfortunately no waveform. Medic visualized the tube thru the cords, good lung sounds, condensation in the tube, chest rise/fall, and colorimetric ETCO2 all indicated a successful intubation. Is there no possibility of a tube becoming dislodged after a successful intubation, particularly in a patient responsive enough to put up some resistance?


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## STXmedic (Jun 11, 2014)

:rofl: at OP changing your name to teletubby


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## LACoGurneyjockey (Jun 11, 2014)

Meh, close enough....


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## Carlos Danger (Jun 11, 2014)

LACoGurneyjockey said:


> Let me clarify. He was apneic on arrival, with shallow, snoring respirations during extrication which improved slightly after OPA placement.
> With the airship, ETA to a level 2 trauma center was roughly 50-60 minutes from our arrival on scene, plus snoring labored respirations and a GCS of 5 were our indications for ET.
> 
> Teetubby, we have colorimetric ETCO2, unfortunately no waveform. Medic visualized the tube thru the cords, good lung sounds, condensation in the tube, chest rise/fall, and colorimetric ETCO2 all indicated a successful intubation. *Is there no possibility of a tube becoming dislodged after a successful intubation, particularly in a patient responsive enough to put up some resistance?*



Certainly that is possible. But it is also quite possible that your partner was mistaken about seeing the tube pass the cords, and that the trachea was never intubated. Happens all the time to inexperienced folks, and occasionally to even very experienced ones. 

Assuming that the ETT cuff was inflated and the tube was properly secured with tape or a commercial device, the latter possibility is much more likely, IMO. Especially if the patient was breathing spontaneously. 

This case really underscores why waveform capnography is so important. If you don't have a tracing to prove the tube was in the trachea, then it wasn't.


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## LACoGurneyjockey (Jun 11, 2014)

LACoGurneyjockey said:


> ...and colorimetric ETCO2 indicated a successful intubation.



I get that it's not waveform, and this wouldn't be the first time our system takes 10 years to catch up, but we had positive color change on the end tidal co2 available to us.


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## kindofafireguy (Jun 11, 2014)

It's possible to have positive color change on colormetrics even with an esophageal intubation. It's not common, but it can happen if they've recently consumed carbonation, CO2 is transported to stomach during bagging, etc. Just like you can get condensation in the tube from esophageal intubation as well.

http://www.mastertrain.8m.com/articles02/co2 and cpr.pdf

Here'S some supporting info.


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## medicsb (Jun 11, 2014)

kindofafireguy said:


> It's possible to have positive color change on colormetrics even with an esophageal intubation. It's not common, but it can happen if they've recently consumed carbonation, CO2 is transported to stomach during bagging, etc. Just like you can get condensation in the tube from esophageal intubation as well.
> 
> http://www.mastertrain.8m.com/articles02/co2 and cpr.pdf
> 
> Here'S some supporting info.



This potential confounder is why you keep the colormetric device on for at least 6-10 ventilations or keep an eye on the wave form and number.  If it is in the stomach and there is CO2 in the stomach, you'll quickly blow it off.  With each ventilation the number should come down precipitously to zero.  The initial reading will often be remarkably high (>100mmHg).  There have been a number of experimental studies with animals and different models that have been published on the topic.


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## kindofafireguy (Jun 11, 2014)

True story. It's also a perfect example of why it takes multiple confirmation methods. And why End Tidal is where it's at.


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## Rialaigh (Jun 11, 2014)

Just to pick apart another point, If the patient had no gag reflex and did have some respirations with an OPA in place. AND the airway appeared clear with no massive amounts of blood or other issues, I would feel a lot better bagging this patient, and calling for orders for a lot of versed prior to intubation, or if flight (with RSI capabilities) will be on the ground in 10-15, just supplement the patients breathing with a BVM and high flow O2. 


Aside from the point of whether the tube was properly placed or not, Im not going to attempt this tube if the patient is breathing with a clear airway (at least semi adequately), I don't have RSI, and I can't get orders for a LOT of versed and probably some morphine. No reason you can't bvm till flight arrives. I'm not saying the patient didn't need a tube, I'm saying he didn't need a tube right then with the medications your able to give. 


Where I am at we have RSI, and when we don't want to utilize that we can call the doc and get orders for just versed if we feel like it, usually 5-10 mg to start.


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## Smash (Jun 11, 2014)

Rialaigh said:


> Where I am at we have RSI, and when we don't want to utilize that we can call the doc and get orders for just versed if we feel like it, usually 5-10 mg to start.



Why on earth would you choose just to use midazolam when you have the option of doing it properly?


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## Rialaigh (Jun 12, 2014)

Smash said:


> Why on earth would you choose just to use midazolam when you have the option of doing it properly?



Why is taking away someones airway who is breathing doing it properly. We have hashed the RSI/No RSI thing over and over in several other threads. If the patient has no gag reflex, and just needs some comfort and a bit of assistance to maintain a tube and will still maintain some of his own breathing I am all for that. My main concern with this patient would be proper sedation, nothing more, and by proper sedation I mean the absolute minimal to keep the patient comfortable and keep my tube safe.


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## Carlos Danger (Jun 12, 2014)

Rialaigh said:


> Just to pick apart another point, If the patient had no gag reflex and did have some respirations with an OPA in place. AND the airway appeared clear with no massive amounts of blood or other issues, I would feel a lot better bagging this patient, and calling for orders for a lot of versed prior to intubation, or if flight (with RSI capabilities) will be on the ground in 10-15, just supplement the patients breathing with a BVM and high flow O2.
> 
> 
> Aside from the point of whether the tube was properly placed or not, Im not going to attempt this tube if the patient is breathing with a clear airway (at least semi adequately), I don't have RSI, and I can't get orders for a LOT of versed and probably some morphine. No reason you can't bvm till flight arrives. I'm not saying the patient didn't need a tube, I'm saying he didn't need a tube right then with the medications your able to give.



I agree with your thought process here. Generally speaking, I think a few good guidelines for the prehospital realm are:


Invasive interventions of any type really should be a last resort. 
Most airways can be more safely management with conservative techniques
When intubation does need to occur, it should be done by the most experienced intubator. In many cases this will be the primary paramedic on scene, but if there is an ED physician 10 minutes away or a HEMS crew enroute, it may be better to defer to them.

This reminds me of an experience. On one of my last shifts before quitting work for grad school, we were requested to respond to an MVC in the county just south of yours. This county had recently "cleared" a handful of "RSI medics". As we were approaching the scene, we could see a second ambulance racing though the streets towards the scene. As we were on short final, maybe 100 feet or so AGL, this second ambulance screeched to a stop on the scene, with the two occupants quickly exiting the ambulance, look towards us landing, and then literally run to the ambulance that the patient was in. We entered the ambulance maybe 60 seconds later, just in time to see vomit spewing out of an ETT like a fire hose and the patient gagging violently. The "RSI medics" had been in such a hurry to beat us to the tube, that they hadn't even given the sux time to work. 



Rialaigh said:


> Why is taking away someones airway who is breathing doing it properly.



Because plenty of research shows that it's easier, which translates into it being safer for the patients. RSI with NMB results in fewer intubation attempts and lesser incidence of aspiration than does sedative-only intubation. 

A small dose of any sedative will preserve breathing and airway reflexes, but will do very little to improve intubating conditions. A large dose of any sedative will improve intubating conditions, but will also result in severely depressed respiratory drive and airway reflexes, with intubating conditions still being not as good as with NMB. So how is sedation only better or safer than NMB?

There are good reasons why even in the controlled environment of the OR, with little risk of aspiration and with extremely experienced people doing the intubating, NMB is still routinely used. There are times when intubating without NMB is the right choice, but it is more difficult to do safely, and the indications do not exist in the prehospital environment.


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## NomadicMedic (Jun 12, 2014)

Remi said:


> [*]When intubation does need to occur, it should be done by the most experienced intubator. In many cases this will be the primary paramedic on scene, but if there is an ED physician 10 minutes away or a HEMS crew enroute, it may be better to defer to them.




Just curious, how does the primary paramedic become the most experienced intubator if they're waiting for the helo... And how does the secondary medic get experience if the primary medic gets all the tubes?

And what is the bench mark for "most experienced"?


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## FiremanMike (Jun 12, 2014)

DEmedic said:


> Just curious, how does the primary paramedic become the most experienced intubator if they're waiting for the helo... And how does the secondary medic get experience if the primary medic gets all the tubes?
> 
> And what is the bench mark for "most experienced"?



Generally speaking, your lemon assessment should dictate who is going to tube.  If you can predict a difficult tube ahead of time, it should go to the "strongest" airway person on the scene.  This can be a scenario that leads to a lot of butt hurt, but it'd be nice to believe that everyone is mature enough to acknowledge who amongst the group is good at intubation and who isn't.


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## NomadicMedic (Jun 12, 2014)

No, the LEMON assessment should determine IF you intubate.


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## Carlos Danger (Jun 12, 2014)

DEmedic said:


> Just curious, how does the primary paramedic become the most experienced intubator if they're waiting for the helo... And how does the secondary medic get experience if the primary medic gets all the tubes?



Not sure. Acquiring airway experience has been a big challenge since before I got into EMS, and I don't see it getting any easier in the future.

All I can tell you is that when you have a sick patient who needs to be intubated, that is not the time to practice or to let your ego influence the decision making.


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## FiremanMike (Jun 12, 2014)

DEmedic said:


> No, the LEMON assessment should determine IF you intubate.



Maybe on an in-betweener,  but some people just need intubated..


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## Rialaigh (Jun 12, 2014)

Remi said:


> I agree with your thought process here. Generally speaking, I think a few good guidelines for the prehospital realm are:
> 
> 
> Invasive interventions of any type really should be a last resort.
> ...



Oh I agree with you here, however this patient in the scenario I would likely approach intubation without any NMB use and very minimal sedative use assuming there is truly no gag reflex at all. 



And I agree that RSI with a NMB is easier, I however would be skeptical that it is safer in the prehospital realm. Given the high percentage of misses that EMS systems tend to have, an RSI may be easier to the tune of 10-15% but if your missing 20% of your tubes in spontaniously breathing patients, and now that 20% has 0 respiratory drive at all....

In a hospital setting with experience airway providers I 100% agree it is easier and likely safer.


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## Rialaigh (Jun 12, 2014)

FiremanMike said:


> Maybe on an in-betweener,  *but some people just need intubated*..



Thats a big negative ghost rider, at least in the prehospital realm...*some people just need a definitive airway*. I would argue that surgical cric would likely have a much higher percentage of success in as short a time with no aspiration as RSI does today in the prehospital realm. King airways could very likely be used for short transport times with 0 negative outcomes on at least half if not the majority of RSI patients as well.

 I like tubes, they are secure if placed properly, they reduce the risk of aspiration after being placed especially after I suction the stomach, and they are what the patient needs in long term care. However from a standpoint of changing outcomes in EMS I'm not altogether convinced they have a net positive outcome.


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## FiremanMike (Jun 12, 2014)

The only thing that skews the numbers is the fact that there are bad medics who can't see or admit that they are bad and are butchering airways without being called on it.

Some people need definitive airways and the ETT is the gold standard for a definitive airway.  I am always going to give at least one attempt for an ETT before going for a king, and I'm damn sure not going to cut someone unless I have absolutely no other choice.


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## Rialaigh (Jun 12, 2014)

FiremanMike said:


> *The only thing that skews the numbers is the fact that there are bad medics who can't see or admit that they are bad and are butchering airways without being called on it.*
> 
> Some people need definitive airways and the ETT is the gold standard for a definitive airway.  I am always going to give at least one attempt for an ETT before going for a king, and I'm damn sure not going to cut someone unless I have absolutely no other choice.




It doesn't skew the numbers, its not like only 5% of medics are bad at intubating, I would venture 50%+ miss their 1st attempt at a tube at least 35% of the time. Im completely making those numbers up but I would bet I'm not wrong. Also their are progressive physicians at very good research hospitals who now state the gold standard for cardiac arrest is a king unless ROSC is reached...period. 

My points about crics is I bet you could spend an hour with bad medics working on RSI, and an hour with medics working on crics, and they would successfully put crics in 95%+ of the time and still have terrible problems with RSI. IMO Cric is a vastly underused airway, with much less time required training to maintain an  acceptable level of proficiency when compared to RSI.


ETT is absolutely the gold standard for definitive airway management, I'm just not sure it is the optimal airway for patient outcomes and prehospital use currently. I hate to say it but patient interests dictate that as long as we do more harm with an intervention then good than lowering the interventions to the lowest common denominator where good outcomes are optimized is the most effective way to go. I'm not saying you can't intubate well, I'm saying across the board research would dictate that if we took intubation away entirely and just used kings and LMA's it is very likely that overall patient outcomes would improve or at least not change a bit.


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## NomadicMedic (Jun 13, 2014)

FiremanMike said:


> The only thing that skews the numbers is the fact that there are bad medics who can't see or admit that they are bad and are butchering airways without being called on it.
> 
> 
> 
> Some people need definitive airways and the ETT is the gold standard for a definitive airway.  I am always going to give at least one attempt for an ETT before going for a king, and I'm damn sure not going to cut someone unless I have absolutely no other choice.




For someone who's bemoaning the ego of unskilled intubators, I sense a little pot/kettle syndrome here. 

Being a skilled intubator is NOT the skill of putting the tube in the trachea, it's the ability to know when a tube is NOT the right choice and being able to quickly move to an SGA or a surgical airway. In my world, with a highly unfavorable LEMON score, chances are the patient might not even get a blade in his mouth, and certainly wouldn't be a candidate for RSI.


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## kindofafireguy (Jun 13, 2014)

Rialaigh said:


> Why is taking away someones airway who is breathing doing it properly. We have hashed the RSI/No RSI thing over and over in several other threads. If the patient has no gag reflex, and just needs some comfort and a bit of assistance to maintain a tube and will still maintain some of his own breathing I am all for that. My main concern with this patient would be proper sedation, nothing more, and by proper sedation I mean the absolute minimal to keep the patient comfortable and keep my tube safe.



While I understand your thought process here, I have to disagree with it. Just because a patient is maintaining their own airway at present does not make it safer OR ideal. In fact, I would argue that anyone with significant potential for airway compromise is not ideal when maintaining their own airway. Waiting until they no longer maintain it puts you behind the curve in treatment and leaves you playing catch-up.

Now, I'm not saying that you need to go around dropping tubes in everyone that might need one eventually. Far from it. But I do feel that if everything points to the tube being the probable end result, it should be done completely and thoroughly. And if you're going to drop the tube, put them to sleep and paralyze them. It's safer for them and decreases the possible of them waking up, dislodging the tube, and therefore compromising the "secure" airway you just limited them to.

Just my $.02 though.


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## FiremanMike (Jun 13, 2014)

DEmedic said:


> For someone who's bemoaning the ego of unskilled intubators, I sense a little pot/kettle syndrome here.
> 
> Being a skilled intubator is NOT the skill of putting the tube in the trachea, it's the ability to know when a tube is NOT the right choice and being able to quickly move to an SGA or a surgical airway. In my world, with a highly unfavorable LEMON score, chances are the patient might not even get a blade in his mouth, and certainly wouldn't be a candidate for RSI.



No ego intended, but it needs to be pointed out that there ARE bad paramedics out there who lack skills and are included in studies that show low success rates and used as evidence that prehospital intubation is a bad idea.  The the fact of the matter is that most of the time, intubation itself really isn't that difficult.  I would definitely agree with you that the decision to intubate can be difficult, but that's another topic.

On a personal note, I feel the reason our overall percentages are so low can be attributed to paramedic mills nationwide that each crank out hundreds of paramedics annually with no standardized method to ensure that students even had a solid grasp on this relatively simple skill.  

For full disclosure, when I went to medic school 15 years ago, we had a requirement that we have 50 successful intubations but they could all be on the mannequin and we did not get OR time.  I had 1 unsuccessful human attempt which taught me more than the 50 successful mannequin attempts, but only the 50 successful attempts counted.  From there, I was fortunate to be mentored by some truly remarkable providers throughout the years who have each played a part in developing my skills, knowledge, and abilities.

Full disclosure #2 - I'm pretty lucky to have access to all the toys I need.  We have intubrite laryngoscopes, an endless supply of adult and pediatric bougies, king visions, king airways, and scalpels.

Lastly, I find the focus on first attempt success rate to be inappropriate.  First, I think it puts undue pressure on that first tube, but most importantly there are just times when you get in there and it's not what you expected.  I think a more comprehensive view of airway skills should include decision making process, anxiety levels during the intubation, how long each attempt takes, what are you doing in between attempts, and whether there is a progression of tools between attempts or are you simply trying the same thing over and over.



***please note, I don't think someone is a bad medic if they struggle with intubation***


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## CANMAN (Jun 13, 2014)

FiremanMike said:


> No ego intended, but it needs to be pointed out that there ARE bad paramedics out there who lack skills and are included in studies that show low success rates and used as evidence that prehospital intubation is a bad idea.  The the fact of the matter is that most of the time, intubation itself really isn't that difficult.  I would definitely agree with you that the decision to intubate can be difficult, but that's another topic.
> 
> On a personal note, I feel the reason our overall percentages are so low can be attributed to paramedic mills nationwide that crank out hundreds of paramedics annually with no standardized method to ensure that students even had a solid grasp on this relatively simple skill.
> 
> ...





I agree with a lot of your thought process on this, and previous posts. If your first DL look is not what was anticipated, is not a lengthy look, AND YOU KNOW HOW to take the corrective actions to make your second attempt successful then I think that's completely acceptable. That being said, screwing around in there for 30 seconds, patient's Spo2 is 90%, and "thinking" you can get it on the second attempt is not the situation I think is acceptable or support. 

At the end of the day, we all have different protocols, tools, training, resources, and opinions. I would argue a lot of the trauma scene flights I do might have something going on under the Obstruction tab of LEMONS, but that doesn't mean if they need an airway intubation is off the table. There will never be a one size fits all approach to airway management obviously. 

I also agree that providers MUST be able to give an adequate, honest, humble assessment of their knowledge, skills, and experience level when evaluating patients for airway management. Especially when a difficult airway is encountered. I am lucky enough to work for an extremely robust program that provides us with constant training, quarterly O.R. time for intubations on top of field tubes, and video laryngoscopy.


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## Carlos Danger (Jun 13, 2014)

DEmedic said:


> Being a skilled intubator is NOT the skill of putting the tube in the trachea, it's the ability to know when a tube is NOT the right choice and being able to quickly move to an SGA or a surgical airway. In my world, with a highly unfavorable LEMON score, chances are the patient might not even get a blade in his mouth, and certainly wouldn't be a candidate for RSI.



This is probably the most reasonable and mature thing I've ever seen written on an EMS forum about airway management. If more paramedics thought this way, we would not have the problems we have with airway management.



FiremanMike said:


> Some people need definitive airways and the ETT is the gold standard for a definitive airway.  *I am always going to give at least one attempt for an ETT before going for a king, and I'm damn sure not going to cut someone unless I have absolutely no other choice.*



This is a terrible way to approach airway management. It's a cookie-cutter mentality that doesn't use any critical thinking and is the exact opposite of what should be taught. Most paramedics seem to be taught to think this way though, and it is probably a direct result of the lack of experience that I address below. 




FiremanMike said:


> On a personal note, I feel the reason our overall percentages are so low can be attributed to paramedic mills nationwide that each crank out hundreds of paramedics annually with no standardized method to ensure that students even had a solid grasp on this relatively *simple skill*.



Airway management is only simple until it's not. Sure, it _usually_ goes well and most patients are not a difficult intubation. But I'm not sure how anyone can read the literature on paramedic intubation and then say with a straight face that it is a "simple skill". If it were so simple, the research would look a whole lot different, and we wouldn't be having this discussion.

The reason overall percentages are so low is obvious, really: paramedics receive very minimal initial training in airway management, and then go on to do it only occasionally. That's not how you get good at anything. I'd argue that it takes most people 100 actual, live intubations to reach a novice level of experience, and at least three times that, maybe even four or five times that, using different tools and techniques, to become an expert. Very few paramedics have that type of background, so the only ones who are really, truly good at it are the very few who do somehow gain that much experience, plus the relatively small percentage who for some reason just have the aptitude to master the skill with much less experience than it takes most. 




FiremanMike said:


> Lastly, I find the focus on first attempt success rate to be inappropriate.  First, I think it puts undue pressure on that first tube, but most importantly there are just times when you get in there and it's not what you expected.



The focus on first-attempt success comes from the fact that each successive attempt is less and less likely to be successful. 

Why do you ever need to "change" things on subsequent attempts? Why not just do it right the first time?

The point behind the "first attempt should be your best attempt" approach is that whatever changes you are making should have been done before the first attempt was made. Whatever tool you had to use on your second or third attempt to finally get it, you should have just used on your first attempt.

Take the time to do your positioning CORRECTLY before the first attempt. Use the right blade and the right tube on your first attempt. Use the bougie on your first attempt. Use VL if you have it - yes, on the first attempt. A prehospital RSI is not the time to screw around.


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## FiremanMike (Jun 13, 2014)

There is just so much about your mentality that I don't agree with that I'm just going to bow out.


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## Carlos Danger (Jun 13, 2014)

FiremanMike said:


> I'm just going to bow out.



Why not discuss professionally instead?


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## FiremanMike (Jun 13, 2014)

Remi said:


> Why not discuss professionally instead?



I believe I pretty clearly articulated my point of view and then you shared yours.  I think our views are fundamentally very different and I find it unlikely that we will come together in our opinions.

I will say this, I find your ideology that you will choose right the first time, every time, to be dangerous.  In my opinion, mindsets like this can and do lead to "vapor lock" in the event that your assessment and tool choice was wrong.  As I said, the ability to react to the unexpected is far more important than the theory that you can always choose correctly the first time.

We do agree on one thing, an RSI is not the time to screw around.


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## Carlos Danger (Jun 13, 2014)

FiremanMike said:


> I will say this, *I find your ideology that you will choose right the first time, every time, to be dangerous.* In my opinion, mindsets like this can and do lead to "vapor lock" in the event that your assessment and tool choice was wrong.  As I said, the ability to react to the unexpected is far more important than the theory that you can always choose correctly the first time.



The research clearly shows that in the ED, each intubation attempt is less likely to be successful than the one before it. That isn't my opinion; that is fact. I can think of no reason why it wouldn't apply to the pre-hospital realm as well. 

With that in mind, how could it possibly be _dangerous_ to take steps to make your first attempt your best attempt?

That doesn't mean that you'll always be successful on your first attempt, of course. It means that, if you can be confident that you've done everything you could on the first try, then you can leave that attempt knowing that it's time to seriously consider an alternative to DL. That's the opposite of "vapor lock". Rather, it gives you mental permission to move on, rather than continuing to tweak meaningless factors in order to justify essentially trying the same thing over and over.

It sounds as though you overestimate your ability to "react to the unexpected". If your first and second attempt don't go well, then what do you do? You probably reach for VL or an SGA. Why not just do that initially, then?


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## SandpitMedic (Jun 13, 2014)

Well jeeze... In that case why not just do a surgical cric on everyone. :/

Less invasive to most invasive. A difficult intubation in the ER? I've yet to see a doc break out that cric kit.... DL or VL.... Both are effective. Provider errors will happen inevitably at times, which is why being able to quickly adapt your tactic is a strong quality to have.


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## VFlutter (Jun 14, 2014)

SandpitMedic said:


> A difficult intubation in the ER? I've yet to see a doc break out that cric kit.... DL or VL.... Both are effective.



But how many times have you seen an ER doc butcher a few airway attempts before calling Anesthesia?


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## Carlos Danger (Jun 14, 2014)

SandpitMedic said:


> Well jeeze... In that case why not just do a surgical cric on everyone. :/



No, that doesn't even begin to follow from what I wrote.



SandpitMedic said:


> Less invasive to most invasive. A difficult intubation in the ER? I've yet to see a doc break out that cric kit.... DL or VL.... Both are effective. Provider errors will happen inevitably at times, which is why being able to quickly adapt your tactic is a strong quality to have.



So you consider proper positioning, blade/ETT preparation, and the use of adjuncts such as VL or a bougie to be "invasive"?


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## LACoGurneyjockey (Jun 14, 2014)

Remi said:


> So you consider proper positioning, blade/ETT preparation, and the use of adjuncts such as VL or a bougie to be "invasive"?



Yes, yes I do.


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## SandpitMedic (Jun 14, 2014)

Chase said:


> But how many times have you seen an ER doc butcher a few airway attempts before calling Anesthesia?



Lol. Touché.


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## jcroteau (Aug 17, 2014)

LACoGurneyjockey said:


> Yes, yes I do.




How on earth is preparing for success before you put the blade in their mouth invasive???


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## MSDeltaFlt (Aug 19, 2014)

Wow, threads evolve.  And toes tend to become a tad long.


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