# Intubation WITH gag reflex



## MedicPatriot (Jan 6, 2012)

I have heard of this done before and I am wondering if people here have actually done it. I know a guy who has orally intubated a CHF patient that was actually conscious back in the day before CPAP as well as someone who has done that to an unconscious agonal breather with a gag reflex. We don't have RSI around here by the way, and don't ask why they didn't nasally intubate...because I don't know why.

I know it can't be good for the anatomy, especially in a head injured patient as it would increase ICP. I'm just wondering if anyone here has done it, or seen it, and how hard was it? I can't imagine its easy to do. In fact when I heard about it I was shocked, as it seems so barbaric.


----------



## EMSLaw (Jan 6, 2012)

Our medics have RSI if necessary, so no, I've never seen this done, or heard of it being done.  

My understanding is that 'back in the day' as you say, before CPAP, nasal intubation was the go-to treatment for CHF patients.  It has since fallen out of use, which is why only medics with older certifications are still permitted to do it here.  If the patient was conscious, but had no gag reflex...  I guess it would work, though it would involve a major protocol variation.  I'll plead ignorance on that.  

I can't say much about the second case, other than that I'd think agonal respiration wouldn't go along with a protective gag reflex. 

The problem is not that it seems barbaric - medicine occasionally involves doing unpleasant things to patients (cardioversion comes to mind).  But the patient will likely vomit if you trigger the gag reflex and that is: A) an aspiration risk and B) likely to result in my needing a new uniform and being covered in disgustingness.


----------



## the_negro_puppy (Jan 6, 2012)

How do you use a laryngoscope successfully on a person with a gag reflex?


----------



## usalsfyre (Jan 6, 2012)

http://emcrit.org/misc/awake-intub-video/

Done correctly it's not particularly barbaric.


----------



## EMSLaw (Jan 6, 2012)

usalsfyre said:


> http://emcrit.org/misc/awake-intub-video/
> 
> Done correctly it's not particularly barbaric.



They make it all look so easy, too.  That's really fascinating.


----------



## 18G (Jan 6, 2012)

I would never recommend orally intubating a patient with a gag reflex. If you really had to you could try lidocaine spray to back of throat to suppress the gag reflex. We're allowed to nasally intubate so never had that issue arise.


----------



## MedicPatriot (Jan 6, 2012)

18G said:


> I would never recommend orally intubating a patient with a gag reflex. If you really had to you could try lidocaine spray to back of throat to suppress the gag reflex. We're allowed to nasally intubate so never had that issue arise.



We can nasally intubate too, thats the strange part


----------



## MSDeltaFlt (Jan 6, 2012)

MedicPatriot said:


> I have heard of this done before and I am wondering if people here have actually done it. I know a guy who has orally intubated a CHF patient that was actually conscious back in the day before CPAP as well as someone who has done that to an unconscious agonal breather with a gag reflex. We don't have RSI around here by the way, and don't ask why they didn't nasally intubate...because I don't know why.
> 
> I know it can't be good for the anatomy, especially in a head injured patient as it would increase ICP. I'm just wondering if anyone here has done it, or seen it, and how hard was it? I can't imagine its easy to do. In fact when I heard about it I was shocked, as it seems so barbaric.



On the pt who was conscious with "an active gag reflex".  What it a real gag?  Or was the pt merely biting down on the blade?  There is a difference.


----------



## silver (Jan 6, 2012)

EMSLaw said:


> They make it all look so easy, too.  That's really fascinating.



This guy makes it look even easier (Though he has a fiberscope).

http://www.youtube.com/watch?v=bDRTzmuwMnQ


----------



## medicsb (Jan 6, 2012)

I think it would be damn near impossible to do it on someone with a fully intact gag reflex. Twice on severely obtunded patients (both were overdoses) where when I scoped them, it was obvious that they had some gag reflex left, but it was weak, thus I was able to pass the tube.


----------



## Medic Tim (Jan 6, 2012)

Is retrograde intubation in anyone's protocols?


----------



## Akulahawk (Jan 6, 2012)

Medic Tim said:


> Is retrograde intubation in anyone's protocols?


I assume you mean via guidewire? Not in Sacramento's system...


----------



## NomadicMedic (Jan 6, 2012)

Medic Tim said:


> Is retrograde intubation in anyone's protocols?



We had it in the protocols at my last job. Never used it, never practiced it, never heard of anyone using it.


----------



## CANMAN (Jan 7, 2012)

If you are to the point of considering a retrograde intubation then just pull the trigger on a surgical airway and be done with it....

Although CPAP is prob one of the best things to happen to EMS in the recent years, I miss nasal intubation


----------



## NomadicMedic (Jan 7, 2012)

CANMAN13 said:


> If you are to the point of considering a retrograde intubation then just pull the trigger on a surgical airway and be done with it....
> 
> Although CPAP is prob one of the best things to happen to EMS in the recent years, I miss nasal intubation



Yep, if you're making a hole, why use a wire? Just shove a tube in there! And we still have nasal intubation, although CPAP has nixed my last few nasal tube opportunities. :/ Agreed that CPAP, the EZ-IO and the LUCAS device are the three best EMS innovations in recent history.


----------



## rayzon20mg (Jan 7, 2012)

if the patient has a gag reflex for intubation here we can drop the patient with either scoline or dipravan and intubate.


----------



## medicsb (Jan 7, 2012)

CANMAN13 said:


> Although CPAP is prob one of the best things to happen to EMS in the recent years, I miss nasal intubation



The same sentiment from many of the long timers I worked with.  When I came on, we had CPAP and RSI, so I only once had an attempt (it failed) in 5 years.  Every now and then one of the long timers would nasally intubate someone and everyone in the ED would swing by to have a look and word would spread to other medic units.  I think that out of 800ish ETIs, only about 10-20 would be attempted nasally per year.


----------



## IrightI (Jan 16, 2012)

MedicPatriot said:


> I have heard of this done before and I am wondering if people here have actually done it. I know a guy who has orally intubated a CHF patient that was actually conscious back in the day before CPAP as well as someone who has done that to an unconscious agonal breather with a gag reflex. We don't have RSI around here by the way, and don't ask why they didn't nasally intubate...because I don't know why.
> 
> I know it can't be good for the anatomy, especially in a head injured patient as it would increase ICP. I'm just wondering if anyone here has done it, or seen it, and how hard was it? I can't imagine its easy to do. In fact when I heard about it I was shocked, as it seems so barbaric.



The joys of having Succs and Etmoidate on the truck.

RSI for the Win!


----------



## usalsfyre (Jan 16, 2012)

IrightI said:


> The joys of having Succs and Etmoidate on the truck.
> 
> RSI for the Win!



For the win...up until you run into a 400 pounder with no neck who you can't get preoxygenated above the the high 80s and looks to be severely acidotic. What now?

RSI is an incredibly useful tool, but it's not a cureall.


----------



## IrightI (Jan 16, 2012)

usalsfyre said:


> For the win...up until you run into a 400 pounder with no neck who you can't get preoxygenated above the the high 80s and looks to be severely acidotic. What now?
> 
> RSI is an incredibly useful tool, but it's not a cureall.



Sounds like my regular pts :rofl: You say what now...and I say Cric.  There is always a way, and just for kicks il have bicarb on standby.

The last thing you want is to paralyze someone, and have to bag them through the ER doors without having a tube.  We make sure that never happens with our service.


----------



## usalsfyre (Jan 16, 2012)

IrightI said:


> Sounds like my regular pts :rofl: You say what now...and I say Cric.  There is always a way, and just for kicks il have bicarb on standby.
> 
> The last thing you want is to paralyze someone, and have to bag them through the ER doors without having a tube.  We make sure that never happens with our service.



You are most assuredly a paramedic student judging from this statement.

If you can bag a patient effectively and still cut their throat you'd be decredentialed so fast your head would spin here. That's a gross misunderstanding of airway management. The "gold standard" is not a tube. The gold standard is the chest going up and down in an effective manner.


----------



## IrightI (Jan 16, 2012)

usalsfyre said:


> You are most assuredly a paramedic student judging from this statement.
> 
> If you can bag a patient effectively and still cut their throat you'd be decredentialed so fast your head would spin here. That's a gross misunderstanding of airway management. The "gold standard" is not a tube. The gold standard is the chest going up and down in an effective manner.



Maybe its just our progressive protocols that allow us to "cut their throats" if there is no other option.  BLS before ALS, you should know this.  And im glad that you understand that the chest going up and down and blood going round and round is the gold standard.  

Dont fear the Cric.


----------



## usalsfyre (Jan 16, 2012)

IrightI said:


> Maybe its just our progressive protocols that allow us to "cut their throats" if there is no other option.


I've worked under one or two sets of progressive protocols as well...



IrightI said:


> BLS before ALS, you should know this.  And im glad that you understand that the chest going up and down and blood going round and round is the gold standard.


And yet, earlier you stated you'd still cric even if a BVM was working? Which is it? 

Not to mention those "progressive protocols" I've worked under (so progressive they read more like "general suggestions" in many cases) allowed me to bypass basic measures and jump straight to the scalpel in an appropriate situation. You didn't give an appropriate situation. What you described was knackering an airway because you used NMBAs when you shouldn't have and doing a cric to bail yourself out.    



IrightI said:


> Dont fear the Cric.


If can't intubate/can't ventilate doesn't scare the ever-loving micturation out of you than I feel sorry for your patients. Hopefully you learn to temper your "aggressiveness" before you get in a bad situation.


----------



## feldy (Jan 16, 2012)

While we dont carry any drugs for RSI, we usually have a resident riding along in the sprint who does carry them.


----------



## IrightI (Jan 16, 2012)

usalsfyre said:


> I've worked under one or two sets of progressive protocols as well...
> 
> 
> And yet, earlier you stated you'd still cric even if a BVM was working? Which is it?
> ...



You take things said on a forum wayyy to seriously and relate it to what would be done in the rig.  That is your first short coming.  Your second is assuming that I would jump to such measures when I am in a "bad situation" based off of a comment that I posted.  Chill out dude.  We both have that P-number and we both know the basis and understanding, or shall I say "Standard of Care" to appropiate airway management, this is rudimentary to us.  

There is no CANT in the back of MY rig...EVERYTHING gets done for the benefit of my patient.  So dont tell me to "temper my aggressiveness".  Its that AGGRESSIVENESS that hasnt put me in a bad situation.  Sorry you are in a "mommy may I" system.

Chill out and take forum chit-chat with a grain of salt.  Who knows, you might be a needing a cric if you keep getting yourself all hot and bothered over these forums.  Lets hope its not me who goes enroute to that call, I wouldnt want to get aggressive with you now. :rofl:


----------



## usalsfyre (Jan 16, 2012)

IrightI said:


> You take things said on a forum wayyy to seriously and relate it to what would be done in the rig.  That is your first short coming.  Your second is assuming that I would jump to such measures when I am in a "bad situation" based off of a comment that I posted.  Chill out dude.  We both have that P-number and we both know the basis and understanding, or shall I say "Standard of Care" to appropiate airway management, this is rudimentary to us.


If I hadn't seen a fair number of airway disasters caused by the displayed attitude I wouldn't be so quick to judge.  



IrightI said:


> There is no CANT in the back of MY rig...EVERYTHING gets done for the benefit of my patient.


Even hospitals are willing to defer procedures that they don't have the volume to pull off. Instead, you've got the attitude of "supermedic". This can and will bite you in the butt. It's entirely appropriate to look at an airway and go "not today, they can stick it out". Preferred? No. Ego lacerating? Sure. But you don't end up with a patient you've killed.



IrightI said:


> So dont tell me to "temper my aggressiveness".  Its that AGGRESSIVENESS that hasnt put me in a bad situation.


Thinking with your balls will put your patient in a bad place. Anyone who thinks otherwise hasn't been doing this long enough to be there or is too dumb to realize they painted themselves in that corner. There's times its appropriate to be aggressive and  other times that benign neglect is a GREAT policy.   



IrightI said:


> Sorry you are in a "mommy may I" system.


I think you would likely be stunned at the standing order set I have. I haven't called for an order in 4+ years now. 



IrightI said:


> Chill out and take forum chit-chat with a grain of salt.


If I didn't think you were being serious I wouldn't have jumped your @ss. I see about one guy a week in the QA office with an attitude like yours.  



IrightI said:


> Who knows, you might be a needing a cric if you keep getting yourself all hot and bothered over these forums.  Lets hope its not me who goes enroute to that call, I wouldnt want to get aggressive with you now. :rofl:


 Good luck is all I'm gonna say.

Quick question, without Googling, can you tell me how lemon relates to airway management?


----------



## systemet (Jan 17, 2012)

The knowledge and professionalism displayed in this thread is awe-inspiring.


----------



## NomadicMedic (Jan 17, 2012)

systemet said:


> The knowledge and professionalism displayed in this thread is awe-inspiring.



Eh, consider the source. Read back over some of the other posts made by IrightI.

Not impressive.


----------



## systemet (Jan 17, 2012)

n7lxi said:


> Eh, consider the source. Read back over some of the other posts made by IrightI.
> 
> Not impressive.



What's terrifying is that I'm not 100% convinced he/she's trolling.  Wow.


----------



## Shishkabob (Jan 17, 2012)

IrightI said:


> Lets start with 2 in a shift.  One fly-out and one ground pounded to a level 1.
> And that was on a slow day. Would my weekly total suit you more?.



If you've done more than 2 in any given month (hell... Should be months) outside of the OR, either you're lying or you are clearly RSIing the wrong people.

When I did a somewhat busy rural system with usalsfyre, with an hour transport, I did 2 in 5 months. 

In a VERY busy, VERY progressive system now, there's only 2-5 a month, in the WHOLE system.


----------



## NomadicMedic (Jan 17, 2012)

Linuss said:


> In a VERY busy, VERY progressive system now, there's only 2-5 a month, in the WHOLE system.



Now, now... I work in a somewhat busy, VERY progressive service and we did 29 RSIs in Q3 of 2011. So, not everyone is in the same boat you are.

Do we aggressively manage airways; some say yes... but not ONE of our RSIs was deemed inappropriate by our Medical Directors. (And we have a ridiculously in-depth QI system.)

However, I still believe the attitude displayed by IrightI is dangerously cavalier when it comes to airway management, and rather rude to the rest of the forum members.


----------



## systemet (Jan 17, 2012)

Obviously these numbers are going to depend on the size of the service and the call volume as well.  If you have 4 trucks doing 7500 calls, you're going to do a smaller number of RSIs in a given unit of time than 30 trucks doing 100,000 calls.

Surgical airways should be a very rare event, even for a large system (e.g. population served > 1 million for the sake of having a definition).  There are situations where they are going to be an airway of first choice, and there are going to be situations where a failed RSI is going to require them.  But there's no reason to cric someone if you're getting decent oxygenation and ventilation with basic maneuvers.


----------



## medicsb (Jan 17, 2012)

To RSI weekly, one would have to be in a very low medic concentration system to achieve those numbers.  Not many exist in the US and I would be curious as to which this person is from.  My guess... he's works for the one that exists only inside his head.


----------



## NomadicMedic (Jan 17, 2012)

medicsb said:


> To RSI weekly, one would have to be in a very low medic concentration system to achieve those numbers.  Not many exist in the US and I would be curious as to which this person is from.  My guess... he's works for the one that exists only inside his head.



^this!


----------



## jwk (Jan 17, 2012)

Too many RSI's and too many crics = really crappy airway management skills.  IrightI needs to spend some quality time in an OR with an experienced anesthetist and actually learn how to manage an airway.  Being proud of how many RSI's and crics you've done is really idiotic because in my expert opinion (I can claim that because my profession represents THE experts in airway management), it clearly indicates he doesn't know what he's doing.  Or maybe it's the classic "you don't know what you don't know".  Cowboys like him don't last very long in any profession.  

I try not to stick my nose into these types of "mine is bigger than yours" discussions, because I've been out of EMS for many years   (with the exception of teaching airway management in the OR to a variety of different healthcare students and professionals) and I'm not always up on the latest EMS standards and techniques.  But airway management IS my thing - you're either dangerously cocky or trolling - I'm not quite sure which yet.


----------



## ffemt8978 (Jan 17, 2012)

And that's enough of this one.


----------



## ffemt8978 (Jan 18, 2012)

Thread now reopened after I had to clean it up.  If I have to do it again, somebody is getting a forum vacation.


----------



## NomadicMedic (Jan 18, 2012)

I’m glad this thread is reopened, because it brings to light some interesting discussion points about the polarizing topic of RSI.

I feel there is no such thing as “too many RSIs”. If a patient presents with the need (or anticipated need) to have their airway managed, RSI performed by a trained professional is the best and safest option . I would much rather have a patient sedated, paralyzed and intubated in the back of a well-lit ambulance before climbing into a cramped State Police Bell 407. Safer for the patient and reduces my possibility having to perform a difficult intubation.

Now, having said that, I believe sending Paramedics out into the wild, direct form medic school, with no training other than, ‘This is Sux, push it after the Versed” is dangerous and irresponsible. I am lucky that I work in a system that has extensive training in RSI, quarterly OR time scheduled for the medics that are not getting field tubes and an exhaustive QI process that involves an entire separate packet of paperwork for every intubation, RSI or not, that is reviewed by a peer, the shift FTO, the education coordinator and the medical director. Every tube. 

So, to those who are performing RSI, let's talk about it...


How is your department educating medics for RSI?
What’s the QI process like?
How often are you getting to the OR?
How many field tubes are you actively passing each year?
What is your criteria to determine RSI candidates and then what special protocols do you have to assue success?


----------

