# Trauma Scenario: Thoughts? RE: RSI/Intubation



## medichopeful (Apr 11, 2016)

I'm trying to wrap my head around one of the scenarios we recently did in medic school, so I figured I'd run it by everybody here (I'll try to remember it the best I can.  It was a few days ago so I can't remember a lot of the information):

Dispatched for an explosion at a building.  Upon arrival, you have one patient (middle-aged male) found laying on the ground.  Going head to toe: decreased level of responsiveness (can't recall exact GCS, but 12-13 range maybe?), singed nose hairs, mucous membranes intact.  Burns to chest, forearms.  I don't remember much about the respiratory rate, but I remember that we did place an NPA and provided ventilation with a BVM.  Lung sounds clear and equal.  Bilateral lower leg fractures.  I don't recall exact vitals, but I believe they were relatively stable (with exception of resps).

I wish I could remember more of the scenario and paint a better clinical picture, but unfortunately I'm lacking on the details.

My question is this: would you consider RSI for this patient?  I wasn't the team leader, but I was arguing that the patient should be intubated: decreased level of responsiveness, multi-system trauma, and potential airway burns.  Others were saying that you shouldn't RSI in this situation due to the fact that lung sounds were clear (they were arguing that you don't RSI without stridor or wheezing in a case like this) and because BLS airway interventions were working.

I've been thinking about this scenario for a few days and have convinced myself that I'm on the right track saying that this patient needs a tube.  However, I'm obviously open to having that belief changed.

Anybody have any thoughts on this?


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## zFrostyy (Apr 11, 2016)

You're not really giving enough info here, how bad are the burns? Is there any soot in his airways? what does his airway look like upon visualization? What's his O2 sat & end tidal?


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## ERDoc (Apr 11, 2016)

If you are at the point of NPA and BVM, you need to RSI.  BLS airway interventions are only temporizing measures until someone who can properly intubate comes along.  The pt has declared that they need airway so don't screw around with half useful interventions.


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## medichopeful (Apr 11, 2016)

zFrostyy said:


> You're not really giving enough info here, how bad are the burns? Is there any soot in his airways? what does his airway look like upon visualization? What's his O2 sat & end tidal?


 
I'll be back in class on Tuesday, I'll try to get more info for you then. I put down what I know, I don't remember too much more unfortunately but my classmates might!


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## medichopeful (Apr 11, 2016)

ERDoc said:


> If you are at the point of NPA and BVM, you need to RSI.  BLS airway interventions are only temporizing measures until someone who can properly intubate comes along.  The pt has declared that they need airway so don't screw around with half useful interventions.



The argument one person was making was basically that PHTLS states even one episode of hypoxia can be dangerous, which can happen during RSI. In addition, people kept making the argument that if a BLS airway is working, stay with a BLS airway according to PHTLS. I find both of these arguments to be ridiculous. It's impossible to place a patient on a vent with a BLS airway, and the ER isn't going to pay someone to stand around and BVM someone. In addition, my concern is subsequent swelling of the airway, even though it looked fine at the moment (with the exception of the nose hairs). 

I'm glad I wasn't coming out of left field with thinking RSI was appropriate. I just didn't like the idea of such a minimally secured airway.


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## Carlos Danger (Apr 11, 2016)

medichopeful said:


> The argument one person was making was basically that PHTLS states* even one episode of hypoxia can be dangerous, which can happen during RSI*. In addition, people kept making the argument that if a BLS airway is working, stay with a BLS airway according to PHTLS. I find both of these arguments to be ridiculous. It's impossible to place a patient on a vent with a BLS airway, and the ER isn't going to pay someone to stand around and BVM someone. In addition, my concern is subsequent swelling of the airway, even though it looked fine at the moment (with the exception of the nose hairs).
> 
> I'm glad I wasn't coming out of left field with thinking RSI was appropriate. I just didn't like the idea of such a minimally secured airway.



This is actually a really good point to consider, or at least to bring up for discussion.

In severely brain-injured patients specifically, a single, even brief episode of either hypoxemia _or_ hypotension will increase the chances or mortality by something like 50%, and if both happen, then it's something like 90%. Hypoxemia and hypotension are not uncommon complications of prehospital RSI. In fact it is my strong suspicion that this (along with poor post-intubation management) is a large part of the reason why prehospital intubation has been shown in several studies to be detrimental to these patients. So it's not something to just gloss over; it is a real concern and many in EMS don't have nearly enough respect for it, IMO. You really can hurt your patients if you screw this stuff up, even if you get the tube on your first try.

For the purposes of the scenario though, yes, it sounds to me like the guy should be intubated.





medichopeful said:


> I find both of these arguments to be ridiculous. *It's impossible to place a patient on a vent with a BLS airway, and the ER isn't going to pay someone to stand around and BVM someone.* In addition, my concern is subsequent swelling of the airway, even though it looked fine at the moment (with the exception of the nose hairs).



Well, isn't it kind of obvious that the *Prehospital* Trauma Life Support guidelines don't apply to the ED? When they recommend sticking to a BLS airway if it works, they are talking about the *prehospital *phase? They aren't saying that the patient should _never_ be intubated.


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## Bullets (Apr 11, 2016)

I would also say that RSI would be my choice. With the possibility of burns to the airway, if you dont RSI now and secure the airway, should it swell then youre facing something like and emergency cric, which i assume is much less used than intubation.

One of my problems with PHTLS is that it sometimes pretends that there is this hard line between us and the hospital, not that we are just an extension of the hospital. We do many things that do not show immediate benefit here but will as the patient is in the ER.


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## CANMAN (Apr 11, 2016)

How substantial were the burns to his chest? Are we talking circumferential full thickness which could be impeding your respiratory effort, or like partial thickness...? What was the patients respiratory effort when you arrived and what factors caused you to assist him with BVM? 

I would be tubing this guy. Obviously as other have stated there's a lot of other things we like to know about this guys, but decreased LOC, and singed nasal hairs post explosion is about all the reason I need to make a decision. The lightly good that the rest of the airway exam is going to show some signs of superheated gas inhalation is probably high, and you don't want to wait around until you have stridor and hypoxia to intubate some with those findings and mechanism. 

I would certainly be concerned for hypoxia and hypotension during the RSI based off the potential for head injury and poor outcomes as Remi highlighted really well. If your already assisting with BVM great, bag him up, and I would also put on a nasal cannula at high flow for apneic oxygenation during the intubation. Hang fluids and select appropriate agents for induction and post RSI sedation, and it sounds like this guy would be fine based off the limited info we have. 

The biggest thing in my opinion that leads to the issues Remi was talking about is a lack of SUFFICENT training, and a blanket approach used by most places.... You can't use a blanket approach to all RSI's, each scenario is going to be different, and how you manage it should be based off multiple factors. Educating providers on which agents to utilize and why, and giving them protocols that not only allow them to pick different agents, but also heavily focuses on great preparation and oxygenation, as well as good post RSI management is key.


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## Nova1300 (Apr 11, 2016)

Remi said:


> This is actually a really good point to consider, or at least to bring up for discussion.
> 
> In severely brain-injured patients specifically, a single, even brief episode of either hypoxemia _or_ hypotension will increase the chances or mortality by something like 50%, and if both happen, then it's something like 90%. Hypoxemia and hypotension are not uncommon complications of prehospital RSI. In fact it is my strong suspicion that this (along with poor post-intubation management) is a large part of the reason why prehospital intubation has been shown in several studies to be detrimental to these patients. So it's not something to just gloss over; it is a real concern and many in EMS don't have nearly enough respect for it, IMO. You really can hurt your patients if you screw this stuff up, even if you get the tube on your first try.
> 
> ...




I'm not sure if the numbers are exact, but they are very close if not.  In a brain injured patient, hypoxia and hypotension dramatically increases mortality and worsen outcomes.


And both of these things are relatively common with induction and intubation.  But again, those statistics are in reference to brain injury.  

I'm going to argue against intubation here.  Given the exam, the clear and equal lung sounds, and under the supposition that the patient was not dyspneic, but breathing comfortably, I would hold off and transport immediately on high flow oxygen.  

I think the risk of intubation here outweighs the benefit.  

There are generally three reasons this guy is going to have respiratory failure and require intubation:
1. Carbon monoxide If there was also fire post-explosion
2. Pulmonary edema from the lung injury
3. Loss of the airway from burns.

If the mucosa is intact, the saturations are normal, he is protecting his own airway, and the breathing is non-labored, I personally would not intubate him until one of these things was no longer true.  

Pulmonary edema would not hinder your need to intubate, should the need arise.  Nor would carbon monoxide.  And quiet, unlabored breathing is not an airway at imminent risk.  

I think the rush to intubate burn patients is a bit overzealous at times.


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## Nova1300 (Apr 11, 2016)

I missed the ventilating part.  I do agree that if you need to support ventilations, you need to intubate this patient


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## Akulahawk (Apr 11, 2016)

Given the limited information known to us, the fact that you've inserted an airway adjunct _and_ have to provide additional mechanical ventilation via BVM, the patient needs to be intubated. The question that remains is _how_. Given that the patient has a decreased GCS but not seriously low, probably has an intact gag reflex, and the like, I would suggest that RSI would be very appropriate for this patient. 

Burning the nares means that seriously hot gas has at least reached the face long enough to cause damage. I wouldn't wait with this patient to get a secure airway. If you do wait for airway symptoms to show themselves, you've probably waited too long because airway edema would be quite advanced at that point.


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## SpecialK (Apr 12, 2016)

Yes, I'd give this pt a general anaesthetic and intubate him for the following reasons:

1.  He is likely to be in severe pain (general anaesthesia with fentanyl and ketamine will remove not only his perception of pain but also the deleterious pathophysiological effects from his pain)
2.  Even if he does not have poor airway due to burns, it has the high potential to become poor at very short notice
3.  If his airway does become poor due to burns, it will likely make intubation difficult

Given our standard approach to burns is 20 minutes of cooling with cool water I'd be happy to wait on scene for an RSI Officer unless it was going to be much faster to just take him to hospital instead.


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## medicsb (Apr 12, 2016)

If you have the skills (having the drugs and an RSI protocol does not equal skills), then you intubate this patient all day, everyday, and twice on Sunday.


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## Carlos Danger (Apr 12, 2016)

We are all taught to have a high index of suspicion for airway compromise in burn patients, and that if you wait until there are signs of airway involvement, it's too late. I wonder how much of a concern that really is. In other words, how likely _is_ lower airway injury if a patient presents with soot in the mouth, or singed nasal hairs?

The HEMS program I used to work for had a contract with a major burn center, and we transported patients there from all over the southeast. My experience with that leads me to believe that we probably significantly exaggerate the risk of airway involvement in these cases. I've transported many burn patients who had the classic warning signs and I don't remember one ever having lower airway involvement. Especially not the very rapidly developing kind (where they are fine one moment and their airway has swollen shut the next moment) that we are always warned about. I'm not saying it doesn't happen, but I think it is a lot less of a risk than we are taught. For sure I've seen lots of smoke inhalation cases where they needed albuterol, and even ventilatory support, but that's a totally different thing.

A large percentage of patients with bad burns will end up intubated - even if the burns are nowhere near the face - because of high opioid requirements and the fluid shifts that eventually do cause some facial and pharyngeal edema, but it isn't usually something that has to happen immediately.


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## NomadicMedic (Apr 12, 2016)

I think this post from @Remi nails it. I had a patient that was in a house fire, trapped in the house, and was rescued by fire fighters. When I arrived, she was a bit confused, but the confusion cleared up quickly following some oxygen. She had soot around her mouth and in her airway, but no burns. I was questioned by the Doc and the senior FTO about why I didn't RSI the patient. Well, she was conscious, had no respiratory difficulty or pain and was mentating correctly. Turns out she never needed airway management, but I was questioned about knocking down and tubing a woman with a dirty face because we're so brainwashed that anyone who was in a fire with soot in their oropharynx buys a tube.


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## CANMAN (Apr 12, 2016)

I agree that we tend to be over aggressive in some burn patients. That being said, and having worked in a burn institution, I typically associate explosion type burns with a higher incidence of respiratory issues. I doubt there's evidence to prove that, however almost every patient I have some in contact with that had exposure to a significant explosive type injury facial involvement eventually has some respiratory component. We have lots of dumb farmers who love to "clean up" with gasoline around my way... 

Sure lower airway stuff is a concern, and you can listen to lung sounds etc etc, but what I see more often is upper airway issues which present with hoarseness and stridor, and those scare me more.... That person is buying plastic before then become too inflammed to where it's now a problem. All else fails, they do well and didn't need it, you extubate them and all is well. I would rather be slightly over aggressive in that scenario then waiting til last minute, end up not being able to get that patient intubated, then looking at a surgical airway because I was being passive.


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## Nova1300 (Apr 12, 2016)

Remi said:


> We are all taught to have a high index of suspicion for airway compromise in burn patients, and that if you wait until there are signs of airway involvement, it's too late. I wonder how much of a concern that really is. In other words, how likely _is_ lower airway injury if a patient presents with soot in the mouth, or singed nasal hairs?
> 
> The HEMS program I used to work for had a contract with a major burn center, and we transported patient there from all over the southeast. My experience with that leads me to believe that we probably significantly exaggerate the risk of airway involvement in these cases. I've transported many burn patients who had the classic warning signs and I don't remember one ever having lower airway involvement. Especially not the very rapidly developing kind (where they are fine one moment and their airway has swollen shut the next moment) that we are always warned about. I'm not saying it doesn't happen, but I think it is a lot less of a risk than we are taught. For sure I've seen lots of smoke inhalation cases where they needed albuterol, and even ventilatory support, but that's a totally different thing.
> 
> A large percentage of patients with bad burns will end up intubated - even if the burns are nowhere near the face - because of high opioid requirements and the fluid shifts that eventually do cause some facial and pharyngeal edema, but it isn't usually something that has to happen immediately.




100% yes.  

Granted, I have only managed a few of these cases when called by the ER to be on standby for the intubation.  But in all of those cases, the airway compromise was not immediate.  There had been signs and symptoms of respiratory distress prior to being called.  

Even in those cases, I have delayed induction until someone brought me a perc trach kit to bedside and pressors hanging. 

And every time, the ER residents have managed the airway just fine while I sip my coffee and chat up the medics.  

Rarely is something absolutely wrong in medicine.  I would just keep in mind that every induction has some degree of risk, no matter how skilled of an intubator you are.  

These patients are very likely to have capillary leak syndrome.  You induce him, he is probably going to get hypotensive, no matter which agent you chose.  Between that and his enormous inflammatory response, the likelihood of knocking his beans off is pretty high.  

Again, if you are needing to assist respirations, yes intubate him.  But, if you don't have a hard indication (burned mucosa, noisy respiration, depressed mental status) I personally would transport emergently on high flow O2. 

That is simply my opinion, take it for what it's worth.  

Just to make one other point.  If you are going to intubate this patient in the field, he absolutely needs rapid sequence.  He is a multi system trauma and is considered full stomach, even if he was on hunger strike for the last 3 days.


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## Jim37F (Apr 12, 2016)

Just out of curiosity, what if this patient was in a system that doesn't have RSI? You medics wouldn't attempt to intubate unless the GCS was closer to a 1-1-1 right?


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## CANMAN (Apr 12, 2016)

Jim37F said:


> Just out of curiosity, what if this patient was in a system that doesn't have RSI? You medics wouldn't attempt to intubate unless the GCS was closer to a 1-1-1 right?



Great post Nova.

And yes Jim like Nova said, without RSI this guy needs rapid transport and 100% oxygen, a heads up to the ED, and let them do the show therefor the reasons Nova stated above.


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## Tigger (Apr 12, 2016)

CANMAN said:


> Great post Nova.
> 
> And yes Jim like Nova said, without RSI this guy needs rapid transport and 100% oxygen, a heads up to the ED, and let them do the show therefor the reasons Nova stated above.


Nasal tube perhaps?

Certainly not to replace RSI, but an option for those that don't have it.


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## CANMAN (Apr 12, 2016)

Tigger said:


> Nasal tube perhaps?
> 
> Certainly not to replace RSI, but an option for those that don't have it.



Yeah perhaps if we had to manage this guys ventilations for an extended transport time, but if we were close to the hospital I would defer if I didn't have RSI. Nasal intubation can cause pretty dramatic spikes in ICP and for the guy with a potential head injury idk if I would venture down that path or not personally. But a great idea and glad people still think of it. Definitely a lost art and a lot of medic schools don't even teach it anymore...


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## DesertMedic66 (Apr 12, 2016)

Out here it's code to the closest ED. We don't have RSI, nasal intubation, or even crics.


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## medicsb (Apr 13, 2016)

I generally agree with the notion that soot in the airway and/or singed facial/nose hairs should not be an indication for intubation.  Nor should isolated facial burns.  Add on respiratory distress, voice change, sloughing of oral mucosa, etc. and then you have some solid reasons to intubate.  I do, however, think that if you are on the fence, it is probably better to intubate.  Having spent 4 weeks working in a Burn ICU, I've seen the sort of damage to the tracheal and oral mucosa that can occur - swelling and sloughing of necrotic mucosa.  I've seen patients go extended periods of time with no cuff leak due to swelling.  And there were a few who were extubed the next morning after positive cuff leak and negative bronchoscopy and then sent home directly from the ICU.  In the ED, I have the benefit of having an NPL, so I can look directly at the vocal cords and hypopharyx to eval for edema.  We frequently brought patients in for "airway watch" and then D/C'd to home when everything was fine the next day.  We probably do "over intubate" burn patients, but I'd never want to be behind the curve of an airway burn.


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## Nova1300 (Apr 13, 2016)

Tigger said:


> Nasal tube perhaps?
> 
> Certainly not to replace RSI, but an option for those that don't have it.



It's funny, the only time I ever placed a nasal ETT in the field was a burn.  Fire pulled a gentleman out of a house with 100% full thickness from the top of his head to the bottom of his feet.  He was still moaning, but otherwise non-communicative.  

Having never placed one, and frankly never even seen one, I used a trigger tube (some of you may remember those), down the nose, watched for mist, synchronized my own respirations with the patient's, prayed, here we go, on the next breath we are going for it.....another quick prayer.... bam! A few joyous expletives and an ambubag later I emptied the morphine and the Valium tubex into his IV and pedal to the floor.  

18 years old, brand new cardiac tech (probably now equivalent to an intermediate), absolutely terrified.  It was certainly one of those calls that sticks with you the rest of your career.  

Somehow we managed pre-RSI.  But, wow would I never like to do that again.  I still don't know how that tube ended up in the trachea.  Beginners luck, 100%.

Now that I have a substantially larger knowledge of airways, I would be way too chicken to attempt a nasal intubation on a burn.  But, it can work in a pinch.


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## CANMAN (Apr 13, 2016)

Guessing you guys didn't have BAAM's then Nova? Before the days of CPAP a lot of our tanking CHF'ers would buy a trigger tube and a BAAM and those things work like magic!


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## Carlos Danger (Apr 13, 2016)

Whenever someone says "RSI isn't an option for me", someone else always pipes up an says "well, what about blind NTI?" and then they or someone else goes on to explain how they've done many of them and how they are a really feasible alternative to RSI.

I'm not disagreeing or saying I don't believe those who say that've done them, because I've never done one myself. I'm just wondering....are they really that easy? Do you still not encounter a violent gag reflex? And if they do work well, why aren't they done more? 

I was taught how to do them years ago in paramedic school, and it was touched on again in my anesthesia program. We carried BAAM's several places that I worked, but I don't recall ever even attempting a BNTI.



Nova1300 said:


> I emptied the morphine and the Valium tubex into his IV



That's like a blast from the past, because when I was a new paramedic, the only analgesia and sedation we carried was morphine and valium.....both in 1ml tubex's. I recall a few times getting orders to combine those with brutane in order to facilitate intubation. It was always ugly, but sometimes it worked.


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## CANMAN (Apr 13, 2016)

Remi said:


> Whenever someone says "RSI isn't an option for me", someone else always pipes up an says "well, what about blind NTI?" and then they or someone else goes on to explain how they've done many of them and how they are a really feasible alternative to RSI.
> 
> I'm not disagreeing or saying I don't believe those who say that've done them, because I've never done one myself. I'm just wondering....are they really that easy? Do you still not encounter a violent gag reflex? And if they do work well, why aren't they done more?
> 
> ...



Well I don't believe they are an ideal replacement for RSI by any stretch, but they aren't overly difficult to place if you have the right gear.

Right gear being Endotrol "trigger tubes" and a BAAM. Alternatively you could use an in line end-tidal but the BAAM is a nice audible confirmation with spontaneous respirations. I have never put larger then a 6.0 in due to nare size, and obviously they require copious lube. I have had people with a strong gag, and some without a gag, or very weak all accept a tube. Most of the people with a strong gag were CHF patients before the days of CPAP that were so air hungry they literally would suck the tube down. That being said I have done about 7 in my career, all but one successful with relative ease.

Biggest issue I have had is making sure the ET adapter is pushed down tight enough in the tube so it doesn't come out, and securing it, which can be done with IV tubing.

I think they aren't done as frequently now a days because of the introduction of Narcan and CPAP. Also the increase in ICP is a concern with head injured patients as we know.


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## Akulahawk (Apr 13, 2016)

I've seen NTI done and was trained in the technique in Paramedic school but I've never done one. This is mostly due to the fact that most of the systems I worked in did not authorize NTI. Since some did, we were trained in how to do it though. My observations are pretty much what CANMAN stated. It's not too difficult as long as you have the correct tools, one being an Endotrol trigger tube ETT and the other being a BAAM device. The intubations were generally well tolerated. 

Even in this age of RSI, it's not a bad idea to have this in your toolbox, so to speak, though I would expect it to be rarely used these days. One other technique I was trained in was digital intubation... but generally speaking, I'm not too keen on the idea of putting my hand/fingers into someone's mouth and working entirely by feel.


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## Carlos Danger (Apr 13, 2016)

Akulahawk said:


> Even in this age of RSI, it's not a bad idea to have this in your toolbox, so to speak, though I would expect it to be rarely used these days. One other technique I was trained in was digital intubation... but generally speaking, I'm not too keen on the idea of putting my hand/fingers into someone's mouth and working entirely by feel.


I've done several digitals in messy airways. THAT is a great technique to stay comfortable with. Along with retrograde. Those are my old-school party tricks.

You damn kids these days have it so easy with your bougies and your VL's.


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## Akulahawk (Apr 13, 2016)

Remi said:


> I've done several digitals in messy airways. THAT is a great technique to stay comfortable with. Along with retrograde. Those are my old-school party tricks.
> 
> You damn kids these days have it so easy with your bougies and your VL's.


I was also trained to do retrograde...  Because of VL and bougies, I've yet to see any of my ER Docs have to use that technique, let alone doing a cric.


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## Tigger (Apr 13, 2016)

Remi said:


> Whenever someone says "RSI isn't an option for me", someone else always pipes up an says "well, what about blind NTI?" and then they or someone else goes on to explain how they've done many of them and how they are a really feasible alternative to RSI.
> 
> I'm not disagreeing or saying I don't believe those who say that've done them, because I've never done one myself. I'm just wondering....are they really that easy? Do you still not encounter a violent gag reflex? And if they do work well, why aren't they done more?
> 
> ...


We still learn them in our program and it isn't a "this is a skill that you'll never use but we have to teach it" sort of thing. We carry the trigger tubes and BAAMs and while I would never say I am comfortable in doing something I have never done to a live patient, I do feel that I was educated to the point of being willing to attempt it, especially with a long transport (minimum of a half hour for us).


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## ERDoc (Apr 15, 2016)

I agree that we do go a little overboard about tubing these sorts of pts, but I think the pt in the original scenario has shown us that she is one of them that needs a tube.  Anyone inside a fire is more than likely to have soot in their nose, throat and everyone else but it doesn't mean they inhaled hot gasses so you have to look at the soot in the full, clinical context.


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## Doczilla (Apr 17, 2016)

ERDoc said:


> I agree that we do go a little overboard about tubing these sorts of pts, but I think the pt in the original scenario has shown us that she is one of them that needs a tube.  Anyone inside a fire is more than likely to have soot in their nose, throat and everyone else but it doesn't mean they inhaled hot gasses so you have to look at the soot in the full, clinical context.



I agree both to this, and your previous sentiment about taking minimalist approaches to airways that need tubes. 

Not everyone needs a tube, or RSI for that matter. But when you need RSI, you NEED it. Over the years there's been many more "risk adverse" adjustments to airway guidelines (which are actually protocols lol) in response to the overwhelming notion that prehospital tubes are causing further harm. 

Yeah, some of em are. But we've gotta use the same solvent analysis that we use for other stuff and address deficiencies in ourselves before we downgrade airway management resources in a knee-jerk, blanket fashion. 

We owe it to our patients, and ourselves as clinicians.


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## MackTheKnife (Jun 8, 2016)

medichopeful said:


> I'm trying to wrap my head around one of the scenarios we recently did in medic school, so I figured I'd run it by everybody here (I'll try to remember it the best I can.  It was a few days ago so I can't remember a lot of the information):
> 
> Dispatched for an explosion at a building.  Upon arrival, you have one patient (middle-aged male) found laying on the ground.  Going head to toe: decreased level of responsiveness (can't recall exact GCS, but 12-13 range maybe?), singed nose hairs, mucous membranes intact.  Burns to chest, forearms.  I don't remember much about the respiratory rate, but I remember that we did place an NPA and provided ventilation with a BVM.  Lung sounds clear and equal.  Bilateral lower leg fractures.  I don't recall exact vitals, but I believe they were relatively stable (with exception of resps).
> 
> ...


If you're having to bag him, you need to tube him.

Sent from my XT1585 using Tapatalk


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## Melbourne MICA (Jun 9, 2016)

The question is, what proportional correlation is there between certain visible airway burn markers and the need for prophylactic intubation? Well, the juries still out. A large proportion of airway burns intubations whether done in the field or at the ED/burns unit are extubated in the 1st 24hrs. I'll hunt up some references, but  current evidence does support any particular combination of airway signs as a reliable model for ETT decisions. Like so may paramedic decisions, it's a judgement call - a balance between potential serious risks from RSI and whatever benefits we suspect may be derived from an early intubation.


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