# Airway - Trauma Scenario



## Handsome Robb (Nov 13, 2016)

Ran this call this morning. Wondering what people's decision would have been. 

35 year old male was crossing the street when he was struck by a sedan-type vehicle traveling approximately 20 mph. 

Arrive on scene to find ALS fire on scene with an NPA in place and assisting ventilations. 

GCS 3, pupils are fixed at 2mm, laceration noted to the occipital region with moderate bleeding. Face is autraumatic, jaw is trismussed, cheyne-stokes respiratory pattern. His chest is atraumatic, lung sounds are clear to auscultation bilaterally, abdomen is soft and his pelvis is stable. Upper and lower extremities are atraumatic, strong peripheral pulses x4.

Vitals:
HR 46, sinus, without ectopy.
RR 0-28, cheyne-stokes pattern
136/70
100% with ventilations assisted with 15lpm via BVM.

You're approximately 6-7 minutes from the level 2 trauma center, 30 minutes from the level 1.

You're a dual medic, RSI capable ground unit with an ALS engine crew on scene.

Do you intubate? Why or why not? Do you have any other questions as far as the scenario or assessment findings? 



Sent from my iPhone using Tapatalk


----------



## VentMonkey (Nov 13, 2016)

Handsome Robb said:


> Ran this call this morning. Wondering what people's decision would have been.
> 
> 35 year old male was crossing the street when he was struck by a sedan-type vehicle traveling approximately 20 mph.
> 
> ...


Probably wouldn't RSI with that ETA. O2 sats are good as is, closest trauma center probably has neuro capabilities, so go there, if not the Level 1 that does.

These things along with presentation are enough to scream TBI/ ICH, with a good chance said patient needs or may need a crani...rapidly.

Only thing I would be aggressive with is seeing his is (safely) taken to the right place to perform said surgery, and if CT is clear then meh better safe than sorry, just me though.


----------



## VentMonkey (Nov 13, 2016)

To add to this, if the Level 1 has neurosurgery and the Level 2 doesn't (highly doubt it?), ground it the extra ~25 minutes to the Level 1 with plenty of time to RSI if need be, assuming his GCS doesn't begin to improve en route; don't forget to place them on the vent though.

All I got for now, Robb.


----------



## DesertMedic66 (Nov 13, 2016)

I would go with the same treatment route that @VentMonkey stated.


----------



## Handsome Robb (Nov 13, 2016)

Level 2 has all the same capabilities as the level 1 minus being a teaching facility. That was my little test of all y'all's knowledge of level 2 va level 1 trauma centers  

Sent from my iPhone using Tapatalk


----------



## VentMonkey (Nov 13, 2016)

Handsome Robb said:


> Level 2 has all the same capabilities as the level 1 minus being a teaching facility.


We only have one trauma center in our county, a level 2, which is also a teaching hospital.


----------



## StCEMT (Nov 13, 2016)

I wouldn't based on the info you gave. If it ain't broke, don't fix it.


----------



## zzyzx (Nov 13, 2016)

Yes, I would intubate. This guy needs an airway.
Once he's intubated, you can control his oxygenation and ventilation very nicely, which is also going to be important for someone with a head injury like this.
If I didn't have RSI, I would see if he could maintain perfect sats with only a mask and not the BVM. I would be worried about gastric insufflation in this scenario.
Level II trauma center is fine.


----------



## SpecialK (Nov 13, 2016)

RSI with fentanyl, ketamine and rocuronium.  Would love to be able to mechanically ventilate him, but as not, ventilate to ETCO2 of 35-45 mmHg.

I would bind his pelvis (but absolutely not "spring" or firmly palpate it)

Take him to a major trauma hospital directly.


----------



## TXmed (Nov 13, 2016)

With this guy displaying cushings i would use ron walls "crash airway algorithim". 

Administer succs (or roc) alone for the airway procedure and attempt to intubate. with that kind of ETA im not too concerned about getting the intubation (although try) as i am just maintaining an airway and keeping the O2 sats up.


----------



## EpiEMS (Nov 13, 2016)

Quick high level reference for trauma centers -- level 2 hospitals have 24 hour neuro coverage. 

Robb, did you get an ETCO2 reading?


----------



## RRTMedic (Nov 13, 2016)

Handsome Robb said:


> Ran this call this morning. Wondering what people's decision would have been.
> 
> 35 year old male was crossing the street when he was struck by a sedan-type vehicle traveling approximately 20 mph.
> 
> ...



Okay, so without looking at anyone elses' posts and giving you my clear cut opinion... this is a grab and go case. Sounds like he has a clear case of cushing reflex and will have the potential for neurosurgical intervention. Airway of course is a definite, but also a priority, doesn't seem to be completely compromised. You're BVM'ing him well and his blood pressure is stable. So far, you have hit on two of the three keys to traumatic brain injury: Hypoxia (spo2 100%), hypotension (136/70) and hypoglycemia (???). Sounds to me that you cannot truly justify paralyzing him in the field and risk a failed airway when there is a capable hospital 6 minutes away. What he needs is intubation and Head CT.... and I don't think that hanging out and intubating would be the best idea. IF, you did not have the option to go to the Level 2 and then had a 30 min transport time... I'd reconsider.


----------



## Carlos Danger (Nov 13, 2016)

Turn & burn to the level 2. I would intubate and hyperventilate only if I could do it enroute. 

Someone mentioned intubating with only sux.....what is the advantage of driving ICP even higher than it is?


----------



## Tigger (Nov 13, 2016)

With that ETA I think I would call an alert into the hospital as soon as we got on scene and tell them to expect to RSI him on our arrival. No reason to sit out there. Get a line or two enroute and ensure that the BVM is being used appropriately. 

If he was entangled or something and I had time to set everything up while they're bringing him to me I'd be more inclined to do so. 

Would you consider lidocaine?


----------



## VentMonkey (Nov 13, 2016)

Tigger said:


> Would you consider lidocaine?


 Only as a_ pre-RSI_ measure, but if there's no reason for an immediate advanced airway, there's no need for Lidocaine.


----------



## VFlutter (Nov 13, 2016)

Lidocaine is no longer in my protocols for pre-RSI.


----------



## Handsome Robb (Nov 13, 2016)

EpiEMS said:


> Quick high level reference for trauma centers -- level 2 hospitals have 24 hour neuro coverage.
> 
> Robb, did you get an ETCO2 reading?



32 mmHg. We ended up turning the O2 off and just BVMing him through his periods of apnea with room air. SpO2 stayed at 99-100%. 

We discussed intubating him with ketamine and roc but deferred it due to proximity to the TC. We actually don't RSI, only DSI so even once you've got a line in place and give the ketamine it's still a 4.5 minute procedure and transport was about 6 minutes.

Found out he ended up herniating and as a donor. His ICP was in the 80s per the neurosurgeon when we checked in on him later. 


Sent from my iPhone using Tapatalk


----------



## Summit (Nov 13, 2016)

Load and go to the Level 2. You could think about RSI, but by the time you finish you'll be at the ED doors, so pass given the presentation.


----------



## VentMonkey (Nov 13, 2016)

Handsome Robb said:


> 32 mmHg. We ended up turning the O2 off and just BVMing him through his periods of apnea with room air. SpO2 stayed at 99-100%.


Nice job with the ETCO2 threshold. I am unfamiliar with the second part of this quote though, what's the theory?


----------



## TXmed (Nov 13, 2016)

Remi said:


> Someone mentioned intubating with only sux.....what is the advantage of driving ICP even higher than it is?



with the crash airway algorithm its more about airway control rather than intubation. So if i was to administer succs and walk into the ER with an OPA, good BVM, Good o2 sats, and good ETCO2 thats more what this patient needs rather than a piece of plastic between his vocal cords (although i would try an intubation). We know laryngescopy increases ICP but it hasnt been proven that laryngescopy alone leads to poor patient outcomes (or atleast from the studies i have read) and fentanyl/lidocain are more thoughts rather than proven science, or atleast that is the view of my MD. If this patient was to seize, vomit, combative, and even their trismus is raising their ICP, atleast with a paralytic on board we can help this.


I fully support peoples affinity for short scene times. but me personally on this call i would slow everyone down, properly manage the airway, (good job on the NPA and ETCO2 by the way), administer a paralytic, suction, ensure proper o2 sats, etco2, and airway protection. all these things is what the ER facility is going to do in the first 10 minutes.  But that is just my personal opinion. i dont think anyone who commented above is wrong in their thinking.


----------



## SpecialK (Nov 13, 2016)

TXmed said:


> With this guy displaying cushings i would use ron walls "crash airway algorithim".
> 
> Administer succs (or roc) alone for the airway procedure and attempt to intubate. with that kind of ETA im not too concerned about getting the intubation (although try) as i am just maintaining an airway and keeping the O2 sats up.



Sorry? Where on earth did you get the idea you could paralyse somebody with suxamethonium without a general anaesthetic first? 

I cannot for the life of me think of why anybody would even try such a thing?

With a severe TBI and a 30 minute drive to a major trauma hospital I'd want to be underway as soon as possible however it's worth spending the extra 10 minutes to perform an RSI.  That means he is asleep and intubated in 10 minutes, not the 30 it is going to take to drive to the major trauma hospital, plus the 10 minutes it is going to take to get the ambulance parked, get him inside and have everything handed over and set up until he can be intubated.


----------



## VentMonkey (Nov 13, 2016)

SpecialK said:


> Sorry? Where on earth did you get the idea you could paralyse somebody with suxamethonium without a general anaesthetic first?
> 
> I cannot for the life of me think of why anybody would even try such a thing?
> 
> With a severe TBI and a 30 minute drive to a major trauma hospital I'd want to be underway as soon as possible however it's worth spending the extra 10 minutes to perform an RSI.  That means he is asleep and intubated in 10 minutes, not the 30 it is going to take to drive to the major trauma hospital, plus the 10 minutes it is going to take to get the ambulance parked, get him inside and have everything handed over and set up until he can be intubated.








I believe this is the algorithm @TXmed is referring to, but he's more than welcome to correct me if I am wrong.


----------



## TXmed (Nov 13, 2016)

SpecialK said:


> Sorry? Where on earth did you get the idea you could paralyse somebody with suxamethonium without a general anaesthetic first?
> 
> I cannot for the life of me think of why anybody would even try such a thing?
> 
> .



My medical director fully support ron walls and george kovacs veiws on this. THAT is where i got this crazy idea. This patient is very critical, he is also not alert enough to comprehend what is going on when you do this. 

Scott weingart from emcrit talks about this in his LAMW podcast as we must treat the patients life threats and THEN pain, and THEN possible sedation in the critical patient.


----------



## VentMonkey (Nov 13, 2016)

TXmed said:


> My medical director fully support ron walls and george kovacs veiws on this. THAT is where i got this crazy idea. This patient is very critical, he is also not alert enough to comprehend what is going on when you do this.
> 
> Scott weingart from emcrit talks about this in his LAMW podcast as we must treat the patients life threats and THEN pain, and THEN possible sedation in the critical patient.


I agree somewhat, but admittedly, I have yet to listen to this particular series by Doc Weingart, so I'll ask what the risk/ benefit ratio is in regards to time savings to definitive care?

Granted, I can respect how this can be spun (i.e., saving the ED the extra steps in performing ETI, and reducing arrival time to CT vs. them performing this procedure in-house). I'm merely trying to keep this thread alive for the sake of a nice healthy airway debate.


----------



## Tigger (Nov 13, 2016)

VentMonkey said:


> Only as a_ pre-RSI_ measure, but if there's no reason for an immediate advanced airway, there's no need for Lidocaine.


Should have been more clear...if you're going to intubate would you give lidocaine. As far as I can tell lidocaine does prevent ICP spikes and suppressed the cough reflex but might not really matter anyway.


----------



## StCEMT (Nov 13, 2016)

VentMonkey said:


> I agree somewhat, but admittedly, I have yet to listen to this particular series by Doc Weingart, so I'll ask what the risk/ benefit ratio is in regards to time savings to definitive care?
> 
> Granted, I can respect how this can be spun (i.e., saving the ED the extra steps in performing ETI, and reducing arrival time to CT vs. them performing this procedure in-house). I'm merely trying to keep this thread alive for the sake of a nice healthy airway debate.


While that podcast is one I will have to listen to a few times to let it fully sink in, I found it to be pretty informative. Worth a listen if you have 20 minutes to spare.


----------



## VentMonkey (Nov 13, 2016)

Tigger said:


> Should have been more clear...if you're going to intubate would you give lidocaine. As far as I can tell lidocaine does prevent ICP spikes and suppressed the cough reflex but might not really matter anyway.


Lol, don't get @Remi started. Honestly though his view is not without reason.

 The way I understand it is basically since any patient short of having bolts placed directly into theor skull for ICP monitoring to "study" any increase in ICP with vs. without Lidocaine, there are no hard, and fast studies, or proof, so it's still very much something people are hard pressed to prove with definitive studies.

With that said, it sounds discretionary, though I am sure people can very much argue for either or, but in grand scheme of "prehospital measures", I hardly doubt it matters that much so @Tigger it sounds as though we're on the same page.


----------



## TXmed (Nov 13, 2016)

VentMonkey said:


> I agree somewhat, but admittedly, I have yet to listen to this particular series by Doc Weingart, so I'll ask what the risk/ benefit ratio is in regards to time savings to definitive care?
> 
> Granted, I can respect how this can be spun (i.e., saving the ED the extra steps in performing ETI, and reducing arrival time to CT vs. them performing this procedure in-house). I'm merely trying to keep this thread alive for the sake of a nice healthy airway debate.



yea his Laryngescope as a murder weapon series is great. he talks about the differences in RSI'ing hypoxic patients, hypotensive patients, using push-dose pressors, DSI ETC. really interesting.

admittingly this is tough thought process to get on board with. But after reading some books by some of the people i named previously ive become more open to it.


----------



## VentMonkey (Nov 13, 2016)

I'll have to check it out, his energy and enthusiasm are second to none.

Great discussion, BTW everyone.


----------



## TXmed (Nov 13, 2016)

haha glad i could offer something. Yea airway stuff on this site always offers a lengthy discussion. But their is alot of very knowledgeable people on here to offer up their opinions and advice.


----------



## VentMonkey (Nov 13, 2016)

TXmed said:


> their is alot of very knowledgeable people on here to offer up their opinions and advice.


100% in agreement.


----------



## SpecialK (Nov 14, 2016)

This patient has an SpO2 of 100% with an NPA and an ETCO2 of 32 mmHg.  Looks pretty good.  What doesn't look so good is their intermittent apnoea.

I don't see any point in giving them suxamethonium alone if the initial attempt at intubation is unsuccessful which is what the above picture talks about.  Just because somebody has a GCS of 3 doesn't mean they should be paralysed without an anaesthetic first.  A single bit slug of ketamine is pretty much the standard general anaesthesia for RSI in most places and it has a reasonably fast onset (at most 30 seconds) and if you give your neuromuscular blocker immediately after the anaesthetic the patient will be fast asleep about the same time as they are being physiologically paralysed.

If the patient is so obtunded and near death, they will accept a basic airway for the two minutes it is going to take to set up for an RSI.  What is going to make a clinically significant difference is ensuring adequate oxygenation.  You could even have an attempt without RSI, but I wouldn't really want to, indeed the CPGs state GCS of 3 *and *ineffective breathing as the only indication for doing so, with the point the risks of intubation generally outweigh the benefits without RSI, and I agree.

What saves lives (and brains) is good airway care done well; even if that is a nasoairway and a bag mask; what you use doesn't matter; it's the end-result of good oxygenation and normocarbia, and avoiding hyperventilation.  

There are no studies I am aware of looking at this, but to me it's half measures, if you are going to do RSI, do it properly, and not half measures.  I have seen some services around the world who seem to just give people enough sedation until they are unconscious enough to be intubated, and now somebody wants to paralyse people without a general anaesthetic when they'd just as easily accept an LMA in the interim.  If you are going to do something, do it properly.  And, how are we to know somebody who has a GCS of 3 hasn;t got, or will not develop, some awareness?  

For this patient, with a 30 minute drive time to a major trauma hospital, if an RSI capable ICP was not available in a few minutes and could not meet us en-route, I would have one single attempt at intubating without RSI.  If that didn't work I'd just stick with an LMA.


----------



## Bullets (Nov 14, 2016)

With a 6 minute hit to a Level II, i would probably forgo intubation as long as an OPA and BVM are working to maintain oxygenation through the apenic period. Should i think i need to place something more advanced i would prefer doping an iGel in that short time period. And then a call to the ER to get ready to tube when we arrive. I also think i would go with Ketamine up front if he tolerates the OPA. If he starts gagging then a paralytic, maybe Vec

No reason to divert to a Level I with a Level II that close


----------



## Carlos Danger (Nov 14, 2016)

Alright, here's my take on what's been discussed so far here:

First, what does the evidence tell us about how to manage these patients, airway wise? It's been looked at a lot, and while there are no conclusive prospective studies out there, I don't think there is any study anywhere that indicates that intubating a patient with an Sp02 of 100% who is only six minutes from a trauma center is anything but a bad idea. In fact, outcomes have repeatedly been shown to be _worse_ in patients who we intubate in the field. Not better, not the same.....*worse*. So there's that. I'm not trying to convince anyone that we should throw away our laryngoscopes, but I think any time we talk about the best way to manage a given scenario, one of the first things we should do is consider what the research has to say about it

CNS trauma victims are very sensitive to hemodynamic changes. You can cause secondary injury by not blunting the sympathetic response to intubation properly, or by causing hypotension with your sedation. Hypotension is almost certainly worse than hypertension, but that doesn't mean it's OK to do things to them that cause their ICP to go even higher than it is.

@TXmed, you are absolutely correct that sometimes it is appropriate to forgo sedation. People have laughed at my "Sux --> tube --> apologize later" saying but it really is the best approach on occasion. I don't think it is in this case, though. Partly because of the issues I described in the last paragraph, and partly because I don't think any patient with an intact respiratory drive and an Sp02 of 100% meets any definition of "crash airway". This patient requires the exact opposite of a crash airway....a slow, methodical, gentle approach with as much attention paid to hemodynamics as possible.

@Tigger, it is true that lidocaine has not been shown to improve outcomes in TBI patients. It does blunt the sympathetic response to intubation which decreases the increase in ICP, but that hasn't translated into improved outcomes in this population. I still use it pretty routinely though. A healthy serum level of lido has all sorts of effects that, at least in theory, could be helpful. It potentiates opioids and anesthetic agents, it can reduce coughing if you are a little trigger happy with your laryngoscopy (as I tend to be), it reduces myalgia from succinylcholine, it reduces the incidence of chronic pain development, maybe delays the onset of ectopic activity if we start to get hypoxemic, etc. If I were by myself in the field and already task-saturated with dealing with a critical patient, I would definitely not worry about trying to give lido 5 minutes before I intubate. But if I'm preparing for a case in the OR, or if I get paged that an unintubated trauma is 10 minutes out from the ED and they are calling for help from anesthesia, then yeah, I'll take a few seconds to draw up lido with my other drugs, and it'll be the first thing I give, as I'm assessing the airway and getting my other stuff ready.


----------



## VentMonkey (Nov 14, 2016)

@Remi for the win, excellent post.


----------



## harold1981 (Nov 14, 2016)

For the time being an airway is secured by the NPA, and the B is managed by proper ventilations with the BVM. The C is stable, despite a bradycardia. 
Overall I have an ABC-stable patient, with a lifethreatening TBI. What will save his life is neurosurgery, which is available quickly with a pre-alert to the level 2 trauma center. I would not perform RSI up to this point.
Now if he vomits in those six minutes I have a big problem. I had an airway, now I don´t. I can´t properly suction, because of the trismus. 
An open airway is not necessarily a safe airway. With TBI I can expect the patient to vomit anytime soon. An LMA or antiemetics is not going to stop that. 
With that in mind, I prefer to perform the RSI before transporting.


----------



## VentMonkey (Nov 14, 2016)

harold1981 said:


> The C is stable *because of a reflexive and protective mechanism such as* a bradycardia.


So as long as we're both understanding this correctly. There's no need to treat or worry about the HR in this patient population. As others mentioned the two factors that kills any brain injured patient are hypoxia, and hypotension, so the reflexive HTN, and relative bradycardia seen in "classic" Cushing's is actually helping keep said patient afloat.


----------



## harold1981 (Nov 14, 2016)

I said: even though this patient is bradycardic, he has a stable circulation. I wasn´t intending to worry about it or treat it.


----------



## VentMonkey (Nov 14, 2016)

harold1981 said:


> I said: even though this patient is bradycardic, he has a stable circulation. I wasn´t intending to worry about it or treat it.


It was meant more in terms if a general statement towards us both, and everyone else. 

I have seen some crazy rationalizing for treatment rendered way out of protocol or thought process, and often things get lost in translation in terms of what the individual thought of a specific procedure at the time.

I was mainly clarifying, it's more so directed at the masses as this is what an online forum is for...to help others get a better understanding of things missed elsewhere. I never said, indicated, nor assumed you specifically would treat it.


----------



## harold1981 (Nov 14, 2016)

okidokie VentMonkey, no problem  sorry I misinterpreted.


----------



## VentMonkey (Nov 14, 2016)

harold1981 said:


> okidokie VentMonkey, no problem  sorry I misinterpreted.


----------



## SpecialK (Nov 14, 2016)

So I've just read what a "Level II" is; and we do not have these. 

We have a national network of five major trauma hospitals.  We have a larger network of "secondary hospitals" which are fine for some trauma, for example somebody who needs a nail in their femur or has a flail chest or needs general medical intensive care but they do not handle major trauma.  Our five major trauma hospitals are the only centres which have neurosurgery.

We do not transport major trauma to a non-major trauma hospital unless the patient has an immediately life-threatening problem with their airway, breathing or circulation which cannot be handled by ambulance personnel; for example, somebody who needs their chest opened to relieve a pericardial tamponade, or a formal chest drain inserted, or has had a cricothyrotomy for complete airway obstruction and needs a definitive airway.  If we do this it is called "staging" and Control will activate a helicopter to transfer the patient to a major trauma hospital approximately 20-30 minutes after arriving a the staging hospital.

Much of the country is a long way away from a major trauma hospital (several hours by road and an hour or so by helicopter) so the network of "staging" hospitals is good in the rare instance you absolutely need something lifesaving done before the patient can be taken to a major trauma hospital.


----------



## VentMonkey (Nov 14, 2016)

Very interesting @SpecialK, do you mind me asking where you work (country/ continent)?


----------



## SpecialK (Nov 14, 2016)

VentMonkey said:


> Very interesting @SpecialK, do you mind me asking where you work (country/ continent)?


----------



## Nova1300 (Nov 14, 2016)

I waffle a lot on this question.  On the whole, I'm not convinced prehospital intubation does much to save lives.  Anecdotally, there are likely cases in which it helps. But to play it out statistically, it probably makes little mortality difference in the grand scheme.  


That being said, I have always suspected that brain injured patients may be the one population in which there could be a benefit.  I will tell you, a large number of these patients aspirate.  You may not see it happen, but their bronchs consistently look awful on hospital day 1.  

I have to wonder a couple things:
1. Does protecting the airway with a balloon, prior to strapping these patients supine and moving them around, decrease the incidence of these aspirations?  
2.  Does the sedation provided for intubation in the field provide a protective effect to the injured brain  by decreasing the cerebral metabolic demand during a time of great stimulation( lifting, moving and transporting)? 
3. Does early control of respiratory acid/base status improve outcomes?  Specifically when instituted prior to moving and transporting the patient? 

Perhaps these things would only have a benefit for longer transport times?  Who knows.  But this has always been a nagging question in the back of my mind.  Because I have a hunch early intubation in these folks, specifically before transport, really could be of benefit.


----------



## VentMonkey (Nov 14, 2016)

Nova1300 said:


> I waffle a lot on this question.  On the whole, I'm not convinced prehospital intubation does much to save lives.  Anecdotally, there are likely cases in which it helps. But to play it out statistically, it probably makes little mortality difference in the grand scheme.
> 
> 
> That being said, I have always suspected that brain injured patients may be the one population in which there could be a benefit.  I will tell you, a large number of these patients aspirate.  You may not see it happen, but their bronchs consistently look awful on hospital day 1.
> ...


These are just my thoughts, Nova. Feel free to chime in with yours.


----------



## TXmed (Nov 14, 2016)

@VentMonkey  i agree with you. Ive learned alot of applicable information when i learned about ventilator management and it has helped me become a better clinician even without the vent. Im also a big fan of resuscitate before you intubate and that placing that ET tube alone is not a treatment. i also feel that not all RSI is created equal. The patient mentioned above should have a different RSI then the septic patient, asthmatic, CHFer ETC. and thus the medications, dosage, pre and post treatment should differ and maybe prehospital intubation would have better outcomes.


----------



## VentMonkey (Nov 14, 2016)

TXmed said:


> @VentMonkey  i agree with you. Ive learned alot of applicable information when i learned about ventilator management and it has helped me become a better clinician even without the vent. Im also a big fan of resuscitate before you intubate and that placing that ET tube alone is not a treatment. i also feel that not all RSI is created equal. The patient mentioned above should have a different RSI then the septic patient, asthmatic, CHFer ETC. and thus the medications, dosage, pre and post treatment should differ and maybe prehospital intubation would have better outcomes.





Nova1300 said:


> early intubation in these folks, specifically before transport, really could be of benefit.


@TXmed, good point, and to further elaborate on the last part of @Nova1300's post, my personal opinion is that not all providers are created equal, and hence those _properly _trained for such specific situations should probably be the only ones coming near their airway with an advanced approach in the prehospital setting.


----------



## Tigger (Nov 15, 2016)

Incidentally in the past I was taken to task for giving lidocaine to a bradycardic patient (completely different bigeminy scenario). Obviously if the patient happens to be in a bi/trifasicular block lidocaine is bad, but I don't really see sinus bradycardia as an issue for premedicating with lidocaine, am I wrong?


----------



## VentMonkey (Nov 15, 2016)

Tigger said:


> am I *in the *wrong *thread*?


Yes, but I did this recently and caught all kinda of crap for it as well, sooo...


----------



## VentMonkey (Nov 15, 2016)

Tigger said:


> Incidentally in the past I was taken to task for giving lidocaine to a bradycardic patient (completely different bigeminy scenario). Obviously if the patient happens to be in a bi/trifasicular block lidocaine is bad, but I don't really see sinus bradycardia as an issue for premedicating with lidocaine, am I wrong?


Unless you're referring to the earlier post re: treatment of the bradycardia, nonetheless, it sure is easy to ger things crossed.

And nah, I would equate it to the prophylactic treatment of bradycardia with Atropine, mainly in the pediatric RSI population, though, many places are moving away from that in their treatment tree as well TMK.


----------



## Carlos Danger (Nov 15, 2016)

Tigger said:


> I don't really see sinus bradycardia as an issue for premedicating with lidocaine, am I wrong?



I don't really, either. I know bradycardia is listed as a side effect of lido, but I don't think I've ever noticed it decrease HR at all.


----------



## Tigger (Nov 16, 2016)

VentMonkey said:


> Unless you're referring to the earlier post re: treatment of the bradycardia, nonetheless, it sure is easy to ger things crossed.
> 
> And nah, I would equate it to the prophylactic treatment of bradycardia with Atropine, mainly in the pediatric RSI population, though, many places are moving away from that in their treatment tree as well TMK.


Some people see bradycardia as a contraindication to lidocaine. I am not sure why.


----------



## VentMonkey (Nov 16, 2016)

Tigger said:


> Some people see bradycardia as a contraindication to lidocaine. I am not sure why.


I can honestly say I don't recall learning this; guess it's time someone revisits this med, huh?


----------



## VentMonkey (Nov 16, 2016)

@Tigger, so I did a brief dig, and it seems to be an outdated theory as most articles cited are from the 70's (like this one).

Maybe this is something just trickled down over the decades? Here's the most recent publication that came up on my first search.

http://www.sciencedirect.com/science/article/pii/S0022073674800129

It would also appear that it's more specific with heart disease patients, although I am not sure if it's a small amount of this patient demographic or not. 

Either way, it seems like something to keep in the back of ones mind, but in an emergent situation (RSI) I don't know that it would be that high up on our list as providers.

Hopefully it dispels some questions for you, as it did for me. If you or anyone can find something more recent, please, share it with the forum.


----------



## RocketMedic (Nov 17, 2016)

Barring some odd situation like a predicted difficult airway, I'd tend to go along with TXMed: This guy ought to be intubated fairly quickly, transported quickly to the trauma center, and so on. For me, the trismus is the deciding factor- vomiting and trismus do not mix well and we can expect vomiting to occur fairly quickly.


----------



## FLMedic311 (Nov 22, 2016)

Handsome Robb said:


> 32 mmHg. We ended up turning the O2 off and just BVMing him through his periods of apnea with room air. SpO2 stayed at 99-100%.





VentMonkey said:


> Nice job with the ETCO2 threshold. I am unfamiliar with the second part of this quote though, what's the theory?



I believe he is referring to the idea of trying to avoid hyperoxia....?


----------



## zzyzx (Nov 28, 2016)

What's harder to do, ET intubation or properly using a BVM?
Considering how ****ty nearly all medics are at using a BVM, I'd say BVM use is at least as hard as intubation.
Sometimes paramedics brag about their intubation skills. Ever hear anyone brag about how great their are at using a BVM? Usually the task of BVM ventilations isn't done by the medic anyway. It's passed on to a single firefighter or EMT.
Consider how much damage you can do to a head-injured patient by improperly bagging him--even if it's only for a few minutes before you get to "definitive care."


----------



## Akulahawk (Nov 28, 2016)

I guess I'm going to be an outlier on this then. Given the 6 minute transport time to a L2 TC, I'm going to forego the intubation and simply BVM this patient. While I am a Paramedic and still remember how to intubate, I'm not above using my basic skills when they're quite appropriate to use and this is one such case. I'd just call ahead, give the radio report, and request that they be ready to do an RSI asap upon arrival due to trismus/Cushing's response. They need time to get a room ready for this and time to clear out a CT scanner for this patient. 

Taking the time to RSI this patient on scene just eats up time that can be used getting him to definitive Neuro care and have them be ready to mange this guy's airway. 

This is just one of those times when an ALS assessment results in BLS care getting the patient to definitive care in an expedient manner, but wouldn't change the outcome much.


----------



## NomadicMedic (Nov 28, 2016)

Akulahawk said:


> I guess I'm going to be an outlier on this then. Given the 6 minute transport time to a L2 TC, I'm going to forego the intubation and simply BVM this patient. While I am a Paramedic and still remember how to intubate, I'm not above using my basic skills when they're quite appropriate to use and this is one such case. I'd just call ahead, give the radio report, and request that they be ready to do an RSI asap upon arrival due to trismus/Cushing's response. They need time to get a room ready for this and time to clear out a CT scanner for this patient.
> 
> Taking the time to RSI this patient on scene just eats up time that can be used getting him to definitive Neuro care and have them be ready to mange this guy's airway.
> 
> This is just one of those times when an ALS assessment results in BLS care getting the patient to definitive care in an expedient manner, but wouldn't change the outcome much.



This. 1000x this.


----------



## Carlos Danger (Nov 28, 2016)

zzyzx said:


> What's harder to do, ET intubation or properly using a BVM?
> Considering how ****ty nearly all medics are at using a BVM, I'd say BVM use is at least as hard as intubation.
> Sometimes paramedics brag about their intubation skills. Ever hear anyone brag about how great their are at using a BVM? Usually the task of BVM ventilations isn't done by the medic anyway. It's passed on to a single firefighter or EMT.
> Consider how much damage you can do to a head-injured patient by improperly bagging him--even if it's only for a few minutes before you get to "definitive care."



Just because some paramedics brag about being good at intubating doesn't mean they really are good at it. 

You can easily cause more damage with a botched RSI attempt than with less-invasive airway maneuvers, not to mention spending a lot more time on scene. Even with first-pass success, you can cause hypotension, a huge spike in ICP, and/or hypoxemia. This is probably the hardest type of patient to intubate without making them worse. Which is exactly why the literature does not support prehospital intubation in these patients. 

With such a short transport time, a SGA is really the way to go here.


----------



## VentMonkey (Nov 28, 2016)

On topic with @Remi's above post, at the conclusion of the advanced airway lecture I was reviewing this morning, the conclusion of the instructors lecture was basically:

"The whole purpose of airway management isn't to successfully intubate, it's to _properly oxygenate and ventilate."
_
I don't know if, or when as a whole paramedics will accept this cold, hard fact as I am sure there are plenty out there still of the "it's the gold standard" train of thought who still lack the support in patient outcomes to back their train of thought.

I would love to be a fly on the wall in a room with two veteran paramedics who have been around long enough to have been trained this way; one with this backwards and outdated thought process, and the other the progressive and most likely more proficient of the two.


----------



## Carlos Danger (Nov 28, 2016)

VentMonkey said:


> On topic with @Remi's above post, at the conclusion of the advanced airway lecture I was reviewing this morning, the conclusion of the instructors lecture was basically:
> 
> "The whole purpose of airway management isn't to successfully intubate, it's to _properly oxygenate and ventilate."
> _
> ...



Medicine on the whole is pretty bad about sacred cows and doing things just because it's how you were trained, or just because it seems to make sense. And EMS is far worse than the rest of medicine in this regard. And anything to do with airway management is even worse because for some reason, there's this irrational, almost emotional attachment to intubation.

In EMS we are quick to embrace the evidence when it supports something we want to do anyway, but we simply ignore the evidence when it tells us that something we really like doing might not be the best thing for our patients.


----------



## VentMonkey (Nov 28, 2016)

Remi said:


> Medicine on the whole is pretty bad about sacred cows and doing things just because it's how you were trained, or just because it seems to make sense. And EMS is far worse than the rest of medicine in this regard. And anything to do with airway management is even worse because for some reason, there's this irrational, almost emotional attachment to intubation.
> 
> In EMS we are quick to embrace the evidence when it supports something we want to do anyway, but we simply ignore the evidence when it tells us that something we really like doing might not be the best thing for our patients.


----------



## EpiEMS (Nov 28, 2016)

Remi said:


> Medicine on the whole is pretty bad about sacred cows and doing things just because it's how you were trained, or just because it seems to make sense. And EMS is far worse than the rest of medicine in this regard. And anything to do with airway management is even worse because for some reason, there's this irrational, almost emotional attachment to intubation.
> 
> In EMS we are quick to embrace the evidence when it supports something we want to do anyway, but we simply ignore the evidence when it tells us that something we really like doing might not be the best thing for our patients.



All, if you're looking for a new forum signature, this is it. Remi, well summarized, my good sir!


----------



## Akulahawk (Nov 28, 2016)

Remi said:


> With such a short transport time, a SGA is really the way to go here.


Considering that the patient is in trismus, it might not be easy to place a SGA without having to resort to RSI or DSI...


----------



## Carlos Danger (Nov 29, 2016)

Akulahawk said:


> Considering that the patient is in trismus, it might not be easy to place a SGA without having to resort to RSI or DSI...



I was thinking in more general terms than the specific scenario that Robb posted.

There will always be occasions where an airway can not be managed without NMB, which is why I'm not completely opposed to prehospital RSI. 

But whether everyone can do RSI or only a small % of medics, it should only be done when there is a reasonable expectation that it will make things better for the patient.


----------



## StCEMT (Nov 29, 2016)

I don't have RSI in my protocols, only the critical care medics do. So answering in the context of what I actually have available, a cric would be my only choice if I wanted/needed something more definitive than a BVM.


----------



## Akulahawk (Nov 29, 2016)

Remi said:


> There will always be occasions where an airway can not be managed without NMB, which is why I'm not completely opposed to prehospital RSI.
> 
> But whether everyone can do RSI or only a small % of medics, it should only be done when there is a reasonable expectation that it will make things better for the patient.


I'm not opposed to prehospital RSI either. You and I are very much on the same page in that it should only be done when there's a reasonable expectation that it will make things better for the patient. In that vein, so to speak, if a given crew is authorized to do RSI, they should be provided with a few options for accomplishing the task, not just one single tool (med or recipe).


----------

