# Intubating without Ventilatory Assistance



## redcrossemt (Jun 8, 2010)

A coworker of mine responded to a young female in status epilepticus. 

Seizures continued for 20+ minutes without the patient arousing at all prior to their arrival. Upon arrival the patient's GCS was 3 and some vomit was suctioned from the oropharynx. Vital signs were otherwise non-specific and WNL except for sinus tachycardia. The patient subsequently had three seizures each a few minutes apart and treated with 5 mg of diazepam per our protocol. The patient finally stopped seizing after 15 mg of diazepam IV. 

The patient was noted to continue to have some vomit in the airway and was suctioned several times enroute to the hospital. 

The paramedic ended up placing an endotracheal tube via direct laryngoscopy enroute to the hospital for airway protection. The tube was left open to air with oxygen provided by blow-by. The patient was breathing 10-12 times per minute with good chest rise and a SpO2 of 98% on oxygen.

There's some controversy regarding whether intubation was indicated. I've heard from both physicians and paramedics on both sides of the argument, but figured I'd get some input here as well.

Would you have placed an endotracheal tube even though ventilation was not necessary? Or was ventilation indicated and necessary?


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## Smash (Jun 8, 2010)

From that limited info, it doesn't seem unreasonable to me to intubate that patient: it sounds like she definitely needed airway protection regardless of her ventilation.  I'm not sure about the leaving the tube open, I would prefer to have it in a circuit so I can adjust ventilation and oxygenation parameters if necessary and particularly to have EtCO2 and capnography available.


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## redcrossemt (Jun 8, 2010)

Smash said:


> From that limited info, it doesn't seem unreasonable to me to intubate that patient: it sounds like she definitely needed airway protection regardless of her ventilation.  I'm not sure about the leaving the tube open, I would prefer to have it in a circuit so I can adjust ventilation and oxygenation parameters if necessary and particularly to have EtCO2 and capnography available.



For reference, the crew did not have a ventilator of any sort, nor waveform EtCO2 available to them.


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## Aidey (Jun 8, 2010)

EtCO2 is very quickly becoming a must have if you intubate. 

Frankly, I'm a little surprised she was breathing adequately on her own, but tolerated the intubation. 

I likely would not have intubated her, and rather used Zofran, positioning and suctioning. If I had intubated her, I would have RSId her, which also eliminates the physical concerns of another seizure. 

The pt can till be having seizure brain waves, but they physically can't have a seizure because of the RSI meds. We had one frequent patient that this was the only sure fire way to stop his seizures because they could go on for days.


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## JPINFV (Jun 8, 2010)

Aidey said:


> The pt can till be having *a* seizure, but they *won't have the physical manifestations because of the *RSI meds.


Fixed.


Sorry, but pet peeve. A seizure is simply abnormally synchronized brain waves. A patient with, for example, Torettes, Wilsons, on drugs with extrapyramidal side effects, or have plenty of other diseases can cause abnormal muscle contractions similar to a seizure, but they aren't having a seizure. Unless you can restore the brain to normal function, then you didn't stop the seizure, you just stopped one of the physical manifestations of it. It's like claiming to cure diabetes because you gave someone who was hypoglycemic dextrose.


As to the original question, doesn't the increase in conduction airway and decrease in cross sectional area that having an ET Tube in place means that ventilation assistance would be a best practice? After all, just because you're using a BVM doesn't mean you can't synchronize squeezes with the patient's respiratory effort.


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## Smash (Jun 8, 2010)

With no capnography I wouldn't be intubating this patient.  I also assumed that the patient was obtunded long enough that the crew was concerned that this patient was not just post-ictal. 

Also I agree with JP. Seizures should an absolute contraindication to long term paralysis unless you have an EEG to monitor the seizure activity. Just because the physical manifestation has gone due to muscle relaxants, doesn't mean you have terminated the seizure. Activity may be continuing unabated which means they are still using energy at around 250% of baseline, building up toxic metabolites and burning up O2 and glucose. Still cooking off neurons in other words, only we are blissfully unaware. 
Short term agents like succinylcholine may be appropriate to obtain a patent airway but certainly nothing much longer term.


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## redcrossemt (Jun 8, 2010)

Aidey said:


> EtCO2 is very quickly becoming a must have if you intubate.



Absolutely agreed. Unfortunately the initial cost is prohibitive to us currently, and administrators don't see it as a need because our medical control authority doesn't require it.



Aidey said:


> If I had intubated her, I would have RSId her, which also eliminates the physical concerns of another seizure.



True; point well taken. Unfortunately we don't have RSI. I suppose this was a sort of medication-assisted intubation with the valium, but she had been GCS of 3 the entire time with no response to vomit in the back of her throat.


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## redcrossemt (Jun 8, 2010)

Smash said:


> I also assumed that the patient was obtunded long enough that the crew was concerned that this patient was not just post-ictal.



Yeah, she was down for approximately 25-30 minutes without any improvement before our medic intubated. Per family, she was down for an unknown amount of time before they arrived (possibly hours).


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## FLEMTP (Jun 8, 2010)

Intubation was totally appropriate.. however I would have used a BVM and assisted her respirations. With that much valium on board, I would be concerned with the adequacy of her respirations, on top of the need to protect her airway.


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## Aidey (Jun 9, 2010)

JPINFV said:


> Fixed.
> 
> 
> Sorry, but pet peeve. A seizure is simply abnormally synchronized brain waves. A patient with, for example, Torettes, Wilsons, on drugs with extrapyramidal side effects, or have plenty of other diseases can cause abnormal muscle contractions similar to a seizure, but they aren't having a seizure. Unless you can restore the brain to normal function, then you didn't stop the seizure, you just stopped one of the physical manifestations of it. It's like claiming to cure diabetes because you gave someone who was hypoglycemic dextrose.



I worded it badly, but that is what I said,.


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## MSDeltaFlt (Jun 9, 2010)

redcrossemt said:


> A coworker of mine responded to a young female in status epilepticus.
> 
> Seizures continued for 20+ minutes without the patient arousing at all prior to their arrival. Upon arrival the patient's GCS was 3 and some vomit was suctioned from the oropharynx. Vital signs were otherwise non-specific and WNL except for sinus tachycardia. The patient subsequently had three seizures each a few minutes apart and treated with 5 mg of diazepam per our protocol. *The patient finally stopped seizing after 15 mg of diazepam IV*.
> 
> ...


 
This blows my mind that there are some so skittish as to over think a situation without being there. Assess your pt. Assess the situation. Never say never. Never say always. 

I've had pts just like this on my ground service that does not have EtCO2 or even vents.  15 mg of Valium is not that much for status epilepticus.

Let's focus on the Primary survey. A is compromised. B is adequate. C is also good. D is so compromised that it is effecting A. The ETT alone for airway control is completely appropriate. It's even money on whether to ventilate or not. Moot point. Not only would I have done the same thing, I *have* done the same thing.

That medic did a good job. Kudos to him/her.


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## Smash (Jun 9, 2010)

MSDeltaFlt said:


> This blows my mind that there are some so skittish as to over think a situation without being there. Assess your pt. Assess the situation. Never say never. Never say always.



Do you mean that it blows your mind that when asked for an opinion, people give an opinion?  Or that when information is limited people will inevitably speculate on could haves? Or that some services don't expect their medics to operate without appropriate equipment?


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## MSDeltaFlt (Jun 10, 2010)

Smash said:


> Do you mean that it blows your mind that when asked for an opinion, people give an opinion? Or that when information is limited people will *inevitably speculate on could haves*? Or that some services don't expect their medics to operate without appropriate equipment?


 
Which is why I posted "Assess your pt. Assess the situation".  On my air service, if I noticed the pt was breathing adequately and EtCO2 was good, I'd leave him intubated and place him on CPAP.  Why?  Because we have adequate equipment.  My ground service, a non-profit service in an impoverished area, can't afford adequate equipment (or doesn't choose to) so I would have done the exact same thing the medic did.  Because I have.

One of the many strenghts medics have isn't intubation.  Any moron can be taught that.  One of the many major strengths of a medic is being able to think outside the box, yet *understanding* his protocols, and all the while advocating for the pt.

The medic did a good job.


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## mycrofft (Jun 11, 2010)

*TAkes a WHOLE lot of Valium per kilogram to compromise respiration*

That's why it is used instead of librium or a barbiturate like phenobarb. Valium is not "mother's milk" but 15 mg..we'd use 20 (oral or IM)  within four hours on ETOH detoxers just to load em up to prevent grand mal.

If the pt went back into status without a guarded airway, or vomited again, then bad things will continue. I would wonder if a deeper suction is possible via trache tube because that long seizing plus vomit in oropharynx means there is likely vomitus to the vocal cords, maybe almost to the mediastinum if at any point the victim attempted a recovering gasp.


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## usalsfyre (Jun 11, 2010)

Don't disagree at all with the descion to pull the trigger on a tube. Airway control was completely indicated the way I read the description. Lack of ETCO2 put's the provider's in a crappy position, but you can only do as much as your funding allows. 

As for no BVM, I might have thrown a BVM on the tube with PEEP, but let the pt breath through it on their own. If respiratory effort is adaquate there is no reason to shove PPV down their throats.


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## usalsfyre (Jun 11, 2010)

double post


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## Melbourne MICA (Jul 3, 2010)

*Mmm*

A few unsettling things about this job. Perhaps not enough info?

*Intubation without capnography and SPO2 sensing? I would have thought that was mandatory - it is in our guidelines. You are asking for trouble if you can't confirm ET placement with capnography and thereafter modify your ventilations based on SPO2/ETCO2 readings.

(For Aidey) Capnography is not "becoming a must have for intubation" - it has already been that for many years. It is called "the gold standard" for ETT confirmation of placement. (Though yes you are right some EMS services have been slow to catch on and spend the bucks).

*Had the pt actually aspirated? (Auscultation findings?). If the pt presented as hypoxic post ictal and SPO2's were crap despite adequate pt ventilation's then you have to deal with the situation. For us this would have meant first BVM with 100% O2 then a sedate to intubate (not RSI - for us that would have meant adding Panc post induction with the sux - contraindicated for seizure pts especially this one - likely to have more)

(For Aidey - "RSI eliminates the physical concerns of another seizure" - So how will you know if the pt is still seizing if you have paralysed them? - You would never use paralytics (RSI) in a seizing pt pre-hospital - the drugs will mask underlying seizures not stop them - not a good idea really)

*Intubation without ventilation on 100% whether by manual BVM or via a ventilator? An ET tube open to air? Sounds like a way to increase dead space - stick a tube in, blow up the cuff and don't add 100% - the adult pt now has a child sized airway with only their own ventilation's. 

I don't follow why you would not go all the way with an ETT if that was your approach. An ETT must be connected to ventilation equipment of some kind whether manual or mechanical and 100% O2  especially given large amounts of sedation already on board. I can't say I have ever heard of a tube being used just as a makeshift vomit protector. If one goes in here it is to take over control of ventilation *and* secure the airway. 

I also take it the pt had no airway reflexes when intubated or did she? If she did how did the Paramedic manage her when intubating and post intubation? Either way she will need further sedation to hold down the tube.

Was there any other treatment required or provided after the intubation? Fluid loading etc? 

Some more info would help if I have speculated too much and mistaken your description of the event.

MM


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## Smash (Jul 3, 2010)

Melbourne MICA said:


> For us this would have meant first BVM with 100% O2 then a sedate to intubate (not RSI - for us that would have meant adding Panc post induction with the sux - contraindicated for seizure pts especially this one - likely to have more)



This is curious.  Do you only have long acting Non-depolarizing NMBA's for drug assisted intubation?  Or does your protocol call for mandatory long term paralysis following induction/paralysis with short term agents?

Personally I would have thought that sedation plus suxamethonium would be appropriate for induction and intubation, followed by ongoing sedation/seizure management with benzos.  Sedation alone to get a tube down would make life rather problematic in many cases (or downright lethal in some, like traumatic brain injury)


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## Melbourne MICA (Jul 3, 2010)

*Correction*



Smash said:


> This is curious.  Do you only have long acting Non-depolarizing NMBA's for drug assisted intubation?  Or does your protocol call for mandatory long term paralysis following induction/paralysis with short term agents?
> 
> Personally I would have thought that sedation plus suxamethonium would be appropriate for induction and intubation, followed by ongoing sedation/seizure management with benzos.  Sedation alone to get a tube down would make life rather problematic in many cases (or downright lethal in some, like traumatic brain injury)



Your'e quite right. It must be getting late. I stand corrected.

We do an induction on the status pt just withold the Panc because its long acting. But certainly Sux and sedation yes.

Having said that a status pt who actually becomes a respiratory pt following aspiration and hypoxia from lower airway obstruction (which is where I got myself sidetracked) is an interesting conundrum. 

In our guidelines we can't RSI  a respiratory pt - in this case the pt may be having frequent seizures but had aspirated sufficiently to now become a hypoxic pt in whcih case we are supposed to sedate to intubate only - paralyse them and can't get the tube and you have a dead hypoxic airway obstructed pt in no time.

I wonder if lots of the guys out there would RSI or STI such pts and why. This particular post talks about vomit and airway protection but not much info about actual aspiration leading to significant lower airway obstruction and hypoxia.

(Apologies Aidey as well - my mistake on the RSI for Status pts.)

PS We do RSI for traumatic and non-traumatic brain injured pts by the way as well as for hypoxic brain injured pts like hangings, near drownings, overdose pts, hyperthermic pts and of course status epilepticus pts.

MM


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## MrBrown (Jul 3, 2010)

Our guideline for RSI says to use midaz 0.1mg/kg for neurogenic cause of coma with GCS < 10.

Regardless of whether we use ketmaine or midaz we also use sux and are supposed to use vec as well after we have confirmed ETT placement.

Given that this patient has already recieved a large amount of benzos and is uncoscious I am not sure more benzos are the answer.  

Where is my trusty cancer-casuing cellphone, its time to ring up an Ambuance Service Medical Advisor.


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## usafmedic45 (Jul 4, 2010)

> The tube was left open to air with oxygen provided by blow-by. The patient was breathing 10-12 times per minute with good chest rise and a SpO2 of 98% on oxygen.



If he were my medic, he would be suspended without pay pending disciplinary action against his license.  The resistance of breathing through the tube alone makes what you described a very bad idea and I would eat him alive for it, both as a supervisor and as someone who is an admitted expert witness for court cases.  The reasoning for the intubation is completely sound, but the execution of the procedure was exceedingly stupid. 



> For reference, the crew did not have a ventilator of any sort, nor waveform EtCO2 available to them.



If you don't have waveform ETCO2, perhaps you should be restricting your practice to non-visualized airways. 



> Unfortunately the initial cost is prohibitive to us currently, and administrators don't see it as a need because our medical control authority doesn't require it.



Then you probably should be relying on LMAs and Combitubes.



> Sounds like a way to increase dead space - stick a tube in, blow up the cuff and don't add 100% - the adult pt now has a child sized airway with only their own ventilation's.



Dead space isn't going to be much of a concern since the tube is actually smaller than the diameter of the airway itself.  The bigger problem is the increased resistance and I believe this is what you are trying to get across.


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## Fox800 (Jul 4, 2010)

I agree with what's already been posted. It's an exceedingly stupid idea to intubate a patient and leave the tube open to the air/place a nonrebreather on it. The intubated patient needs to receive ventilation from a BVM/ventilator, no questions asked. Also, intubating without ETCO2 waveform equipment available is very dicey, we would be decredentialed/suspended for doing any of this. We are required to verify ETCO2 waveform for any advanced airway placement, be it ETT or rescue airway (King LT), and I ALWAYS have it on the BVM even when I'm using that by itself.


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## somePerson (Jul 13, 2010)

*woah*

I was reading trough this and I realised it took two pages of posts for someone to point out why not ventilatig the pt. with a BVM is a horrible idea. Common sense, breathing trough an ET tube without assistance is like trying to breath trough a slightly over-sized drinking straw.


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## JPINFV (Jul 13, 2010)

somePerson said:


> I was reading trough this and I realised it took two pages of posts for someone to point out why not ventilatig the pt. with a BVM is a horrible idea. Common sense, breathing trough an ET tube without assistance is like trying to breath trough a slightly over-sized drinking straw.




Try post number 5 in the thread...



> As to the original question, doesn't the increase in conduction airway and decrease in cross sectional area that having an ET Tube in place means that ventilation assistance would be a best practice? After all, just because you're using a BVM doesn't mean you can't synchronize squeezes with the patient's respiratory effort.


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