# Bariatrics Pt.! What would you do?



## Mrmackay82 (Jul 8, 2011)

Scenario, 53 female, dispatched for SOB, on arrival Pt 600-700 lbs., CHF with rales bilateral SaO2 45% on personal bipap at 1lpm.  P-120 sinus tach R-32 BP- 190/100. Hx. CHF, htn, diabetic. BGL-110. Small room with narrow hallways, rural county with one additional unit(emt & paramedic), volunteer first responders, any additional resources more than one hour response.

This is the initial scene. Backup unit 10 minutes out volunteers(aka lift assist 15+ minutes out).  

I'm curious what your initial treatment, plan of action would be.  I will advise what my plan and outcome would be after the Monday morning quarterbacking has begun. 

Ps. Pt could have weighed up to 900 lbs for all I know. I'm being conservative as once you get to that level it's hard to determine!


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## ah2388 (Jul 8, 2011)

Nitrates/CPAP for Tx, if pt unable to be extricated via stretcher/ambulation, you'd have to consider extrication through a window if necessary.  Most homes in my experience have large windows in the bathroom/living area.

Get on the radio, request all the help you think you'll need.

If you find yourself unable to perform the above, youre going to need to consider extrication through the structure itself, which opens up a whole can of worms id rather not even begin to get into.

-adam


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## Shishkabob (Jul 8, 2011)

Cpap/Nitro/Enalapril

If that doesn't relieve symptoms in 5ish minutes, it's time to RSI.  Once RSI'd, you have all the time in the world to figure out how to move them.


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## Cawolf86 (Jul 8, 2011)

This is my initial plan-
-Sit her high-fowler's
-NTG 0.8mg w/ repeat dosing based on BP and response to Tx
-CPAP titrated to relief
-Contact dispatch for FD with tools for poss extrication through wall or down the hall
-IV TKO

I would basically attempt to stablize the suspected CHF exacerbation and wait for help. There is no way that we can move this patient without the proper equipment and I don't want to get me or my EMT hurt.


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## ah2388 (Jul 8, 2011)

Linuss said:


> Cpap/Nitro/Enalapril
> 
> If that doesn't relieve symptoms in 5ish minutes, it's time to RSI.  Once RSI'd, you have all the time in the world to figure out how to move them.



I'm not saying that RSI doesn't have a place in this pt's future, but what about this pt's condition leads you down that path at THIS point?

I'm not being hostile by any means when I say this, but this sounds like a poor treatment plan in THIS situation with THIS pt.

Sounds like an absolute disaster waiting to happen in a situation where it may not be indicated.


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## ah2388 (Jul 8, 2011)

I suppose I may answer my own question with this question butttttt..

what is the pt's mental status, the pt's current dyspnea, how far off is it from baseline(sort of irrelevant) 

-Adam


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## Shishkabob (Jul 8, 2011)

ah2388 said:


> I'm not saying that RSI doesn't have a place in this pt's future, but what about this pt's condition leads you down that path at THIS point?
> 
> I'm not being hostile by any means when I say this, but this sounds like a poor treatment plan in THIS situation with THIS pt.
> 
> Sounds like an absolute disaster waiting to happen in a situation where it may not be indicated.



How is RSI not indicated in this situation after  CPAP/Nitro/Enalapril have failed?  What else is left aside from taking definitive control of the airway?



Aside from NTI*


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## ah2388 (Jul 8, 2011)

i find it hard to justify tubing a pt who is C, A&Ox4 c/o of resp. distress, who may oftentimes be short of breath due to generalized poor health.

I think it's poor practice to be buying vent days for these pt's, diminishing there already diminished quality of life, perhaps by leaps and bounds.  

This is all obviously going to be based on assessment skills and what not, just not sure RSI is indicated here with the information we have.

If the pt is showing mental status changes and is losing the ability to protect there own airway, then I think obviously we have to take over it ourselves, but keep in mind that this is potentially a disasterous airway situation, and failure to plan for failure could make that worse.

As they say, I ain't skurred to do what needs doin, but dont you have a couple more questions before immediately jumping down that road.


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## Aidey (Jul 8, 2011)

Mrmackay82 said:


> Scenario, 53 female, dispatched for SOB, on arrival Pt 600-700 lbs., CHF with rales bilateral _*SaO2 45%*_ on personal bipap at 1lpm.  P-120 sinus tach R-32 BP- 190/100. Hx. CHF, htn, diabetic. BGL-110. Small room with narrow hallways, rural county with one additional unit(emt & paramedic), volunteer first responders, any additional resources more than one hour response.



Are you sure that isn't a typo? Neither the LP 12 or 15 will read below 50%.


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## Handsome Robb (Jul 8, 2011)

Call for the additional unit and vollies and tell them to bring the truck since this is more than likely going to be an extrication as ah2388 said. I'd advise dispatch of the situation and the size of your patient, sometimes you can get 2 extra hands sometimes you get 10 from a volunteer squad, so worst case scenario you may need that mutual aid. Its part of the scene size up as well.

Like mostly everyone else said, CPAP, NTG, I might consider furosemide if the NTG doesn't reduce the rales and for the reason that it has a slower onset but a longer duration for what seems to be a long transport time.

If you can't get the edema under control and the SpO2 up she's going to need airway control, so get your kit ready.


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## Shishkabob (Jul 8, 2011)

I'm not saying ETI is the first step to go to, and didn't even claim as much, but if you've done everything else you could have done (Again, CPAP/Nitro/Enalapril) you need to do something for oxygenation of the patient.  A 58% sat, if correct, is not a sat that is to be tolerated for any length of time.  (Granted we don't know the EtCO2 on this patient either, which is going to be another determining factor in how quickly you move on to the next step.)  But just because the numbers look good, or the patient is awake and "alert", is not reason to not do RSI.  Infact, if you just looked at the numbers for my last RSI, you'd think I was crazy for doing it, but it had to be done.




I'm not one to take RSI lightly.  Scares the bejeezus out of me.  I shook more than Japan in an earthquake on my first RSI.  However, as you stated, I will do what needs to be done.





Keep in mind I'm also part of a rural service with an extended transport... so we tend to be a lot more aggressive with airway control than someone who has a 5 minute transport.


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## ah2388 (Jul 8, 2011)

What is to say that the Sa02 feature is not functioning properly etc.

The point I am attempting to make is that we need to combine assessment and diagnostic tools to make decisions.

Is this pt's RR due to anxiety?

Then, is the anxiety secondary to hypoxia?  Is it due to being self conscious of the exact challenge we are faced with as far as extrication?  Is it due to other factors?  All signs are pointing to this being a CHF exacerbation, probably related to the sympathetic nervous system freaking out because of some fluid backup in the lungs.  These pt's generally respond well to NTG and CPAP.  I agree that this pt is boogered if interventions are unsuccesful due to prolonged extrication time/pt's generalized health.  


I would argue with you at length that if clinical assessment does not indicate RSI, and utilization of assessment tools does not indicate RSI, then RSI is not indicated.

I also work for a busy rural 911 service, we have transport times ranging from 10 minutes-1 hour.  With that being said, RSI is rarely performed, especially with CPAP/Tridil and SL NTG being used.  Non Invasive PPV is a hell of a tool.


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## Aidey (Jul 8, 2011)

ah2388 said:


> I would argue with you at length that if clinical assessment does not indicate RSI, and utilization of assessment tools does not indicate RSI, then RSI is not indicated.



Yet. You are forgetting the word yet. Planning ahead is not a bad thing. Steps 1-6 might work, and RSI won't be needed, but if you get to step 5 and nothing is working it is a lot better to have step 7 planned in advance rather than doing it on the fly.

There are plenty of patients whose vital signs don't indicate the need for RSI right then, but that does not mean they aren't going to decompensate.


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## ah2388 (Jul 8, 2011)

Aidey said:


> Yet. You are forgetting the word yet. Planning ahead is not a bad thing. Steps 1-6 might work, and RSI won't be needed, but if you get to step 5 and nothing is working it is a lot better to have step 7 planned in advance rather than doing it on the fly.
> 
> There are plenty of patients whose vital signs don't indicate the need for RSI right then, but that does not mean they aren't going to decompensate.



Of course, however in this scenario, it was stated that "If that doesnt work after 5 or so minutes then its time for RSI" or something to that effect.

It is reasonable to state that if this pt does not get better, they will get worse, but when it becomes evident that airway control is mandated, would you prefer a team of airway guru's paged from the bowels of the hospital (OR/Anesthesia), or a paramedic who may intubate real tissue 4 times a year?

Think about it from the patients perspective.


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## Aidey (Jul 8, 2011)

Considering that in Linuss' area the bowels of that hospital are an hour away, and the patient is 700+lbs, I think the paramedic is as good as it is going to get.


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## Shishkabob (Jul 8, 2011)

ah2388 said:


> would you prefer a team of airway guru's paged from the bowels of the hospital (OR/Anesthesia), or a paramedic who may intubate real tissue 4 times a year?


  Of course I'd prefer being in a place with alot more help, and when I was actually in a station that gave me the ability to be at the hospital in 10 minutes, I deferred 2 RSIs until we got the the ER.  Had respiratory waiting for us, and both were RSId pretty darn quick.




> Think about it from the patients perspective.



You mean "Oh God I can't breathe, I wish they would do something besides stare at me for 45 minutes?"


Like I said, I am in a place where my average transport is 45+ minutes to anything that can be considered a hospital.  My patients don't have the luxury of waiting at times, which is why I have the tools, medications and (aggressive) guidelines that I have.


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## Handsome Robb (Jul 8, 2011)

The thing about this is. You don't have a bunch of airway gurus to page from the bowels of this pt's house. Unless you want to activate an aircrew to fly to you then ride back in your bus cause they can't fit the patient in the chopper. But thats being unrealistic. I don't know what system your in but here for my internship, we are required to get 6 field tubes in 4 months to pass...and last year my school had 100% pass rate. You do the math. 

If the patient is dying, I don't think they are going to nitpick about who tubes them to save their life.


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## ah2388 (Jul 8, 2011)

NVRob said:


> The thing about this is. You don't have a bunch of airway gurus to page from the bowels of this pt's house. Unless you want to activate an aircrew to fly to you then ride back in your bus cause they can't fit the patient in the chopper. But thats being unrealistic. I don't know what system your in but here for my internship, we are required to get 6 field tubes in 4 months to pass...and last year my school had 100% pass rate. You do the math.
> 
> *If the patient is dying, I don't think they are going to nitpick about who tubes them to save their life.*




This is obvious, and I have never advocated for deferring this procedure if it's indicated.

Linuss, you're adding things to this scenario that were not initially presented.  I will presume that is in an effort to justify your decision making, it appears you are unwilling to consider that we simply don't have enough information to determine whether or not RSI is necessary for this pt at this time.

Additionally, our services sound a lot alike, I am not at all impressed by your "rural" transport time's, nor your "aggressive" guidelines, we are both fortunate enough to work for services that have both.

The bizarre thing about this discussion, is that I am mostly advocating that we need more information about this pt in order to make our decision in the best interest of the pt.

NVRob, again, it is clear that we do not have anesthesia on scene with us, and it is somewhat unreasonable to request a flight crew for a pt who isnt going to be flown(although not unheard of.)  I am advocating with the limited information provided, that we consider non invasive positive pressure ventilation, whether with CPAP or BVM, as a bridge to RSI by a team of trained clinicians in an "ideal" environment.  If the presentation of this pt does not allow for us to lollygag, and instead forces us to take definitive control of the airway, then of course that is what we will do.


With the information provided, as I'm not sure I'm buying into the saO2 finding(would use etco2) beyond the pt's respiratory rate, what other findings in the scenario as presented lead you to believe that this pt requires RSI after "5 minutes without dramatic improvement"  What about 5 minutes without decompensation?  Then what?

Anyway, I suppose I'm ranting without any real purpose, truly, we are saying the same thing.  Just trying to get everyone to open there minds and justify the reasoning for this procedure as it is certainly not without consequence.


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## Shishkabob (Jul 8, 2011)

ah2388 said:


> Linuss, you're adding things to this scenario that were not initially presented.  I will presume that is in an effort to justify your decision making, it appears you are unwilling to consider that we simply don't have enough information to determine whether or not RSI is necessary for this pt at this time.



If you REALLY want to go down the road of "not enough information for treatment", then you will have to redact your statement of




ah2388 said:


> Nitrates/CPAP
> -adam


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## ah2388 (Jul 8, 2011)

i suppose youre right, I was assuming the pt is sick, which ironically enough is exactly what I am advocating that we don't do now.

Congrats, you owned me.

Now prove me wrong, I issue that only as a challenge, if you can legitimize your argument as I believe I have mine, then I think it would be an opportunity to learn, certainly I would take it as such.


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## ah2388 (Jul 8, 2011)

I would however state additionally that CPAP certainly has far fewer lethal side effects than RSI, and I think the same could be said for NTG.

With that being said, with clinicians who have planned for failure, this shouldnt be an issue.


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## nemedic (Jul 8, 2011)

one thing about this scenario outside of the airway discussion: I noticed you said the hallways were narrow. what about doorways? i have seen some bari pts with specially widened doorways that have been put on 2 lsb lashed together and then placed on tarps and pulled down the hallway, then carried out. if there are narrow doorways, then i think it is time to break out the power saws and sledge hammers and ask which is the least favorite wall.


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## jwk (Jul 9, 2011)

OK - let's say you've decided this patient needs an ETT.  How are you going to do it?

These patients are nightmares in a controlled situation in the OR.  I wouldn't even consider an RSI on this patient this size in the OR - they'd get an awake fiberoptic intubation with minimal if any sedation.  Obviously you don't have that luxury in the field.

So - what's your plan?  Position?  Drugs?  Plan B and C?


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## TxMedic512 (Jul 12, 2011)

jwk said:


> These patients are nightmares in a controlled situation in the OR.  I wouldn't even consider an RSI on this patient this size in the OR -QUOTE]
> 
> this....


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## usafmedic45 (Jul 12, 2011)

> OK - let's say you've decided this patient needs an ETT. How are you going to do it?



Surgical airway or a non-visualized airway (Combitube)


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## Shishkabob (Jul 12, 2011)

jwk said:


> OK - let's say you've decided this patient needs an ETT.  How are you going to do it?
> 
> These patients are nightmares in a controlled situation in the OR.  I wouldn't even consider an RSI on this patient this size in the OR - they'd get an awake fiberoptic intubation with minimal if any sedation.  Obviously you don't have that luxury in the field.



I have many options in to how I get a tube in to the trachea in the field.  It doesn't have to be full blown RSI with Fent, Etomidate and Roc.  Heck, I could nebulize some lido and do an NTI.  I could do an LMA or a King.  I have bougies.  I can needle or surgically cric them if need be.  


Or I could call in flight, who DOES have video-laryngeoscopy, and use their assistance, even though they can't fly the patient.



That airway is coming under my control if I need it to.


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## usafmedic45 (Jul 12, 2011)

> Or I could call in flight, who DOES have video-laryngeoscopy, and use their assistance, even though they can't fly the patient.



http://en.wikipedia.org/wiki/Sikorsky_S-64_Skycrane


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## boingo (Jul 12, 2011)

usafmedic45 said:


> Surgical airway or a non-visualized airway (Combitube)



Really?  700 lb woman, do you realize how much tissue you are going to need to get through to cric her?  Nightmare senario.   Supra-glottic airway is also a bad idea, the amount of pressure needed to properly ventilate a morbidly obese patient is going to exceed the cuff pressure and quickly fill her belly, puke to ensue....I'd stick with PPV, then RSI, and only then your 2 choices, because at that point you are out of options.  Not an airway to take lightly, but if it NEEDS securing, then thats what gets done.  Just my opinion.


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## usafmedic45 (Jul 12, 2011)

> 700 lb woman, do you realize how much tissue you are going to need to get through to cric her? Nightmare senario.



Been there...done it.  It's not as bad as you might think although far from ideal.  The idea of being knuckle deep in someone's neck is not something to be taken lightly but then again neither is the prospect of a dead patient.




> Supra-glottic airway is also a bad idea, the amount of pressure needed to properly ventilate a morbidly obese patient is going to exceed the cuff pressure and quickly fill her belly, puke to ensue.



Just a quick question:  How many 600+ lb people have you dropped airways into just out of curiosity?

As opposed to the same thing definitely happening with PPV without a device?  I have used a Combitube on several exceedingly large patients and never encountered the problem you are discussing.  Also, if you're using a Combitube and somehow do manage to rupture the oropharyngeal cuff, the air is going to take the path of least resistance and come out the mouth due to there not being a mask being held over it.  The same risk you are discussing would theoretically (as is what you're suggesting) exist just the same with a cuffed ETT.  Now I would be very hesitant to rely upon an LMA as anything but a way to pass a bougie and then place an ETT, but I have used them as a last resort in a couple of cases in the past.  

A helpful hint in these cases when it comes to ventilatory pressures is NOT to lay the patient flat.  The more upright you can keep them, the easier they are to ventilate and to place airways into.



> then RSI



That is about the last thing I would do.  Maybe some light sedation and a nasal intubation but the last thing I would do is give a morbidly obese patient with an uncontrolled airway a paralytic.


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## boingo (Jul 12, 2011)

I honestly couldn't tell you, I'd guess a few dozen in excess of 500 lbs, maybe more, and have been lucky in having always secured it with an ET tube.  We have a rehab hospital in my city with an entire floor dedicated to bariatric patients, never look forward to going there. 

As for supra glottic airways and high airway pressures, my experience is limited to the LMA, having never placed on in the field in this kind of patient I speak from what anesthesia has told me, so take it for what its worth.  I have seen problems with high airway pressures and asthma in real life, and can speak, anectdotaly at least that an LMA sucks in a tight asthmatic.  

As for the cric, of course it can be done, but been involved in one way or another with several that have gone bad, it would be a last ditch attempt, at least from where i sit.


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## usafmedic45 (Jul 12, 2011)

> anectdotaly at least that an LMA sucks in a tight asthmatic



I'll agree with you there.  That's one reason why if you're going to use an LMA in someone with a restrictive process you really need to have a ventilator standing by that is able to accurately and effectively deliver an adjustable inspiratory time and pressure.


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## usafmedic45 (Jul 12, 2011)

> As for the cric, of course it can be done, but been involved in one way or another with several that have gone bad, it would be a last ditch attempt, at least from where i sit.



Honestly, a cric is a technically more simple procedure than standard intubation.  The hardest part about a cric is the decision to pick up the knife and most of the mistakes I have seen or heard about with it are due to lack of practice or excessive stress secondary to a misguided fear of the procedure.


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## Shishkabob (Jul 12, 2011)

boingo said:


> Really?  700 lb woman, do you realize how much tissue you are going to need to get through to cric her?  Nightmare senario.   Supra-glottic airway is also a bad idea, the amount of pressure needed to properly ventilate a morbidly obese patient is going to exceed the cuff pressure and quickly fill her belly, puke to ensue....I'd stick with PPV, then RSI, and only then your 2 choices, because at that point you are out of options.  Not an airway to take lightly, but if it NEEDS securing, then thats what gets done.  Just my opinion.



And I'll ask you...


Do you realize how bad of an idea it is to sit around doing nothing when your patient goes in to respiratory, and than cardiac, arrest, because "It's less than idea" to do a cric or supraglottic airway?


Gotta do what you gotta do when it's gotta get done to get things done.


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## boingo (Jul 12, 2011)

Linuss said:


> And I'll ask you...
> 
> 
> Do you realize how bad of an idea it is to sit around doing nothing when your patient goes in to respiratory, and than cardiac, arrest, because "It's less than idea" to do a cric or supraglottic airway?
> ...



I have a pretty good idea, I also realize that no improvement in 5 minutes doesn't equal RSI either.  No one is suggesting "doing nothing", perhaps a bit of patience, PPV, TLC and pharmacology is what is needed, padawan....


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## boingo (Jul 12, 2011)

usafmedic45 said:


> Honestly, a cric is a technically more simple procedure than standard intubation.  The hardest part about a cric is the decision to pick up the knife and most of the mistakes I have seen or heard about with it are due to lack of practice or excessive stress secondary to a misguided fear of the procedure.



absolutely agree, however in the morbidly obese patient, picking up the knife should probably be the last resort, unless you are very comfortable in opening up a neck.  Been there, done that, wouldn't want to do it again.


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## amessernremtp (Jul 12, 2011)

Hey guys...can pt walk and has anyone done 12 lead? Remember....ABC...ambulate before carry..

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## amessernremtp (Jul 12, 2011)

Also, sounds like the o2 sat may be off if she is caox's 4. Ntg, bipap at higher settings and maybe some lorazepam for the anxiety could help...not being able to breathe is pretty scary. RSI is a lingering thought but doesnt sound like this one is there yet to me..

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## Shishkabob (Jul 12, 2011)

EDIT:  Forget it.


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## amessernremtp (Jul 12, 2011)

Not saying airway shouldnt be a concern, as ppv is a very good treatment for fluid. But, as far as I have read, noone stated that treatments weren't working or pt was digressing. I have performed numerous RSI procedures, all of which were warranted. Not saying you are wrong, but for me, with the info I am seeing, I would hold off.

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## usafmedic45 (Jul 12, 2011)

> absolutely agree, however in the morbidly obese patient, picking up the knife should probably be the last resort, unless you are very comfortable in opening up a neck. Been there, done that, wouldn't want to do it again.



I'd rather do one in a fat person than someone who is very muscular.  Less bleeding.


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## amessernremtp (Jul 12, 2011)

True.. .but rather not let it get to that point

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## amessernremtp (Jul 12, 2011)

I cant disagree with him that RSI is an option...my avg t-port time is over an hour, sometimes more. And we used to rsi chf alot....before we had cpap....as for the cric, could do but last resort...consider retrograde before that...

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## usalsfyre (Jul 13, 2011)

Short of SEVERE laryengospasm, there's no way I'm letting this lady even catch a whiff of a paralytic agent. 

If she can be coached through it we'd do it awake. Preparation and positioning are key here. 

If that doesn't work, we're probably going to end up cutting. I'd perfer a cric to a retrograde intubation though. If your putting a hole in the neck, why not just put a tube in it?


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## usafmedic45 (Jul 13, 2011)

> I'd perfer a cric to a retrograde intubation though. If your putting a hole in the neck, why not just put a tube in it?



The main argument against a retrograde in this setting isn't the argument over putting a tube in subglottic versus transglottic but rather that we often won't have a long enough needle to perform a retrograde in a morbidly obese patient.  This means you'd have to use a modified technique and at that point, you're right- just put in a cricothyrotomy.  

The main reason retrograde intubations have their place is that a crike isn't a long term solution so the person either winds up trached formally or has an ETT passed down orally.  Think of it as saving a step. LOL


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## ah2388 (Jul 13, 2011)

usafmedic45 said:


> The main argument against a retrograde in this setting isn't the argument over putting a tube in subglottic versus transglottic but rather that we often won't have a long enough needle to perform a retrograde in a morbidly obese patient.  This means you'd have to use a modified technique and at that point, you're right- just put in a cricothyrotomy.
> 
> The main reason retrograde intubations have their place is that a crike isn't a long term solution so the person either winds up trached formally or has an ETT passed down orally.  Think of it as saving a step. LOL



Interesting thoughts, different angle with another host of issues...have we made it to the hospital yet?


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## Melclin (Jul 13, 2011)

*Aside from giving a funeral director the heads up?*

Other than the obvious (nitro, cpap etc), I'd be on the radio to the managers. 

This character is crook and not going anywhere untill the bariatric ambulance arrives which could be shortly after next christmas. Obviously requires intensive care paramedics and the adult retrieval team might wanna come and fiddle about.

It would certainly be an interesting task to move a half ton intubated and ventilated pt. 

I cant say I fancy the idea of intubation in this fella either, but I'm with Linus, if you've tried everything else in the book, and you have a crashing pt, who isn't going anywhere anytime soon, what else can you do?


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## usafmedic45 (Jul 13, 2011)

> Interesting thoughts, different angle with another host of issues...have we made it to the hospital yet?



No, just making a point though for educational purposes.


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## amessernremtp (Jul 13, 2011)

Has anyone asked if the pt could walk?

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## ah2388 (Jul 14, 2011)

usafmedic45 said:


> No, just making a point though for educational purposes.



as i took it!


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