# ROSC intubation scenario



## TF Medic (Dec 13, 2015)

This is a call I am familiar with and it has brought up some discussion. Curious to hear other opinions. 

Called for full arrest for 84 YOF. 
Hx:
DM2, A-fib, lung cancer, chronic pain. Last seen normal last night.
Meds:
Coumadin, levothyroxine, fentanyl patch, unknown others (family doesn't have a list)

Family couldn't wake her around 10am. Pressed life alert button. Life alert asks if PT is breathing, family says no, life alert instructs to start compressions. 

You arrive to find PT laying in recliner with family doing ineffective compressions. Skin is pale but not ashen, warm centrally, cool in extremities. No carotid felt on initial attempt. Pt moved to floor, compressions continued. After about five compressions spontaneous breathing noted, compressions stopped, carotid pulse is weak and irregular. 

Partner now has monitor patches on showing a-fib. PT is breathing spontaneously around 6/min. Ventilations assisted by BVM while fire helps package, secure, and move pt to ambulance. 

Vitals:
PT unresponsive to pain
139/51
BGL 133
HR 100-130 A-Fib
SPO02 up to 96% with BVM. Good compliance with NPA placed. 

Transport initiated, IV established, 12 lead unremarkable, ETCO2 is easily managed around 40 with BVM. PT remains stable but unresponsive in transport. Spontaneous respirations improve to around 16 with BVM assistance, fall back to around 8 if BVM is withheld. Carotid pulse is now strong and irregular. Crew unable to find fentanyl patch. 2mg Narcan pushed, no changes. 

Fire is driving. You have two medics in the back. Airway remains patent with good compliance on BVM ventilations. Intubation would require RSI protocol. 

Unknown if PT ever fully arrested, general agreement is probably not. Transport to Level 1 is approx 15 min. Do you intubate enroute? Why or why not?


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## chaz90 (Dec 13, 2015)

So this is really more of an RSI scenario than ROSC, but fair enough. 

If this were my patient, I would not intubate her. We're already moving to the hospital, so by the time we've established these kinds of baselines, we're probably a few minutes into the 15 minute transport time. She's maintaining adequate oxygenation and ventilation status as measured by SpO2 and EtCO2, her heart rate doesn't seem to indicate dire distress, and her respiratory rate unassisted isn't even too bad. 

Do her SpO2 readings change much if she's left on O2 and allowed to breathe spontaneously 8 times/minute without using a BVM? This whole call seems to be on an upward trend, and I'm reluctant to commit to intubation and ventilator usage when I'm not so certain she'll need it in another 10 minutes. If things don't improve or maintain well enough without a BVM, we can always go back to using a BVM as we have already shown it is perfectly feasible on this patient. With all vitals improving, is there any change to her mental status or purposeful movement? Gag reflex present?

This seems likely to be some kind of positional or opioid induced apnea that led to a decline in HR and BP. With improving oxygenation, she seems to be improving as well. Or of course, it could be any of a hundred other things and she may be intubated shortly after arrival at the ED. Either way, I'm confident I would not need to do this RSI pre-hospitally in the back of a moving ambulance with only two people.


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## TF Medic (Dec 13, 2015)

chaz90 said:


> So this is really more of an RSI scenario than ROSC, but fair enough.



Yeah. I posed it as ROSC since arrest protocols include advanced airways, and even though cardiac arrest is questionable, compressions were performed which makes this post-arrest in our protocols.

GCS remains 3, no purposeful movement. SPO2 falls when BVM stopped.


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## NomadicMedic (Dec 13, 2015)

I'm at a service with no RSI now, so I'd be limited on intubation; it's only available if there was no gag or if I wanted to use a big dose of brutane. However, this is a patient that most likely needs a tube. 

The bigger question is, do you REALLY feel that this patient won't need vent support in another 10 minutes? I'd guess that this patient would have been tubed shortly after arrival at the ED.

If you had the experience and protocol to intubate this patient, I would have done it prior to leaving. 

BTW, my guess is CVA.


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## chaz90 (Dec 13, 2015)

Yeah, I still don't know if I'd be completely sold on prehospital RSI here. This patient may not improve any more with EMS, but she has already gone from apneic with pulses too weak to palpate (or just not felt as the crew was conditioned to expect an arrest) to breathing spontaneously (albeit slowly) and with a stable HR and BP. With this transport time and the fact that we're already moving in the back of the ambulance, I don't think it would be unreasonable to continue with the BVM and advise the ED of a possible need for intubation shortly after arrival. I agree though that if the patient remains in this state at ED arrival she is getting intubated post haste.


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## teedubbyaw (Dec 13, 2015)

Low GCS, unable to effectively breath on her own, unknown etiology of AMS/unconscious. Is she protecting her own airway? Nope. Is her LOC improving? Nope.

I'm toobin her. +1 on probable CVA.


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## NomadicMedic (Dec 13, 2015)

Sure. You know I'm a fan of "just because you can, doesn't mean you should". Certainly nothing wrong with bagging this patient all the way to the ED, but I believe this patient DOES need ventilatory support and will continue to require it for the foreseeable future. Use a BVM and NPA for the short ride in (and be behind the 8 ball when she starts to vomit after all that BVM ventilation) or take another few minutes on scene and secure an airway for the transport and continued clinical course.

In all honesty, I dont think either path would be a QI red flag, as both positions are justifiable based on the experience and comfort level of the provider.


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## TF Medic (Dec 13, 2015)

Thanks for the discussion guys, it mirrors the conversations we've had here about it. Anybody else with different input?

I'll post an update to this thread later this evening or tomorrow.


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## Carlos Danger (Dec 13, 2015)

chaz90 said:


> If this were my patient, I would not intubate her. We're already moving to the hospital, so by the time we've established these kinds of baselines, we're probably a few minutes into the 15 minute transport time. She's maintaining adequate oxygenation and ventilation status as measured by SpO2 and EtCO2, her heart rate doesn't seem to indicate dire distress, and her respiratory rate unassisted isn't even too bad.
> 
> Do her SpO2 readings change much if she's left on O2 and allowed to breathe spontaneously 8 times/minute without using a BVM? *This whole call seems to be on an upward trend, and I'm reluctant to commit to intubation and ventilator usage when I'm not so certain she'll need it in another 10 minutes.* If things don't improve or maintain well enough without a BVM, we can always go back to using a BVM as we have already shown it is perfectly feasible on this patient



This.

The patient is managing just fine without intubation, and in fact seems to be improving.

Intubation & mechanical ventilation is not a benign procedure. It should only be done when really necessary.


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## MS Medic (Dec 13, 2015)

I agree that if there's no gag reflex, drop pvc. Unresponsive with inadaquete respiration.  I've been on this type of call where I didn't tube the pt before Tx and things went sideways during transport. You can bank on the pt being intubated as soon as you get to the ED. There is no reason not to prehospital. Failing to do so actually neglects proper airway management in my opinion. 

My qualifier here is that the pt doesn't have a gag reflex. I'm not saying to RSI.


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## NomadicMedic (Dec 13, 2015)

Remi said:


> This.
> 
> The patient is managing just fine without intubation, and in fact seems to be improving.
> 
> Intubation & mechanical ventilation is not a benign procedure. It should only be done when really necessary.



I disagree. I believe in this case it is necessary. This patient had a respiratory rate of 8 when not being bagged, a GCS of 3 and was found peri arrest. I wouldn't want to ride for 15 minutes with a patient that didn't have a airway that I could guarantee would stay patent from the whole ride. If she woke up and started breathing to beat the band in the ED, then they can extubate her.

As an aside, I'm not a "GCS less than 8, intubate" kind of guy. There are plenty of folks that I put off tubing in the truck because I thought it would be okay or thought it wasn't necessary. (Or because I wasn't sure I'd be able to place the tube once I RSIed them). This isn't one of those. This woman should have a tube.


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## teedubbyaw (Dec 13, 2015)

Remi said:


> This.
> 
> The patient is managing just fine without intubation, and in fact seems to be improving.
> 
> Intubation & mechanical ventilation is not a benign procedure. It should only be done when really necessary.



Sorry, but if CVA is on your differential for this pt, and I'm sure it is, then they need a tube.


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## Carlos Danger (Dec 13, 2015)

She has a poor respiratory drive, but it seems to be improving. They are managing her airway fine with a BVM.

Folks like this are transported everyday by BLS crews and do just fine.

Maybe she will end up needing a tube. I don't see why she needs one right now.


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## MS Medic (Dec 13, 2015)

TF Medic said:


> PT remains stable but unresponsive in transport. Spontaneous respirations improve to around 16 with BVM assistance, fall back to around 8 if BVM is withheld.





Remi said:


> She has a poor respiratory drive, but it seems to be improving. They are managing her airway fine with a BVM.



I don't consider a respiratory rate that drops from 16 to 8 when ventilations are withheld to be improving. Sorry I don't feel this to be stably self-maintaining an airway and I would tube the pt.


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## reaper (Dec 13, 2015)

Why hold off on securing an airway, that you know will be done as soon as you roll into ED? If she has a true GCS of 3, then she cannot protect her airway. Secure it. If you do not have RSI then drop a NTI.


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## DesertMedic66 (Dec 13, 2015)

reaper said:


> Why hold off on securing an airway, that you know will be done as soon as you roll into ED? If she has a true GCS of 3, then she cannot protect her airway. Secure it. If you do not have RSI then drop a NTI.


We don't don't have nasal as an option here.


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## medicsb (Dec 13, 2015)

To intubate or not really depends on skill and experience of the crew.  BVM will be sufficient, but I would not fault a well trained and experience crew with attempting to intubate.  In the ED, experience, skill, etc. is the difference between "why didn't you intubate" and "thank you [for not intubating]".


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## MS Medic (Dec 13, 2015)

reaper said:


> Why hold off on securing an airway, that you know will be done as soon as you roll into ED? If she has a true GCS of 3, then she cannot protect her airway. Secure it. If you do not have RSI then drop a NTI.


Just because the pt has a GSC of 3 doesn't necessarily mean they can't protect their airway, in fact they quite often can, but in this case the pt has problems maintaining a "decent" (I'm intentionally avoiding using the word adequate) respiration rate. Personal experience has taught me that you are on the front end of real respiratory compromise.  You can start down the road and the pt goes into respiratory arrest or even worse, she starts vomiting. 

In the first case, you still have to get a tube but rather than setting the situation to give you every advantage you can take, your now having to intubate in an emergent situation. In the second case you're actually having to stop ventilations in order to suction. This is a situation where if you get behind, playing catch up can have significant consequences for the pt.


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## zzyzx (Dec 13, 2015)

What if she vomits? That's not unlikely considering how long she's been bagged and that she may have a CVA.


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## ERDoc (Dec 14, 2015)

Absolutely not, only because the ER doc wants to.


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## Akulahawk (Dec 14, 2015)

For that patient, intubating her would be high on my list of things to consider. Sacramento County's protocols state that because the BLS airway management is adequate, that the BLS airway should be continued as this patient is not apneic and the County doesn't have an RSI protocol for Paramedics. If the BLS airway couldn't be adequately maintained, then intubation is directed by protocol. I would imagine that the patient also didn't have a gag reflex, or at least didn't for quite a while.


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## TF Medic (Dec 14, 2015)

Update:

The crew for this call elected not to intubate. The scene time was quite short, and almost all assessment other than cardiac monitoring and initiating the BVM were done enroute. By time the necessary assessment/interventions were performed, the truck was about 5 minutes from the ER. They decided to keep the functioning BLS airway until arrival. 

The PT was RSI'd in the ER upon arrival. ER pushed another 1mg Narcan without effect. I'll see if I can get further on etiology. 

Thanks for the discussion.


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## triemal04 (Dec 14, 2015)

What other interventions and assessments were being done for 10 minutes?


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## TF Medic (Dec 14, 2015)

I wasn't in the back, so I don't know exactly what happened. Based on the report, I gather:

BP/Pulse ox
Bag spike and IV start (2 attempts)
Glucose
D-Fib patches applied
12 lead 
Narcan draw and admin


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## triemal04 (Dec 14, 2015)

TF Medic said:


> I wasn't in the back, so I don't know exactly what happened. Based on the report, I gather:
> 
> BP/Pulse ox
> Bag spike and IV start (2 attempts)
> ...


Oh, I thought you were actually on this call.  From the original post it sounded like all that had been done prior to leaving; was curious what else was being done that took up 10 minutes of time.

And as to the original question, this patient does need to be intubated.  Who does it and where it get's done is dependent on the capabilities and competencies of the providers.  15 minutes is a long time to have to hand ventilate someone, especially someone who is at high risk (higher risk with the BVM in a moving ambulance) for vomiting and aspirating.

Just to add another thought; did anyone ask the family what the patient's wishes were in a situation like this?  See if she had any type of advance directives or if they knew how aggressive care she would want?  The simple fact that they tried CPR (with prompting from a 3rd party no less) doesn't mean that is what the patient wants.


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## Carlos Danger (Dec 14, 2015)

MS Medic said:


> I don't consider a respiratory rate that drops from 16 to 8 when ventilations are withheld to be improving.



A couple issues here.

First, This patient was found apneic, then regained spontaneous respirations at a rate of about 6, and has since improved to a rate of 8. I think that qualifies as "improvement" by any measure. She is normocapneic and normoxic with minimal ventilatory support. Her hemodynamics have also improved. She is absolutely heading in the right direction. Could that trend reverse, and she ends up needing to be intubated in an hour or in 5 minutes? Of course. And it could happen in a hurry. If it does, we'll deal with it. But for right now, she is getting better with minimal intervention.

Second, this is an 84 year old cancer patient with DM2 and chronic pain issues. Putting her on a ventilator is pretty much the last thing I want to do, and I think it's the safe bet that the patient herself agrees. If the family insists that all measures be taken, then fine. But unless they have specifically instructed that, I think management should absolutely fall on the conservative end of the spectrum until that stuff can all be sorted out between the family and the ER physician.

Lastly, airway management encompasses much more than just intubation, and it isn't as if prehospital intubation is some magic panacea that solves all the problems and never causes new ones. There's actually a lot of risk associated with prehospital RSI. Sometimes people just need to be tubed, but other times discretion is the better part of valor. I think a scenario like this is one of those times.


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## MS Medic (Dec 14, 2015)

First I think there was some missed information about opinions and second I think we are going to have to agree to disagree.

I stated in my original post on this thread that I would not RSI, only intubate if there was no gag reflex. I actually don't think the average prehospital personnel should be able to RSI. That should be reserved for CC personnel who have access to an OR if they don't meet minimum intubation requirements, neither of which applies to me.

As far as the pt goes, any respiratory effort is an improvement over apnea, but a pt who has AMS and requires ventilatory support isn't self maintaining an airway. If I could place this pt in a fowlers position with only a NRB and maybe an NPA then I would consider the pt self maintaining.

Second, you have a pt who was found pulseless/apnec and spontaneously converted with only CPR. This situation presents the real possibility of the pt going back into arrest. At this point, your in the position I mentioned of having to intubate in an emergent situation rather than in the more controlled situation I discussed earlier. You also have to worry about prolonged mask ventilations causing gastric distention and subsequent vomiting. At this point, you are suctioning and you're no longer supporting ventilations. 

As for the statement that this should be sorted out by the family and the ER physician, standard of care puts the responsibility for this situation squarely on my shoulders. Issues of advanced directives should have been discussed on scene with the family and if they don't want the pt intubated, then that's that.


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## SeeNoMore (Dec 15, 2015)

It seems to me the only argument in favor of intubation is protection against possible aspiration. I would certainly be expected to intubate this patient by my medical director, ED docs , QA folks etc. Of course that does not mean it is necessarily the right call. I have often wondered whether this risk is given undue emphasis vs the risks of prehospital RSI. I've intubated many patients with an adequate respiratory rate , ventilation and Sp02 for this reason, even when the ED Physician has opted not to. One would think that if lots of patients were suffering negative outcomes from aspiration from not being intubated then more studies would show improved outcomes from ALS airway management.  Many of these patients were also encountered as ground or flight transfers of longer duration than the average 911 call. Would managing vomiting with positioning and suctioning be better than preemptive RSI for this patient? I don't have the data to say. Interesting discussion.


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## MS Medic (Dec 15, 2015)

Concern over aspiration is a legitimate issue in the back of the ambulance, in cramped quarters, with a shortage of trained personnel and in a moving vehicle. But if a pt can be managed by positioning and doesn't require ventilatory assistance then they probably shouldn't be intubated.


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## hogwiley (Jan 1, 2016)

15 minutes out, good ECO2 and spo2? this one is a no brainer to me. I would have done what that crew did. They got her to the ed with adequate ventilation and oxygenation and ed staff were able to rsi her in more favorable circumstances.

First rule, do no harm. What if they tried to rsi her to be proactive and things didn't work out as planned. Now 8 spontaneous respirations per minute are zero.


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## NYBLS (Jan 1, 2016)

hogwiley said:


> 15 minutes out, good ECO2 and spo2? this one is a no brainer to me. I would have done what that crew did. They got her to the ed with adequate ventilation and oxygenation and ed staff were able to rsi her in more favorable circumstances.
> 
> First rule, do no harm. What if they tried to rsi her to be proactive and things didn't work out as planned. Now 8 spontaneous respirations per minute are zero.



And what if they leave her airway unsecured without protective mechanisms and she aspirates and dies?


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## hogwiley (Jan 2, 2016)

NYBLS said:


> And what if they leave her airway unsecured without protective mechanisms and she aspirates and dies?



Well there are risks either way. There is a legitimate case to be made for RSI. I think the case for not doing it in this situation is stronger though.


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## DesertMedic66 (Jan 2, 2016)

Also remember that in the ED patients are often left alone for periods of time on and off of ventilators whereas transporting this patient you are never more than 2 feet away.


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## SeeNoMore (Jan 2, 2016)

This is a good discussion. I still struggle with decision making regarding airway management.  I tend to be somewhere in the middle of the conservative - aggressive spectrum. I would have intubated this patient, but I can see the reasoning behind the arguments for BVM management en route.  I have been trying to come up with a better knowledge base for assessing the need for intubation and from what I have read it  seems the ability to spontaneously swallow and manage oral secretions is  a good indicator of airway pateny. The problem is that many managers, docs etc rely heavily on the notion that GCS <8 requires intubation. Period.

As we have discussed here the argument always goes "they could aspirate and die if you don't intubate them." I've always felt that this was a little overstated given you are at their side able to manage positioning and suction but obviously it is a concern.

In addition the placement of an ETT is no guarantee that aspiration will not occur, and many providers seem to avoid putting in OG tubes despite their concerns over possible aspiration of gastric contents.


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## Carlos Danger (Jan 2, 2016)

SeeNoMore said:


> It seems to me the only argument in favor of intubation is protection against possible aspiration. I would certainly be expected to intubate this patient by my medical director, ED docs , QA folks etc. Of course that does not mean it is necessarily the right call. *I have often wondered whether this risk is given undue emphasis vs the risks of prehospital RSI.* I've intubated many patients with an adequate respiratory rate , ventilation and Sp02 for this reason, even when the ED Physician has opted not to. *One would think that if lots of patients were suffering negative outcomes from aspiration from not being intubated then more studies would show improved outcomes from ALS airway management.*  Many of these patients were also encountered as ground or flight transfers of longer duration than the average 911 call. *Would managing vomiting with positioning and suctioning be better than preemptive RSI for this patient?* I don't have the data to say. Interesting discussion.



Great points. We are trained to be way too aggressive with airway management, and go to intubation way too quickly, IMO. We tend to approach airway management as though _not _intubating will almost certainly result in serious problems for the patient, and in order to justify/support that thought process, we simply ignore both the high rate of complications and proven lack of benefit involved with prehospital intubation. We get it almost exactly backwards.


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## Brandon O (Jan 2, 2016)

Two useful but opposing airway principles could apply here:

1. If they need a tube, sooner is better than later.
2. If they need a tube, ask whether you're the right person to do it and they're in the right place for it to happen.

In other words, it depends on your comfort, resources, and patient factors (difficulty of the airway, etc). It also probably depends on whether you stayed to play or are already halfway to the ED by the time it comes up.


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## SeeNoMore (Jan 2, 2016)

The issue is I still face a little uncertainty regarding whether some patients need to be intubated. It's not an issue of comfort. I intubate regularly in the field, OR and lab and while everyone has room to grow I am not generally overly worried about not being able to either intubate or otherwise manage the airway. To be clear I'm not trying to sound overconfident. I know that there are many possible negative consequences of intubation and that I like any other provider can certainly run into airway problems I did not anticipate.  

The issue really is whether the threat of vomiting and subsequent aspiration is worth intubating a patient who is GCS <8, ventilating appropriately with an adequate 02 sat.  A secondary issue is that where I work this type of patient would be immediately intubated by the ED team and I would be disciplined/educated for poor decision making. I would be more inclined to fight the good fight and argue the case if I could find better info on the true value of intubation in this type of patient (or lack thereof) and had a better approach to deciding whether aspiration was a significant risk, whether patient's managed via positioning and suction did as well as those intubated etc. Studies don't seem to indicate that lots of patients are dying from aspiration from BLS vs ALs transport, at least as far as I can tell. Reading studies is still an area I am shamefully deficient in.

Of course some presentations are easier than others. If someone is obtunded with vomitus or pooled secretions than your choice is not as hard.


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## Brandon O (Jan 2, 2016)

You also need to consider that while you may be able to squeeze air into a patient's lungs with a mask, that is not a reliably controlled situation in the same sense as a tube. How long can you do that for? How much stock would you place in it -- in other words, are you confident mask ventilation will be easily achievable and remain that way without change or issue all the way until transfer of care?

It's true that the problems many people have with the BVM come from inadequate skill, but it's also true that it will never be as certain as plastic in the airway. Masks leak, bellies inflate, and yes, people vomit. (Oh, and maintaining a good mask seal will be extra fun while you carry them down some stairs or across a field.)


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## SeeNoMore (Jan 2, 2016)

I don't disagree Brandon. I  would have intubated the patient in this scenario. I was referring to the patient who does not need BVM ventilation but has a questionable capacity to maintain a patent airway due to altered mental status.


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## SpecialK (Jan 3, 2016)

Based on history and presentation my diagnosis is a cerebral haemorrhage.  

My reasoning for not performing RSI would be

1.  Ventilation and oxygenation are being managed satisfactorily with bag-mask and an NPA
2.  It will be faster by at least 10 minutes to continue to hospital vs. stopping and performing RSI
3.  Given age and comorbidities, she is most likely to be palliated and not admitted to ICU or given neurosurgery

Having said that, this is a good case for RSI because 

1.  Allows definite protection of her airway  
2.  It may speed up imaging (e.g. going to CT directly upon arrival)
3.  Is standard care in hospital
4.  She can be easily extubated and allowed to ventilate spontaneously if palliated

Despite being quite torn on this one, I am fairly confident I would not perform RSI  If hospital was a little further away and if she had a poor airway and/or poor oxygenation with basic airway care I would be more inclined to do it.  Also, I would not perform the procedure in the back of an ambulance, I would stay on scene and perform it given our scene is a regular family home which has much better space, lighting etc than the back of an ambulance.

Given she is unconscious with a GCS of 3 I would also very likely only use suxamethonium for the initial intubation and not utilise rocuronium for post-intubation management unless she became unmanageable despite a fentanyl/midazolam infusion.  

Finally, while an NPA appears to be working well in this scenario, I would change it over to an LMA.


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## SeeNoMore (Jan 3, 2016)

I don't see any reason not to RSI en route if you are going to RSI. The exception would be if you were a two person crew with no provider able to drive. You should at least have a helping hand if not a second ALS provider for RSI.  I think it's also worth reiterating that intubation does not afford definite protection of the airway.


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## SpecialK (Jan 3, 2016)

SeeNoMore said:


> I don't see any reason not to RSI en route if you are going to RSI. The exception would be if you were a two person crew with no provider able to drive. You should at least have a helping hand if not a second ALS provider for RSI.  I think it's also worth reiterating that intubation does not afford definite protection of the airway.



The back of an ambulance with limited space and access to the patient is not an ideal environment to perform RSI.  I'd much rather RSI on-scene at the house where there is good light, lots of room to spread out equipment, can get 360° access to the patient etc.  If the patient is already in the ambulance (for example meeting an RSI Officer enroute) I'd rather unload them to perform RSI so long as it is dry and daytime.

RSI always requires a dedicated, suitable assistant to the intubator.  To not have such a person is a contraindication to performing the procedure.  This can be somebody at any practice level however ideally (although not always possible) this should be a second ICP.  If HEMS are performing RSI there will always be an ICP assisting the Doctor.

Having thought about it more, I'm still not convinced RSI if the best thing for this patient right now given her likely course and time to hospital vs. time to perform RSI.  If the hospital were further away or the patient had a poorer airway or poorer oxygenation then I would very likely perform RSI.  Seeking clinical advice would also not be unreasonable.


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## SeeNoMore (Jan 3, 2016)

I agree that there are advantages to RSI in a non moving well lit setting, but I also think that it is acceptable to minimize out of hospital time and perform RSI en route. We routinely RSI in the back of the ambulance or helicopter (less frequently) with high first pass success rates.


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## SpecialK (Jan 3, 2016)

SeeNoMore said:


> I agree that there are advantages to RSI in a non moving well lit setting, but I also think that it is acceptable to minimize out of hospital time and perform RSI en route. We routinely RSI in the back of the ambulance or helicopter (less frequently) with high first pass success rates.



It can be done, but in practical reality, given the short amount of time it will take to unload the patient why compromise the attempt by not doing it? (provided of course it's dry and well lit - noting if on scene, the Fire Service can often rig up portable scene lights very quickly).

Helicopters are very small and provide limited space for patient treatment.  I wouldn't attempt RSI in the back of a moving helicopter (or even a non-moving one!).  London HEMS, for example, will anaesthetise and intubate all patients they feel might need airway intervention between scene and hospital, they do not do "awake carry-backs" of such patients.  

As for minimising scene times, RSI takes approximately ten minutes.  That ten minutes can be spent on scene or it can be spent on the roadside, next to, or in, a stopped ambulance so your time to hospital is going to be the same regardless.  Unless there is a good reason not to do so, RSI should occur on scene, you can get them nice and settled on the ventilator (if you are mechanically ventilating them), packaged and loaded and then you only have to unload them at the other end.  

The exception to this is if you are meeting an RSI Officer en-route to hospital.


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## SeeNoMore (Jan 3, 2016)

I'm not so sure. There's been a lot of focus lately on ALS scene times and 10 minutes may be significant. Like I said we intubate routinely in the ambulance en route as well as in the helicopter, though this is not always preferre depending on the situation and provider.


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## SpecialK (Jan 3, 2016)

SeeNoMore said:


> I'm not so sure. There's been a lot of focus lately on ALS scene times and 10 minutes may be significant. Like I said we intubate routinely in the ambulance en route as well as in the helicopter, though this is not always preferre depending on the situation and provider.



I don't see the point in getting going to hospital only to stop and do something we could have done before we left.  Scene time is important yes, but considering the "overall clinical picture" as it is said to be, I think in reality it is easier to perform RSI on scene before loading the patient provided there is not a good reason not to do so.

The exception to this is of course meeting an RSI Officer enroute.

I would not perform RSI on this patient.  The time to do so, then load them, then transport to hospital is going to be about thirty minutes minimum vs. 15 minutes to hospital without it.  Her airway is manageable and she is oxygenating well with normal ETCO2 so I can't see a strong reason to do so.  If the hospital were 30 minutes away and her airway were a little worse then yes, or if we had to wait for a helicopter or something like that.


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## Tigger (Jan 3, 2016)

Most of our RSIs happen in the back of a non-moving ambulance prior to transport. Everything is there, plenty of light, and there is a guaranteed second set of hands. Granted we have large Type I ambulances so that makes it much easier. Compared to many houses we find sick patients in I think I'd be inclined to use the ambulance if at all possible.

Did we ever determine if the patient has a gag reflex? I think I agree with those that say they would intubate but not RSI. I think by the time everything is setup and ready to go for a proper RSI we'd be awfully close to the ED doors.


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## chaz90 (Jan 3, 2016)

We do most of our RSIs in the back of the ambulance en route to the hospital. Granted, in every single RSI there are two paramedics in the back and one EMT, and every ambulance we work is an enormous boat like apparatus on a medium duty chassis, so we have tons of room. Most people here say they're most comfortable working on a procedure like that in the back of an ambulance since that's what we're most familiar with and it minimizes delays on scene or out of hospital. 

If I'm transporting and performing an RSI en route I typically have the driver take us in non emergent or at least pull over as we push drugs and do the intubation. We also do occasional RSIs on scene as we wait for a helicopter or in the back of the ambulance prior to moving. Situation dictates all of these things, and as in most of medicine, absolutes can be dangerous.


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## SeeNoMore (Jan 4, 2016)

Approx 30 percent of people have no gag reflex. If they do testing it can promote vomiting. I am still comfortable rsi ing en route. We intubate regularly with guidance from anesthesia in the OR and regularly in our practice. We have video , a bougie adjuncts , many options for induction , sedation , blood pressure support , surgical airways. I don't see the point of waiting routinely.


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## SpecialK (Jan 4, 2016)

I guess I don't see the point in getting going to hospital only to stop to do something you could have done before you left.

In this specific circumstance, I don't feel it is worth delaying the overall time to reach hospital to perform something that is not absolutely needed right now.  

To set up and perform RSI, load the patient and still have 15 minutes to reach hospitals means total time to reach hospital is going to be at least thirty minutes.  Her oxygenation is satisfactory using an NPA and a bas mask (I'd change to an LMA) so to RSI her is only going to delay the amount of time it takes to reach hospital.  If her airway and/or oxygenation were very poor and could not be managed then I'd take the extra time to perform RSI.  

As we are very close to hospital and her airway and oxygenation are satisfactory I'd be comfortable just taking her to hospital.


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## SeeNoMore (Jan 4, 2016)

I feel like we're having a disconnect. I'm advocating RSI en route l. No stopping. No delay. As for this patient , I can see both sides.


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## medicsb (Jan 5, 2016)

I know there is data showing delays to hospital arrival are associated with poor outcomes, but that is for trauma.  Taking time to secure an airway post medical arrest is not unreasonable.   If there are multiple people on scene (hopefully there is for an arrest), you can set up for the RSI while the patient is being moved in order to decrease scene time.  My preference was to RSI in the back of the ambulance when possible.  For the actual intubation I'd have the ambulance stop as the goal was for first pass success and I don't see bouncing around in the back being any help.


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## SeeNoMore (Jan 6, 2016)

Well I mean there was just that study showing ALS was worse for almost all patients than BLS and scene times were presented as a possible explanation.


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## medicsb (Jan 6, 2016)

SeeNoMore said:


> Well I mean there was just that study showing ALS was worse for almost all patients than BLS and scene times were presented as a possible explanation.



The hypotheses generated in the discussion section is the result of brainstorming for an explanation of the findings.  It is not evidence.  If (IF) one can intubate well, it should not matter if it is done in an ED or in the back of an ambulance in the scenario of post-cardiac arrest.  Granted most systems, even those that intubate and RSI, are not actually that good at intubation, then sure maybe better to not do it at all.


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## Gordon Miller (Feb 1, 2016)

How I make my determination to RSI someone are by several questions. 1. Am I taking something away they already have,if the answer to that is yes, I have to have a very good reason to proceed 2. Do they have the  ability to clear secretions with out suction  and swallow. 3.Is their ETCo2 35-45 measured by a cannula,it's a better indicator or respiratory status than they were breathing 8 times a min. 5.Spo2 6. GCS last due to the fact if all the other questions indicate a need for RSI it's about to be a 3 one way other the other.To me GCS is a poor indicator for the need.7. Difficult airway yes/no and time frame I have to manage this airway 5-10 min transport vs  15-60+ mins.Sometimes I don't have the option to perform an assessment this detailed and just habe to go with my gut.I don't like to do this but on one hand I don't like to
delay scene time and on the other I can't assess lung fields one were in the air. I was not on this call so I really can't answer the question,however the crew did their part well so pretty sure they made the right call.Some seem to make RSI out to be this incredibley dangerous difficult skill ,it's not that the procedure itself that's difficult.Its the decision for the need that's the difficult skill. One thing I would be worried about with this patient is knocking her B/P to nothing from the PPV.I would definitely want ensure that wasn't going to be an issue.Both the ground and air service I work for RSI.


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