# No RSI- Teeth clenched from Head Injury-WWYD



## EMS Patient Care Advocate

The Short of it.
Motor vehicle crash, pt unresponsive, teeth clenched. 
In ambulance unable to pass any oral airways, NPA placed. Assisted ventilations, patient respirations are 6 a minute without assistance. Opt not to attempt nasal intubation due to likely complications and increased ICP.
No chest or lung injuries
Pupils unequal
Pt has heavy scarring over veins from what is likely heavy long term IV drug use
This state does not carry RSI medication pre-hospital.
The state does not allow facilitated intubation if you want to keep your license.
You invited air medical with the RSI supplies and protocols. They are not on scene yet. 
Respirations difficult to deliver with clenched teeth.
Constant suction of blood and secretions in airway.
Looking at the big picture, knowing the respirations may be depressed from head injury or drugs- I need the patient to help me help him breath. I pull out the Narcan and slowly titrate and to my not so big surprise- RR came up to about 20 a minute. SP02 improved to 100% just gentle BVM assistance.
Just prior to air medical paralyzing the patient he begins decorticate posturing.
What would you have done?


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## LondonMedic

Nothing different. Although, if I was ventilating and oxygenating well I might have been tempted to hold off naloxone. By giving it, although it sounds like you were sensible about it, you risk making them agitated and you risk making them vomit - both of which could ruin their day.


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## EMS Patient Care Advocate

LondonMedic said:


> Nothing different. Although, if I was ventilating and oxygenating well I might have been tempted to hold off naloxone. By giving it, although it sounds like you were sensible about it, you risk making them agitated and you risk making them vomit - both of which could ruin their day.



something I was weighing heavy in my mind as I have had more problems with Narcan than anything. But it did help patient RR improve and increase oxygenation when I needed it most. I had no way of securing his airway but to have him help me, any other ideas?


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## fast65

I would have done the same thing, just titrate it enough to improve his respirations, which it sounds like you did. The only other option at this point is to cric him. I mean, no RSI, nasal intubation contraindicated, and inadequate ventilations with the clenched teeth all seem like the ingredients for a cric to me.


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## EMS Patient Care Advocate

fast65 said:


> I would have done the same thing, just titrate it enough to improve his respirations, which it sounds like you did. The only other option at this point is to cric him. I mean, no RSI, nasal intubation contraindicated, and inadequate ventilations with the clenched teeth all seem like the ingredients for a cric to me.



If there was much more trouble ventilating there would have been no choice. I just thought it weird to have two near cric scenarios in my first two years as a medic. The first I finally cleared the chicken from her trachea, and this one. Its a pucker factor until I can get air medical on scene in this state for the proper medications to intubate. Thank you for you time and interest.


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## fast65

EMS Patient Care Advocate said:


> If there was much more trouble ventilating there would have been no choice. I just thought it weird to have two near cric scenarios in my first two years as a medic. The first I finally cleared the chicken from her trachea, and this one. Its a pucker factor until I can get air medical on scene in this state for the proper medications to intubate. Thank you for you time and interest.



Yeah, that is kind of odd, but when you think about it, it's all about chance. Hell, I could have three patients that need a cric tomorrow, or I could have none, it's all left up to chance. The important thing is that you're searching for feedback on your calls and that says that you care about improving yourself and your abilities.


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## EMS Patient Care Advocate

fast65 said:


> Yeah, that is kind of odd, but when you think about it, it's all about chance. Hell, I could have three patients that need a cric tomorrow, or I could have none, it's all left up to chance. The important thing is that you're searching for feedback on your calls and that says that you care about improving yourself and your abilities.



im honored. Im gunna shoot out another one I think. Thanks this is exciting.


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## Shishkabob

I've had my fair share of patients needing RSI when I didn't have RSI available.  I hated it.  I now refuse to work for an agency that doesn't have RSI.

If flight was going to be any further, and bagging difficult with a failed airway, I agree, crich, either surgical or needle, would be the next move.


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## EMS Patient Care Advocate

Scary as the state this occured in I can do either needle or surgical airways. In the bordering state where I also work they have removed ALL surgical/needle airways OUT of the protocols. Also currently my system does not have the state requirment of capnography for intubated patients. So that paticular service I currently cannot intubate, cannot cric and do not have RSI. To boot we only carry one adult combi-tube as my back up. I dread going to work because of my fear that I will be standing over the statistical 1% of my patient that will die without a tube. Im acctually fearful im going to end up in court explaining why I breeched protocol just so I can sleep at night knowing I did my best to the level of my training. sorry little vent session there.


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## Shishkabob

Honestly it's retarded to not have cric available to Paramedics that have to maintain an airway.

It's stupid not to have intubation (looking at you, Dallas FD)

It's idiotic to not mandate capnography to confirm placement (though it can still mess up)


And RSI has been proven to be not only as successful, but as safe, when done by a properly educated EMS ground crew as it is in the hospital.  (The issue is making them properly educated... some places don't care, and those places don't need access to RSI)


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## EMS Patient Care Advocate

Linuss said:


> Honestly it's retarded to not have cric available to Paramedics that have to maintain an airway.
> 
> It's stupid not to have intubation (looking at you, Dallas FD)
> 
> It's idiotic to not mandate capnography to confirm placement (though it can still mess up)
> 
> 
> And RSI has been proven to be not only as successful, but as safe, when done by a properly educated EMS ground crew as it is in the hospital.  (The issue is making them properly educated... some places don't care, and those places don't need access to RSI)



I fully agree!!


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## usafmedic45

EMS Patient Care Advocate said:


> The Short of it.
> Motor vehicle crash, pt unresponsive, teeth clenched.
> In ambulance unable to pass any oral airways, NPA placed. Assisted ventilations, patient respirations are 6 a minute without assistance. Opt not to attempt nasal intubation due to likely complications and increased ICP.
> No chest or lung injuries
> Pupils unequal
> Pt has heavy scarring over veins from what is likely heavy long term IV drug use
> This state does not carry RSI medication pre-hospital.
> The state does not allow facilitated intubation if you want to keep your license.
> You invited air medical with the RSI supplies and protocols. They are not on scene yet.
> Respirations difficult to deliver with clenched teeth.
> Constant suction of blood and secretions in airway.
> Looking at the big picture, knowing the respirations may be depressed from head injury or drugs- I need the patient to help me help him breath. I pull out the Narcan and slowly titrate and to my not so big surprise- RR came up to about 20 a minute. SP02 improved to 100% just gentle BVM assistance.
> Just prior to air medical paralyzing the patient he begins decorticate posturing.
> What would you have done?


Crike.


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## Akulahawk

What would you have done, OP, if the Narcan didn't work? (I tend to agree with usafmedic45 on this, btw)

What would really be horrible would be to have that trismus patient and you can't do NTI, you can't cric, you don't have RSI or Facilitated Intubation... and the Narcan doesn't work or isn't indicated. OP:_ you nearly_ _had that patient!_

When that happens, you just do the best you can, get the "right" resources mobilized that can do that stuff and if they're unavailable. PUHA.


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## EMS Patient Care Advocate

Akulahawk said:


> What would you have done, OP, if the Narcan didn't work? (I tend to agree with usafmedic45 on this, btw)
> 
> What would really be horrible would be to have that trismus patient and you can't do NTI, you can't cric, you don't have RSI or Facilitated Intubation... and the Narcan doesn't work or isn't indicated. OP:_ you nearly_ _had that patient!_
> 
> When that happens, you just do the best you can, get the "right" resources mobilized that can do that stuff and if they're unavailable. PUHA.



Well if narcan didnt work, And BVM continue to get more difficult, and I couldnt get bird to me when I did, yes I would have been cutting. I guess I didnt realize I was literally one/two decisions away, WOW. 
 when the patient started to posture I did try calling online med control to request "head injury patient safety sedation" I dont have a spacific protocol for it in this state, but I do in others- but I could defend that I dont want my patient to cause further harm to himself and the sedation may prevent further spinal comprimise. Also I understand by sedating the patient I may make my ventilation/oxygenation nightmare worse. 
However the only thing that doc seemed to hear was narcan, and combative. So when I requested sedation I started getting the "what are you an idot" voice over the radio. I heard lifeflight overhead and discontinued the doc conversation as I was going to get no where and had what I needed, an RSI team.
Thoughts?


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## usafmedic45

> Well if narcan didnt work, And BVM continue to get more difficult, and I couldnt get bird to me when I did, yes I would have been cutting.



So you're willing to wait around to see if the helicopter can beat hypoxia to the scene?


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## EMS Patient Care Advocate

usafmedic45 said:


> So you're willing to wait around to see if the helicopter can beat hypoxia to the scene?



Nope not willing. Hopeful !


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## usafmedic45

No offense, but that's just about the most moronic thing I have ever heard.  Yeah, you're a true patient care advocate if your line of thinking is that skewed.  Do the crike and worry about getting the patient to the hospital after you have an airway.  A helicopter is a transportation modality, not a treatment option.  Calling for the helicopter should be a tougher decision than performing a surgical airway of which the hardest part is simply picking up the scalpel.


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## EMS Patient Care Advocate

usafmedic45 said:


> No offense, but that's just about the most moronic thing I have ever heard.  Yeah, you're a true patient care advocate if your line of thinking is that skewed.  Do the crike and worry about getting the patient to the hospital after you have an airway.  A helicopter is a transportation modality, not a treatment option.  Calling for the helicopter should be a tougher decision than performing a surgical airway of which the hardest part is simply picking up the scalpel.



Yes I always advocate what is in the patients best interest. Dont be so quick to throw such words, yes I do take offense to that. Since you dont know the whole story let me include some things you dont know about the scene. Its 45 min from the nearest level 2 hospital. Its 2 hours by ground. Its 15 min by air. I did NOT wait on a scene for anything. I transported to a location in the direction of the hospital intercepting with a helicopter. Im glad you are so excited to cut someones throat just because a protocol says you can. Use ALL your tools. I had obtained a fully oxygenated patient without cutting his neck. Im ok knowing what I did. And im ok knowing you would have slit his throat. Be nice, you sound smarter.


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## usafmedic45

> I had obtained a fully oxygenated patient without cutting his neck.



Yeah, and congratulations, but you could have more optimally secured the airway.  A "fully oxygenated" patient is not the only issue at hand in the ventilation of head trauma and without the ability to monitor ETCO2 you may be have contributed unintentionally to the downward spiral through your efforts to obtain a 'perfect score' saturation.  If he was in the condition you state, you need to secure the airway, not simply obtain one.



> Since you dont know the whole story let me include some things you dont know about the scene. Its 45 min from the nearest level 2 hospital. Its 2 hours by ground. Its 15 min by air.



Once they get to the scene, do what they need to do and then take off again, _then it's fifteen minutes to the hospital_. Let's not forget to factor in all of the other time constraints that tend to lead to HEMS not being as expedient as people like to believe. It's four to six minutes to hypoxic encephalopathy.  Can you intercept with a helicopter that quickly?  



> Im glad you are so excited to cut someones throat just because a protocol says you can.



I'm not eager but when the option is "brain injury or death" versus a surgical airway, then I do not hesitate and worry about calling for a helicopter before handling step one of _any protocol_.



> Be nice, you sound smarter.



Think your stance all the way through before posting, it tends to have the same effect.


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## EMS Patient Care Advocate

okay, reboot. I didnt feel the patient was currently suffering from any hypoxia after the narcan, though I didnt have an airway secured like I would have preferred. Maybe next time Ill cut, maybe not. I did my best to give him optimal care and recovery, we dont KNOW I contributed to injury, but I think I saved him from further brain injury due to hypoxia, maybe not- another thing is like you say I didnt have capnography. I AM here to learn! I dont like to be insulted when trying so hard and peoples lives are at stake- You saying that I make moronic decisions made me defensive for obvious reasons. If I was accross the boarder protocol does not allow for any needle or surgical airways. I felt if I didnt get a positive response from my current interventions then I would have had to get more agressive. I was using cric as a last resort, maybe I shouldnt hesitate because I AM better than that. Knowing in the back of my mind I was then going to be ONE of a small handfull of medics in this state to EVER need to do one. Dont leave out that Im no pro at expressing myself over a computer in writing. I think you must have taken my comment for being hopeful for additional care such as Helicopter with RSI to prevent the need for surgical intervention as me sitting and waiting. I didnt feel like I did this, but maybe I did? What if there was no helicopter available, you bet my thinking would have changed. But the wait isnt what you think since I requested the helicopter on arrival. By the time the patient was extricated and transported there was a rather seemless transition I thought?


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## NomadicMedic

I'm curious as to where this system is... can you tell me the state?


Sent from my iPhone.


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## EMS Patient Care Advocate

Needle and durgical cric have been removed from NH EMS protocols completely. Its public knowledge, so yes I can tell you.


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## NomadicMedic

Yikes. Sounds like a scary place to work. I would be nervous, when doing my job, knowing that I was not allowed to use life saving skills that are considered a standard of care everywhere else. 

Glad I'm not in NH. 


Sent from my iPhone.


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## EMS Patient Care Advocate

n7lxi said:


> Yikes. Sounds like a scary place to work. I would be nervous, when doing my job, knowing that I was not allowed to use life saving skills that are considered a standard of care everywhere else.
> 
> Glad I'm not in NH.
> 
> 
> Sent from my iPhone.



The state NH also mandated ALL intubation be monitored by capnography- SMART. However they permitted lag time for services to make purchases-DOH. What I am getting at is there is a system I work both 911 and transfers. With no capnography for 911, that means no intubation. Summery - no cric, no needle airway, no intubation and one large size combi tube as the ONLY avail back-up. Anyone looking for a Medic? As a cherry on top I work as a paramedic on one of the ALS 911 trucks- AND WE DONT HAVE A 12 LEAD. Im so lost without it, im such a newbie who likes his toys I guess? When I asked what I should do I was offered the door :-(


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## ah2388

It sounds to me like you seeking new employment might be a good decision for you.

With all this being said, there are several things that concern me regarding some posts in this thread.  If it is true that you are unable to perform surgical airways or RSI because of state regulations and the unwillingness of your service to provide proper equipment that is a standard of care for most systems, I'd definitely suggest finding a different service to work for.  You are setting yourself up for failure by doing anything else.

Usaf is smart, and I would advise you to digest the posts made in this thread as nothing more than a learning opportunity.  Getting defensive won't accomplish much.  At the end of the day, it appears that your heart is in the right place, but the manner in which you approach conversations like these could use some work.


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## EMS Patient Care Advocate

ah2388 said:


> It sounds to me like you seeking new employment might be a good decision for you.
> 
> With all this being said, there are several things that concern me regarding some posts in this thread.  If it is true that you are unable to perform surgical airways or RSI because of state regulations and the unwillingness of your service to provide proper equipment that is a standard of care for most systems, I'd definitely suggest finding a different service to work for.  You are setting yourself up for failure by doing anything else.
> 
> Usaf is smart, and I would advise you to digest the posts made in this thread as nothing more than a learning opportunity.  Getting defensive won't accomplish much.  At the end of the day, it appears that your heart is in the right place, but the manner in which you approach conversations like these could use some work.



I agree. BUT I cant afford to just walk tho, and I love my job-it just morally irks me.
I have a LOT to learn, about paramedicine, life, forums, blogging. My intentions are always good, I worry I do not express it correctly often. I will be careful to avoid being defensive in the future. Thank you for the advice and bearing with me through this learning experience.


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## Wes

Hearing crap about state mandates and protocols makes me exceptionally proud to be a paramedic in Texas.  Thank goodness we are an almost completely delegated practice state where EMS providers' protocols are written by the agency's medical directors.   Thank goodness again that I'm fortunate enough to have an outside career that allows me to be picky on the EMS systems I choose to be affiliated with.  

By the way, IIRC, there have been exceptionally few basilar skull fractures aggravated by nasal intubation.

As I've heard more than once, "If your patient can't breathe, nothing else matters."


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## EMS Patient Care Advocate

Wes said:


> Hearing crap about state mandates and protocols makes me exceptionally proud to be a paramedic in Texas.  Thank goodness we are an almost completely delegated practice state where EMS providers' protocols are written by the agency's medical directors.   Thank goodness again that I'm fortunate enough to have an outside career that allows me to be picky on the EMS systems I choose to be affiliated with.
> 
> By the way, IIRC, there have been exceptionally few basilar skull fractures aggravated by nasal intubation.
> 
> As I've heard more than once, "If your patient can't breathe, nothing else matters."



I considred it. However I feared causing nasal truama and causing blood in the last way I had to get air in. Id that a consideration do you think?


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## Wes

Respectfully, I'd suggest a bit of research.  I would imagine that "nasotracheal intubation" and "basilar skull fracture" on a generic search engine like Google or a medical related site such as PubMed would provide more than enough answers.

It's great that you're a relatively new paramedic and posting lots of questions.  It would be even greater if you developed a go-to list of medical books (Yes, the old fashioned sources of knowledge) and appropriate medical websites to aid you in your quest for knowledge.  As I'm sure you are finding out, the world of medical knowledge, even in emergency medicine, extends way beyond a set of protocols and your paramedic textbook(s).


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## EMS Patient Care Advocate

Wes said:


> Respectfully, I'd suggest a bit of research.  I would imagine that "nasotracheal intubation" and "basilar skull fracture" on a generic search engine like Google or a medical related site such as PubMed would provide more than enough answers.
> 
> It's great that you're a relatively new paramedic and posting lots of questions.  It would be even greater if you developed a go-to list of medical books (Yes, the old fashioned sources of knowledge) and appropriate medical websites to aid you in your quest for knowledge.  As I'm sure you are finding out, the world of medical knowledge, even in emergency medicine, extends way beyond a set of protocols and your paramedic textbook(s).



and research I shall. Thank you. So you promote nasal intubation in this scenario?
Why are you confident we are dealing with a basilar skull fracture?


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## Wes

It's something I'd _consider_ in this situation.  I wasn't there, so it's hard for me to say.  To me, the medical term _consider_ means that you use your clinical judgment to make the best possible decision for your patient, factoring in all considerations such as your skill level, available resources, and time to definitive care.

I too have had some crap-burger trauma calls where airway became an issue.  And I too have had arguments with others about the best way to manage the airway.  I'll probably continue to have such experiences.

I tend to favor Kelly Grayson's "Airway Continuum" approach of doing only so much as is necessary to maintain the airway.  (BTW, I've massively oversimplified his approach.)

I suppose that, in summation, I can't disagree with the approach you took to this patient, especially considering the limitations presented to you.   As a paramedic, attorney, and EMS educator, part of my mission is to present options.


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## usafmedic45

> So you promote nasal intubation in this scenario?



Not in the slightest.



> Why are you confident we are dealing with a basilar skull fracture?



Because a direct blow to the anterior aspect of the mandible will transmit the force straight to the base of the skull through the temporomandibular joints.  It's the standard mechanism for what is known as a 'hinge fracture'.  In the case of facial trauma severe enough to cause airway issues, especially with an altered mental status, one should pretty much operate from the standpoint that they are dealing with a basilar skull fracture until proven otherwise by CT or autopsy.


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## Wes

I am most likely mistaken, probably even flat-out wrong, but isn't there some study that indicated that the risk from nasal intubation (or inserting a NPA) in a patient with a basilar skull fracture is actually fairly minimal?

And if nasal intubation is contraindicated, I seem to remember that a NPA is also contraindicated in these patients.

Again, I'm probably wrong, so please correct me.


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## usafmedic45

> I am most likely mistaken, probably even flat-out wrong, but isn't there some study that indicated that the risk from nasal intubation (or inserting a NPA) in a patient with a basilar skull fracture is actually fairly minimal?



I recall the same study and it makes sense from a biomechanics standpoint, however I would not want to rely on it in court when there are better options for that particular setting.


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## Wes

I don't disagree there.  I just like to throw options out there.  I think the "devil's advocate" role came with the JD....  <_<


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## mikie

*could be wrong as usual*

Not that I'm advocating nasal intubation here, but I think the original fears stemmed from the NG tube and kind of trickled down to every other nasally inserved device (NTI, NPA, etc)


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## usafmedic45

> I don't disagree there. I just like to throw options out there. I think the "devil's advocate" role came with the JD....



Mine's just because I'm difficult.  Oh, and I'm an admitted expert witness for EMS, respiratory therapy and aviation safety.  Suffice to say, I get paid to be that particular blend of "difficult".


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## Smash

Dammit, no-one pays me for my court appearances. "Expert witness" is the same as "defendant" right? 

Anyway, avoiding nasal intubation in the head injured patient is not merely matter of avoiding plunging a piece of plastic through the cribriform plate into the the thinking jelly. We owe it to these patients to do all we can to avoid secondary brain injury and increased ICP or decreased CBF.  That means not fossicking around in the snout with plastic, which one has to imagine is pretty unpleasant and would certainly give rise to more ICP unhappiness.  The OP identified this, which is great, and I wholeheartedly agree with him not poking a tube up the snout. 

Therefore we carefully provide analgesia, sedation and elimination of reflexes with paralytics whilst intubating, and ensure that we continue to do so once the tube is passed. 

If your service does not allow road-based RSI (and that is fine by me, unless everyone is willing and able to step up and do it properly) then you have to make do with what you have. If this means making a hole in the patient's throat, so be it. 

Someone smarter than me like USAF or someone has probably already mentioned it, but one of the biggest failings with surgical airways is not identifying the need and performing it. We are all a bit scared of cutting (and fair enough too) but if it needs to be done we need to HTFU and do it.

If none of this makes sense, or is completely out of context, I apologize. I'm currently tweaking on coffee, cold and flu tablets and no sleep, so my grip on reality is a touch tenuous at the moment.


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## EMS Patient Care Advocate

it was my understanding risk of putting a NPA was more than minimal and worth the gain as far as risking it going into the brain-i thought in this situation. I felt nasal intubation would have been too much. I think there is more science supporting its safety than the possibility of entering into the brain. I agree, you all have me thinking I should have done the cut. I will remember this the next time, so it is a leraning experience. A lot of good conversation has come out of this im glad I brought it out.


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## usafmedic45

> If none of this makes sense, or is completely out of context, I apologize. I'm currently tweaking on coffee, cold and flu tablets and no sleep, so my grip on reality is a touch tenuous at the moment.



Only the part about me being smarter than you.  Give yourself credit where it is due.


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## Nervegas

Linuss said:


> Honestly it's retarded to not have cric available to Paramedics that have to maintain an airway.
> 
> It's stupid not to have intubation (looking at you, Dallas FD)



Dallas doesn't tube? I was in the ER at the meth house the other day picking up a crazy gomer and Dallas rolled in hot with a guy tubed and an EJ in place.


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## Shishkabob

Hmm.. when I spoke to a couple of DFD FFs last year, they said they were losing ETI and just doing supraglottic airways.

I'll admit I haven't looked lately, but I do know BioTel allows each FD to adopt certain parts they want to, which is why some FDs have RSI and other do not.


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## zzyzx

I'm curious if anyone knows of studies showing the failure rate for ED and pre-hospital surgical airways. I would imagine that it's quite high, even in the ED.


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## usafmedic45

zzyzx said:


> I'm curious if anyone knows of studies showing the failure rate for ED and pre-hospital surgical airways. I would imagine that it's quite high, even in the ED.



Why would you imagine that? Fear I am guessing?

Actually, the only study I can recall seeing the rate is far below that of ETI.  It's not a Blalock-Taussig shunt for crying out loud.  It's easier than putting in an IV on most people.  From unpublished data I have seen, the rate is about 1-3% both in EMS and in hospital.


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## usafmedic45

> Am Surg. 1995 Jan;61(1):52-5.
> Emergency cricothyrotomy: a reassessment.
> Hawkins ML, Shapiro MB, Cué JI, Wiggins SS.





> The Medical College of Georgia Level I Trauma Center admitted 5603 adult trauma patients from January 1, 1989 through June 30, 1993. Cricothyrotomy was required in 66 of 525 patients who required emergency airway control but could not be intubated nonsurgically in an expeditious manner. There were three major complications (thyroid cartilage laceration, significant hemorrhage, and failure to obtain a surgical airway) involving two patients, but each resolved without sequelae. Twenty-six patients with cricothyrotomy survived their hospital course, of which seven had decannulation of the cricothyrotomy without further airway procedures, and 19 had conversion to tracheostomy. No patient had clinically significant morbidity from the cricothyrotomy, whether with or without a subsequent tracheostomy. Surgical cricothyrotomy remains an important technique with low morbidity for selected trauma victims needing emergency airway control.



A 1% failure rate.


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## zzyzx

Hmmm....a 1% failure rate at a trauma center, probably with a trauma surgeon doing the procedure. But I wonder what the failure rate would be by a paramedic or ED doc at a community hospital.


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## Handsome Robb

Never done one personally. But from my limited knowledge and experience, it seems much easier than tubing many people.

Just my 0.02


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## usafmedic45

> Hmmm....a 1% failure rate at a trauma center, probably with a trauma surgeon doing the procedure. But I wonder what the failure rate would be by a paramedic or ED doc at a community hospital.



Well, I was a quality control officer and we tracked this.  The rate in the field for surgical airways was between 1-3% for failure.  

Once again, why the assumption when presented with evidence to the contrary?  A literally five-step procedure (pull skin taut, locate landmarks, cut the skin, puncture the cricothyroid membrane, insert tube) is pretty simple.  I'd be more comfortable teaching basic EMTs to do surgical airways than teaching them to intubate.  Not that I think either is a good idea in light of availability of great non-visualized airways but the point that it's a very simple, very low risk procedure stands.

BTW, normally the ones handling the airways at trauma centers are the emergency physicians and RTs.


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## EMS Patient Care Advocate

usafmedic45 said:


> Well, I was a quality control officer and we tracked this.  The rate in the field for surgical airways was between 1-3% for failure..



What size was your service and how often was this procedure performed?


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## usafmedic45

EMS Patient Care Advocate said:


> What size was your service and how often was this procedure performed?



It was a pretty diverse group (final chart review was accomplished at the medical control level, not by the individual services) with a couple hundred medics (this was 10 years ago so forgive me for not remembering the exact figures) and perhaps five or ten crikes per year.  The data set went back to the early to mid-1980s so there were records for approximately a hundred or maybe a hundred and fifty surgical airways. The order was that no patient was to be left with an uncontrolled airway without a damn good reason but not to jump idly into a surgical airway.


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## CANMAN

I agree with everything usafmedic45 said. The hardest part is making the decision and picking up the scapel. I have been lucky enough to have two field surgical airways under my belt. The first one I was slightly nervous ( I was a very green paramedic at the time ) but I was obviously in alot less distress then the paramedic who was originally going to do the procedure. His hand was shaking like a leaf, he had been a paramedic for 13 years and this was his first surgical airway or so he thought. After seeing how nervous he was a quick "give me that" and away I went. Went extremely well and pt. had no complications. 

The above call made it much easier to go right ahead when it came time to do my second one.


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## zzyzx

I'm surprised that the failure rate is so low. We don't have that in our scope, so I'm not very familiar with the procedure, but my understanding was that it is difficult because as soon as you cut you have a lot of bleeding, making it hard to visualize the anatomy. That and the fact that it's so rarely don't by medics.


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## usafmedic45

> but my understanding was that it is difficult because as soon as you cut you have a lot of bleeding, making it hard to visualize the anatomy



Not really.  As long as you make a midline vertical incision, you shouldn't hit anything that will bleed at a significant rate.  All the major vascular structures of the neck are lateral or posterior to the trachea.  The idea that a crike looks like something out of Sweeney Todd is another one of those EMS myths that needs to die a quick death.  I have four crikes to my credit and not one of those has involved a loss of visual reference.  Not to mention that even if it were to occur, one could do the procedure completely by feel.  Our medical director used to demonstrate that they could be done in tactical scenarios (read as: pitch darkness) by turning off all the lights and performing one on a pig trachea covered in skin.


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## usafmedic45

Published field data....



> J Trauma. 1989 Apr;29(4):506-8.
> Surgical cricothyrotomy in the field: experience of a helicopter transport team.
> Miklus RM, Elliott C, Snow N.
> Source
> 
> Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio.
> Abstract
> 
> A retrospective analysis of 3,500 helicopter missions revealed 20 patients who required cricothyrotomy in the field for emergency airway access. Five patients who were in cardiopulmonary arrest succumbed despite cricothyrotomy, all with adequate airway control (Trauma Score, 2.8; ISS, 55.6). Seven of 12 patients with oral, maxillofacial, or cervical trauma survived (Trauma Score, 9.6; ISS, 48.25). *There were no instances of bleeding, malposition, airway obstruction, or dysphonia after decannulation in the survivors. Autopsy revealed no serious airway pathology or compromise in those who expired. *Surgical cricothyrotomy can successfully be performed in the field by a nurse/physician helicopter transport team. When conventional airway maneuvers are unsuccessful we recommend cricothyrotomy for emergency airway access.


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## medicsb

To add on to usaf's one abstract...

While bleeding should be relatively rare, it should be appreciated that many people have vascular anomalies whereby an artery or vein may pass over the area above the cricothyroid membrane.  Additionally, there are some people who have a pyramidal lobe of the thyroid that can lay directly over the cricothyroid membrane.  Also, there is a pair of muscles that extend from the cricoid cartilage to the thyroid cartilage, which could bleed alot if cut.  Essentially, the procedure should be though of as one that is performed based more on feel than sight (as has been said before) because bleeding may obscure visualization of structures.  

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J Trauma. 1997 May;42(5):832-6; discussion 837-8.
Efficacy of prehospital surgical cricothyrotomy in trauma patients.
Fortune JB, Judkins DG, Scanzaroli D, McLeod KB, Johnson SB.
Source

Department of Surgery, University of Arizona, Tucson, USA.
Abstract
OBJECTIVE:

The use of surgical cricothyrotomy (SC) in the prehospital setting is controversial, and the need to teach this procedure to paramedics and intermediate emergency medical technicians remains unclear. The purpose of this study is to define the efficacy, complication rate, and overall survival after SC performed in the prehospital setting.
METHODS:

In our region, emergency medical technicians receive training in this technique using an animal model with bi-annual updates required. We retrospectively reviewed data in our regional trauma register (15,686 injured patients) for the years 1991-1995.
RESULTS:

Prehospital emergency airway intubation was required in 376 patients, 56 of whom received SC. The primary indications for SC were facial fractures and deformities (32%) and blood in the airway (30%). In 79% of the patients requiring SC, attempted orotracheal intubation prior to SC was unsuccessful, with a mean of 1.9 attempts per patient. SC was judged to provide an adequate airway in the field in 89% of attempts. Complications at the scene included *six failed attempts, one case of excessive bleeding, and one adverse patient reaction (agitation)*. When patients arrived at the trauma center, the SC was judged to be acceptable in 64%, whereas 16% were functioning with some question of adequacy and required airway manipulation (most commonly a mainstem bronchial intubation). Overall survival to hospital discharge was 27%; however, survival to emergency department discharge (an indicator of emergency airway adequacy) was 62%. Using TRISS methodology, there were five unexpected survivors and six unexpected deaths. Only three patients were discharged with a "good neurologic recovery."
CONCLUSION:

(1) Prehospital SC can be performed effectively with few complications after training on animal models (2) Good neurologic outcome is rare after the use of this procedure. (3) Although it is effective, clear indications must be developed and followed for the prehospital use of SC.

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J Air Med Transp. 1991 Dec;10(12):7-9, 12.
Prehospital cricothyrotomy in air medical transport: outcome.
Cook S, Dawson R, Falcone RE.
Source

Grant LifeFlight, Columbus, OH.
Abstract

In an attempt to determine outcome, this study reviewed the records of air medical patients undergoing prehospital cricothyrotomy (CRIC) from 1987 through 1989. The study included initial airway management, Trauma Score (TS) before and after CRIC and on arrival to the hospital, outcome, and initiator of airway--either emergency medical services (EMS) or LifeFlight air medical crew (LF). There were 68 CRIC in 3285 completed missions (2%). Patients averaged 31.4 years old with 46 males and 22 females. In rural environments, 60/68 patients were injured, with 65/68 injuries by blunt mechanisms. CRIC was performed by EMS in 24/68 patients and by LF in 44/68 patients. TS before CRIC, after CRIC, and on arrival to the hospital was not significantly different, averaging 5.8, 5.8, and 5.2. *There were three complications of CRIC: two bleeds and one failure to insert*. Five CRIC were changed to another airway at the receiving facility. Twenty-one out of 68 patients survived to discharge. There were no statistically significant differences in complications or overall mortality between LF and EMS CRIC. Prehospital CRIC appeared safe and complications were infrequent. The CRIC, once placed, remained the airway of choice in most patients. The eventual outcome in this population suggested serious injury with the majority of patients (69%) dying.

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Ann Emerg Med. 1990 Mar;19(3):279-85.
Prehospital cricothyrotomy: an investigation of indications, technique, complications, and patient outcome.
Spaite DW, Joseph M.
Source

Section of Emergency Medicine, University of Arizona College of Medicine, Tucson.
Abstract

The records of all patients who presented to a Level 1 trauma center during a two-year period for whom a prehospital cricothyrotomy was attempted or ordered were reviewed. Twenty patients met the study criteria. The average age was 37 years (range, 11 to 65 years). Indications for prehospital cricothyrotomy were massive facial trauma (eight), failed oral intubation (seven), and suspected cervical-spine injury (one). Cricothyrotomy was attempted in 16 patients (80%), with the remaining four having the procedure ordered but not attempted. A successful airway was achieved in 14 patients (88%). Horizontal incisions were used in all cases and were anatomically correct in 15 of 16 attempts (94%). The overall immediate complication rate was 31%. Two patients (12%) sustained major complications (failure to obtain an airway). No hemorrhagic complications occurred, but 16 of the 20 were in cardiac arrest in the field. Long-term complications were not evaluated. All patients sustained major injuries (mean Injury Severity Score, 53.7), except one patient who suffered airway obstruction from food. Three patients (15%) survived; two of the three suffered permanent, severe brain dysfunction. These preliminary findings demonstrate that prehospital cricothyrotomy is being used chiefly in massively injured patients who are already beyond recovery. It is thus difficult to assess whether the procedure is either safe or effective. There is a need for further investigation to determine whether prehospital cricothyrotomy has any beneficial effect on outcome and, if so, in what setting.(ABSTRACT TRUNCATED AT 250 WORDS)

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Ann Emerg Med. 1991 Apr;20(4):367-70.
Can nurses perform surgical cricothyrotomy with acceptable success and complication rates?
Nugent WL, Rhee KJ, Wisner DH.
Source

Department of Nursing Administration, University of California, Davis Medical Center, Sacramento 95817.
Abstract
STUDY OBJECTIVE:

This study was undertaken to determine whether flight nurses can perform surgical cricothyrotomies with acceptable success and complication rates.
METHODS:

This case series examined the survival, success, and complication rates of surgical cricothyrotomy. A specially trained flight nurse retrospectively reviewed all prehospital, emergency department, inpatient, autopsy, and outpatient follow-up records.
RESULTS:

Fifty-five consecutive patients in whom surgical cricothyrotomy was attempted by a flight nurse during a two-and-one-half-year period were studied. Patients ranged in age from 9 to 76 years. The airway was not cannulated successfully by a flight nurse in two patients. In two patients, the tube was not in the cricothyroid space (one in the upper tracheal rings, and the other in the larynx).* In three patients, packing was insufficient to stop bleeding from around the operative site; and in three the tube became occluded by blood in the emergency department*. Finally, two patients developed subglottic stenosis.
CONCLUSION:

Surgical cricothyrotomy in the field can be performed reliably by specially trained nurses. Because only the most critically ill or injured patients with unmanageable airways are subjected to this procedure, a significant complication rate can be anticipated.


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## Shishkabob

"One adverse patient reaction (agitation)"?!


No crap, I'd be angry if someone came at my neck with a scalpel and I was still awake too!


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## mycrofft

*History again, why we have been warned off crikes*

Like tourniquets, they are done infrequently enough in civlian life that practitioners lack practice once taught, and teachers may lack real life experience. Laypeople were trying crikes with steak knives. Rookies were botching enough of them (both of them) that the high foreheads in Admin decided to take them away. So said my old-surgeon anatomy professor.

If a NG airway penetrates into the brain cavity but it was the only means left to try for an airway, then the pt was already doomed, either to hypoxia or a late diagnosis of a significant communication between brain and nasopharynx. The NG tube on the other hand is much longer and the reactive seizures as it tickles the forebrain etc. can be passed off as irritable reaction in a comatose pt.


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## mycrofft

*Oops, sorry.*

"If a NG airway penetrates into the brain cavity" should have read "If a nasopharyngeal airway...". New keyboard and computer, can't do a thing with them.


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