# Was intubation indicated or appropriate?



## FLEMTP (Sep 28, 2010)

Ok.. I have a scenario for you folks... I want some opinions.

You respond to a 21 yo male with facial burns

Upon arrival on scene you find a 21 y/o male laying on the ground next to a full size pickup with an ice pack on his face and crying. He states his face burns. You look at the truck and the hood is raised and the radiator cap is missing. 

When you question him about the series of events, he states about an hour ago he returned home and parked his truck because it was overheating. He let it sit about half an hour to cool off, went outside and took off the radiator cap, and looked into the radiator, and in the process a burst of steam hit him in the face. his face is red and slightly swollen, with some small blisters forming on his lips. He states he cannot open his eyes because it hurts too bad. 

He states he was originally going to have his girlfriend drive him to the ER, but changed his mind because of the pain. He states this happened about 15 minutes ago.

He denies any medical history, medications or allergies. He states he does not smoke, drink, or use illegal substances. He is very insistent that there was only water in the radiator, as he has been dealing with a leak in it & overheating for several weeks now. 

His blood pressure is slightly elevated at 142/90, heart rate is 110 and he is breathing at 24 times a minute. He is showing a sinus tachycardia with no ectopy, and his SpO2 is 97% on room air.

His only complaint is pain to the face at the time of your initial exam, pain score 10/10. He denies any respiratory distress, and his lungs sound clear. When you open his mouth to examine his throat you note that he is a Mallampati Class 3 airway, with the soft & hard palate clearly visible. You note no soot, redness or irritation to the muscosa in the throat when he opens his mouth for you to inspect it.

At this point how would you treat the patient?







ok... now some additional:

5-10 minutes into transport he begins to complain of shortness of breath, and you notice he is coughing quite a bit. You note his Sp02 is now 95% on room air, and when he coughs he has a slight barking quality to it. His respirations are now 28, and he does appear to have some mild difficulty breathing. He is becoming anxious, but has no history of anxiety, and states he is scared because he cannot breathe. 

How would your treatment change if at all?

Some things to consider:

Nearest hospital to your location is 7-10 minutes away. The nearest trauma center is a Level II trama center 15 minutes away. The nearest burn center is an hour away by air, and 2 hours away by ground.

You do have access to and can perform a drug assisted intubation should you need it. You also have an LMA as a backup, and cricothyroidotomy is in your scope of practice and you do have the tools available to perform this. 

You are only with your partner who is driving, but you have access to additional fire or EMS responders who can be to your location within 4 minutes. You have a helicopter available with a 10 minute ETA and a Landing Zone 5 minutes away. 

Im interested to see some responses & ideas.


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## medic417 (Sep 28, 2010)

What was his Capnography readings and waveform on initial assessment and upon this change?  Did the readings rapidly change or was it a slow progression?


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## FLEMTP (Sep 28, 2010)

medic417 said:


> What was his Capnography readings and waveform on initial assessment and upon this change?  Did the readings rapidly change or was it a slow progression?



assume capnography was not placed on initial assessment

Once I get some more responses I'll give out further details. 

I dont want to give out *too* much info until I am able to get some opinions.


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## abckidsmom (Sep 28, 2010)

The LMA is out.  Definitely not a consideration.  I also would definitely not jump right to a cric.

What do his lungs sound like?  How's the air movement? 

As rapidly as he seems to be progressing, I would be hesitant to pack him up and fly him to the burn center, but the trauma center is likely to be ill-equipped to completely manage his care.  

My first inclination is to call for the helicoptor and send him to the burn center, but I say that with a little hesitation.  How's that for sure and decisive action?


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## MasterIntubator (Sep 28, 2010)

First off.... was the face washed off of any residual chems?  Next, pain management.  And I usually dose liberally with burns.  Does this help any possible pain induced anxiety?
If not... I have 2 choices based on how the pt is presenting and then my 'gut' feeling.

1 - Aggresive: Sedate/paralize and intubate before things get to far with edema.  This is one case where I prefer a direct airway vs an indirect method.

2 - Talk calmly with to the pt, consider albuterol and solumedrol for irritation and think strongly about option #1.

Ultimatley he will go to a burn center, but the closest ED will have more tools at hand for stabilization... and they can fly from there. ( and of course... a well placed phone call into med control can help whether to take an extra 5 minutes to the LII center.

Honestly.... with the past thermal airway burns I have had with signs of lower airway involvement... I have gone with option 1, before I have an issue maintaining an airway.


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## firecoins (Sep 28, 2010)

He is getting tubed immediately and we are going to the trauma center 15 minutes away. 

I am not waiting for ems or fire responders.  I am not waiting for a helicopter. 4 and 10 minute responses are too long. Its time I could be closer to the trauma center or at least the closest hospital.  

If I have any trouble getting the tube, we divert to the nearest hospital.  The cric might come into play. I like to avoid it though.  Ill have the ED preped for ti though.


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## CAO (Sep 28, 2010)

At this point in my education, he's getting a tube.

Signs are showing that he will quite possibly need one soon, and I'd think it would be better to go for it before any edema makes it all but impossible.

Then off to the trauma center we go to stabilize before heading to the burn center.

Again, my education isn't complete (Is it ever?), so hopefully I didn't kill him too bad.


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## medic417 (Sep 28, 2010)

Don't forget to call poison control.  Radiator fluid is toxic.


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## Aidey (Sep 28, 2010)

Have you called Poison Control recently?


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## CAO (Sep 28, 2010)

Dang.  Good call on Poison Control.  I'd assumed while reading and shouldn't have missed that.


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## Shishkabob (Sep 28, 2010)

I'd go for the tube, but I'd lean a bit more towards nasal while we still have the ability and he's awake / breathing.

I'd be headed for the trauma center as well.  Let them do what they need to, then fly / drive him to the burn center once 'stabilized'.  




I actually had a facial burn patient the other night with 1/2/3 degree burns to the face, eyes, nose and mouth...


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## Aidey (Sep 28, 2010)

Ok, let me rephrase that. Has anyone called Poison Control recently? Unless you have 10 minutes to spare, let the hospital call them. Seriously. I have had them argue with me because of which center my cell phone routed to. Once you do get through they want a call back number, the name, address, and phone number of the hospital, your ETA to said hospital, the patients name, birthday, address, and SSN before they will give you instructions. I know of a couple of ER doctors who will not call them anymore because of issues they have had.


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## medic417 (Sep 28, 2010)

Aidey said:


> Ok, let me rephrase that. Has anyone called Poison Control recently? Unless you have 10 minutes to spare, let the hospital call them. Seriously. I have had them argue with me because of which center my cell phone routed to. Once you do get through they want a call back number, the name, address, and phone number of the hospital, your ETA to said hospital, the patients name, birthday, address, and SSN before they will give you instructions. I know of a couple of ER doctors who will not call them anymore because of issues they have had.



I've never had a problem.  I do not allow it to delay care.  If I need to do something else I let someone else hold phone.  Never has taken more than a couple of minutes.


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## Shishkabob (Sep 28, 2010)

A few of the agencies around here, mine included, are allowed/expected to call Poison Control with toxicological emergencies and use them in place of med control.  



But have I called?  No.  Never been in the situation to have to.


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## Aidey (Sep 28, 2010)

It may be a question of regional policies/practices, but I know I am not the only one who has had issues. The fact that ER doctors are refusing to call them is a big indication that I'm not imagining things.


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## Shishkabob (Sep 28, 2010)

Meh, rather silly that they choose not to call for that reason.


That's like not asking a cardiologist about a cardiac patient...


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## Aidey (Sep 28, 2010)

If you don't like one cardiologist you can always consult another. Just becuase you don't call PC doesn't mean you can't get the information you need.


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## usalsfyre (Sep 28, 2010)

First, did we visualize any signs of airway burns when we looked at his malampati? Did his pharnyx look unusual at all?

Tubed via medication and flown to a burn center. The flight crew should be able to handle this pt once the airway is secure. If when we go to look at cords there is any damage that looks like it may interfere with airway placement, go directly to crich, do not pass go, do not collect $200.

Once his airway is secure, heavy doses of sedation and pain control as approprite. Hopefully we have access to a vent, as a BVM is a poor choice in this case.


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## abckidsmom (Sep 28, 2010)

usalsfyre said:


> First, did we visualize any signs of airway burns when we looked at his malampati? Did his pharnyx look unusual at all?
> 
> Tubed via medication and flown to a burn center. The flight crew should be able to handle this pt once the airway is secure. If when we go to look at cords there is any damage that looks like it may interfere with airway placement, go directly to crich, do not pass go, do not collect $200.
> 
> Once his airway is secure, heavy doses of sedation and pain control as approprite. Hopefully we have access to a vent, as a BVM is a poor choice in this case.



The thing that makes me hesitant about this situation is that his sats are already dropping off.  With lower airway burns, the longer he's not on a ventilator with controlled airway pressures, the more potential for further trauma to his lungs, so he needs to be on a non-transport vent as soon as possible.  But on the flip side, if he's deteriorating this quickly, he's going to need the burn center because in 3 days he's not going to be tolerating ANY ventilation and will be on an oscillator. 

It's all about buying time to get him to an appropriate facility.

Since it seems like he'll be a relatively difficult intubation, I think it would be best to hold on till we're waiting at the LZ for the helicoptor and tube him then.  Many hands makes light work.  There will only be one attempt on this tube...I would want all the planets that I had control of to be aligned, no shooting from the hip.


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## sir.shocksalot (Sep 28, 2010)

How are his lung sounds? Is there any stridor or increased work of breathing? What about a second look in his mouth, is his tongue getting bigger, do we note any new redness or swelling elsewhere in his mouth? I think without any further findings other than a complaint of difficulty breathing I would be hesitant to tube him. That being said, tubes would be ready and should his voice change or start to have stridor or an increase in anxiety and a further drop in sats I'd nasally tube him. I'm interested to see how it all turns out.


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## Handsome Robb (Sep 29, 2010)

So it appears I am the low man on the totem pole here but I am always looking for critiques on my thoughts so I'll give it a shot. In my county ET tubes are not in the scope for an I, so I'll look at it from an NREMT standpoint if thats ok?

With the fact that his sats are dropping I'd drop an NPA and start with an NRB to try to improve them and start the pre oxygenation for the tube in the event he becomes unresponsive, and call for the flight intercept and head towards the LZ. This guy needs fluids as well, so I'd start an NS drip and call MC for a pain med order. With the potential for lower airway burns this guy NEEDS the burn center, the quicker he gets there the better. As I am not allowed RSI procedures I would monitor the pt and if he becomes unresponsive I would go ahead and drop the tube with a king as plan b.

Ok let the critisim begin...


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## Shishkabob (Sep 29, 2010)

The flaw with your concept is that the potential for laryngeal edema is very high, which is very possibly the reason why the pt is now coughing and desatting.  An OPA / NPA / supraglottic airway will do NOTHING to help if this is the case, and a tube, or even a needle cric, past the area of edema is needed.


If you try to do just an OPA/NPA/SGA, you're wasting valuable time in which the airway can close more, essentially making an ETT impossible and probably necessitating a crich.


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## Handsome Robb (Sep 29, 2010)

So then with my scope would it be better to use the NRB or even attempt bag assisting to keep the sats in the >90 since I am unable to sedate the pt to drop the tube?


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## Shishkabob (Sep 29, 2010)

At the EMT and Intermediate levels, your one and only choice is to get to the closest hospital that has a doctor as fast as humanly possible.  You don't have the luxury of time time.


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## Smash (Sep 29, 2010)

I'm aggressive with burns that have any kind of airway involvement.  Sedate, paralyze and intubate now, rather than wait for things to get worse and make the ETT harder to place.  An edematous airway is not a happy place to be fossicking around in if we leave him too long.


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## MSDeltaFlt (Sep 29, 2010)

With steam being blasted to the face, a barky cough, c/o SOB with decreasing sats, you my friend are stuck on airway. This pt needs to be tubed. However, your only backup airway device remotely close to being usable is a NEEDLE cric which is a temporary airway on an airway that is already closing off. If, and I do mean IF, you decide to tube this man, you have one shot.  Just one shot before his airway closes completely off, for all pretensive purposes. A needle cric won't cut it. You'll need a surgical cric. I personally would call for the bird, or someone who can cut this mans throat open if sugar turns so sh*t.


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## gicts (Sep 29, 2010)

Interesting scenario. 

Before he complained of difficulty breathing did you begin some sort of pain management? 

I would have gone to the trauma hospital and given a report and let them make the call if they want to call in a helicopter.  I'm not sure why you would call for additional resources unless you just wanted someone to bag for you.

While I agree he will be intubated, had the trauma hospital been the same distance as the closest hospital I'm not sure I would have tubed him. By the time you set everything up, let the drugs work, delay transport, and get the tube you would have been well into the ER. Others thoughts?


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## MSDeltaFlt (Sep 29, 2010)

OK, read more thoroughly the scenario. 

First, define DAI. Do you have paralytics?  If you don't, then leave him alone and transport to the Level II and have them have anesthesia on standby. A Mallampati 3 with super heated air and a worsening airway makes for a VERY difficult intubation. Enhance his calm as best you can and transport. 

If you do have paralytics, remember you have one shot. If you decide to tube, failure is not an option.


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## DrParasite (Sep 29, 2010)

as an uneducated one, I would say tube him.  

facial burns, possible airway burns (high probability based on the scenario), and now he's having more trouble breathing?  if the burns are going to cause more airway swelling, and it's going to get worse, then what?  it's going to make tubing him even harder, and even worse if he loses this airway completely.  

Let the hard rigid tube ensure that he maintains an ability to breath at least until until you get to the hospital.  

Again, I am uneducated, but I would imagine it's better to tube the patient who has a high chance of deteriorating from burns, than not tube the patient, than not tube the patient and then have to play catchup when he stops breathing.

is there a downside to being too aggressive and intubating a patient that may not have needed to be intubated int he field?


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## Shishkabob (Sep 29, 2010)

They'll need to be weened off the tube in the hospital, which takes times, and you could cause some damage.


But with how this is presenting, that's the least of your worries.  Hindsight is 20/20, but we don't have the luxury of it in the field.


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## abckidsmom (Sep 29, 2010)

DrParasite said:


> as an uneducated one, I would say tube him.
> 
> facial burns, possible airway burns (high probability based on the scenario), and now he's having more trouble breathing?  if the burns are going to cause more airway swelling, and it's going to get worse, then what?  it's going to make tubing him even harder, and even worse if he loses this airway completely.
> 
> ...



It is not benign, by any means, to intubate someone.  There is a significant risk of infection, injury, and complications of mechanical ventilation.  Additionally, prehospital providers continually fail to recognize esophageal intubations.  Not that I think that the people posting in this thread would fail to recognize an esophageal intubation, but we're talking about the least common denominators, who increasingly have been given the discretion to paralyze and sedate their patients and intubate based on their judgment.

This study showed that 31% of all prehospital intubations could be considered "failed intubations."  An additional 12% were unrecognized esophageal intubations, which is the shocking part.  

Moving intubated patients is a very risky endeavor, especially if the tube is not properly secured.  Without the proper monitoring (ETCO2) and assessment, it actually CAN be life-threatening to intubate someone un-necessarily.

As several posters have pointed out, with this guy and his delicate airway, you only get one shot at this intubation before his vocal cords spasm and swell shut.  Depending on the swelling in his trachea, a surgical cricothyroidotomy may or may not be possible or successful.  He will die if he falls into that 31% of patients who experience a failed prehospital intubation. 

A 1 in 3 chance, just on the basis of being out of the hospital.  I wouldn't take that chance lightly, but I can completely support the idea of taking control of this airway.  It's just one of those times when you're either going to do really, really well, or you're going to kill the guy.


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## Shishkabob (Sep 29, 2010)

I hate studies about pre-hospital intubation.


Until they send anesthesiologist out into the field and find out THEIR averages, I pretty much won't trust the studies.  Totally different monster intubating in a clean OR against in a ditch. 


Let's send medics to ORs and record the success rate there, as that'd be a lot more viable and realistic in determining the success rate of medics, to which you can extrapolate out into the field and why things don't always go right.  





That, however, doesn't excuse not noticing a wrongly places tube, just the "missed" tubes everyone complains about.  But also, I'm weary about how many are "placed wrong" and how many shift during the move from the cot to the ER bed (which should be noted BEFORE it happens)


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## abckidsmom (Sep 29, 2010)

Linuss said:


> I hate studies about pre-hospital intubation.
> 
> 
> Until they send anesthesiologist out into the field and find out THEIR averages, I pretty much won't trust the studies.  Totally different monster intubating in a clean OR against in a ditch.
> ...



I don't put this against medics in general, but it needs to be noted that out of hospital intubations are more difficult and have more risk based on the fact that the patient is going to be moved a number of times before he comes to rest in the ER.

Given this risk, the fact that medics everywhere do NOT continually reassess and document tube placement, especially with almost universally available ETCO2 waveform technology is inexcusable, regardless of how weary we are of the stereotype.

I agree with you, take an anesthesiologist and have him intubate in the ditch (the numbers would likely be really similar to medics intubating, I would think) then move the patient to a backboard, then to the stretcher, then to the truck, then out of the truck and walk into the ER and transfer onto their bed, all while manually ventilating with a BVM.   The anesthesiologist, knowing the extreme risk of every one of those moves, would spend most of the ride reassessing the patency of the tube, and glancing at the waveform on the monitor.  

Why aren't medics everywhere doing the same?


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## MasterIntubator (Sep 29, 2010)

Bravo Linus!  I agree with you on this one.  Working in the field and past in hosp surg, they compare quite similar... of course, no one wants to compare in hosp and out of hosp stats.... but I would be fairly confident they are close.
The difference... of the 43% above stated failure, 95% of those were probably inexperienced medics who were not calm and rushed thru it trying to beat a time curve.  I watch adrenaline high medics rush thru things, forget landmarks, etc... not cool.
Ever watch an anethesiologist miss?  Its like another day in the park... "Ohh hum... guess I better try again.  They recognize it quick, and fix it quick.  And heck... when the first attempt fails, you have fiberoptic assisted direct larygoscopy... with those tools.... the chances of a failure can be dimished greatly.  Yeah, they have $$$$ tools, but we do too. 

Side effects.... the current outcome outwieghs the side effects of intubation.  Infection, irritation and weaning is an easier chore.  Just remember.... deep breath.... gooseflava... and relax with good thoughts of girls on trampolines. ( or guys..... ).  Can't be a total sexist.


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## Shishkabob (Sep 29, 2010)

I can pretty much guarantee we'll be hitting 95%+ success rates once video laryngeoscopy becomes standard.  No reason it shouldn't be, people just don't want to spend the $$$... which can be somewhat understandable in rural areas where they get 1 tube a month but not in cities.


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## abckidsmom (Sep 29, 2010)

Linuss said:


> I can pretty much guarantee we'll be hitting 95%+ success rates once video laryngeoscopy becomes standard.  No reason it shouldn't be, people just don't want to spend the $$$... which can be somewhat understandable in rural areas where they get 1 tube a month but not in cities.



But capnography hasn't even become standard...how can we look for a new toy that may help if the standard for now isn't even being met?


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## Shishkabob (Sep 29, 2010)

Leaving the DoT and getting with a agency that actually makes sense to run EMS, and then get on them about enacting laws.


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## Fox800 (Sep 29, 2010)

abckidsmom said:


> But capnography hasn't even become standard...how can we look for a new toy that may help if the standard for now isn't even being met?



Waveform capnography needs to be required for any agencies with tracheal intubation equipment. If it comes to a state DOH regulation that requires it, so be it. Having ETCO2 equipment available and not using it to verify tube placement should be grouds for loss of certification/licensure.


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## terrible one (Sep 29, 2010)

Seems we are getting a little sidetracked here, 
back on topic - pt needs a tube. Lower airway burns, c/o SOB, with a bark like cough = RSI ETT. Cases can be made for and against the helicopter, with the ETA of the truama center almost identical to HEMS ETA it is a difficult choice. I'm curious as to find out from the OP the decisions made (if it was a real call) and outcomes.


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## FLEMTP (Sep 29, 2010)

ok... im glad to see that a majority of you are on the same page with intubation.


This scenario is based on a patient i had in the not to distant past. I changed some minor details but the basic concept and presentation was the same. 

I too opted for a drug assisted airway, and intubated the patient.

After initial contact, the patient was medicated with fentanyl for pain, prior to complaint of shortness of breath,  which initially only brought the pain level to a 7/10. The patient was checked for signs of allergic reaction to the fentanyl and ruled out as a cause, just FYI

During laryngoscopy some mild redness was noted to the area above the glottic opening. the cords did not appear swollen or burned. There was some slight swelling of the airway. 

Intubation was performed on the first attempt with minor difficulty. The patient was adequately preoxygenated with a NRB mask for 5 minutes prior to induction, and was ventilated via BVM post induction for approx 2 minutes.

The intubation attempt took approx 15 seconds, and the tube was visualized passing the cords, and placement was confirmed via waveform capnography.

The patient was transported emergently to the trauma center 15 minutes away. 

The ER later complained that intubation was inappropriate as they felt the airway did not have sufficient edema or swelling.

I was called on the carpet to explain my "actions" and I wanted to make sure I was not alone in my choice to be aggressive with this particular patient.


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## Smash (Sep 29, 2010)

abckidsmom said:


> This study showed that 31% of all prehospital intubations could be considered "failed intubations."  An additional 12% were unrecognized esophageal intubations, which is the shocking part.



While I agree that 12% of ETI being unrecognized as oesophageal is pretty uninspiring (and totally unacceptable) I have to take issue with 31% of all prehospital intubations being considered as "failed".  More properly, what this study shows, is that in a limited timeframe, in one particular geographical area serviced by different prehospital care providers, a post-hoc study showed that in 31% of patients presenting to a single hospital, passing of an ETI was unsuccessful when attempted by paramedics in severly injured patients. 

This really doesn't come as a shock, given that these paramedics only average 1-3 intubations per year anyway!  If I didn't average 1-3 intubations per _week_ it would probably be because I was driving a desk somewhere.
What's more, as the authors concede, these patients are pretty mashed up anyway with a mean ISS of 40.  

Most importantly though we also see in this study some of the same factors that were in Wang's oh so brilliant study a few years back, although at least these authors admit to them.  

To wit:  Patients with traumatic injuries in whom an airway can be placed, without the use of appropriate pharmacology (sedation and paralysis) are not going to do well anyway.  They must have absent airway reflexes for ETI to be achieved (or even attempted in most cases).  So what we see is that patients that are so severely injured as to have absent airway reflexes and thus are able to be intubated without drugs, do very badly.  Does this really surprise anyone?

The authors acknowledge this to some extent with their comments on the differences between road and flight based medics success at intubation.  However I disagree that succinylcholine is solely a safety thing to prevent an agitated patient being flown.  Succinylcholine, along with appropriate sedation, is an absolutely vital part of managing the airway of brain injured patients.  It not only allows the best possible intubating environment, it also directly mitigates many of the deleterious effects of both the inital insult to the brain, and the subsequent assault on ICP that would otherwise be mounted during intubation.

There certainly seems to be issues surrounding prehospital intubation in North America.  My own personal feeling is that this is due more to the woeful levels of education and exposure (1-3 tubes a year!) rather than any inherent problem with the procedure itself.  To be fair, there _may_ be a problem with the procedure itself, but so far all we know from the research is that a procedure done poorly is bad for patients.

Interestingly enough, in Australia, where they do not seem to have the same problems with intubating that North America has, and where actual randomized, intention to treat studies have been carried out, there are favourable outcomes reported with prehospital intubation and RSI.


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## Smash (Sep 29, 2010)

*Sorry, posted while I was ranting.*

Sorry FLEMTP, your post appeared obviously while I was typing my rant.

It's very nice that the patient didn't deteriorate between you intubating him and arrival at hospital.  I always envy ER staff with their perfect 20/20 hindsight of scenes they were not at and situations they have no experience of...

I would rather be criticized by an ER person for treating a patient, than by the coroner or the courts when the patient died due to me not intubating him.


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## ccfems540 (Oct 2, 2010)

I too have transported to Lee Memorial Hospital and caught flack for intubating and not intubating.  I was scolded by a trauma surgeon for not intubating a patient with a GCS 14 that was confused.  This patient had minor lacerations to the face.  I have very mixed reviews about that facility.


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## JeffDHMC (Oct 5, 2010)

Once his voice changed indicating airway burns....nasal tube. Not the most fun method of airway mgmt, but he needs it. Sitting on this guy for more than a minute once you determine the need is likely going to result in a surgical airway.

Jeff


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## DrParasite (Oct 6, 2010)

abckidsmom said:


> It is not benign, by any means, to intubate someone.  There is a significant risk of infection, injury, and complications of mechanical ventilation.  Additionally, prehospital providers continually fail to recognize esophageal intubations.  Not that I think that the people posting in this thread would fail to recognize an esophageal intubation, but we're talking about the least common denominators, who increasingly have been given the discretion to paralyze and sedate their patients and intubate based on their judgment.
> 
> This study showed that 31% of all prehospital intubations could be considered "failed intubations."  An additional 12% were unrecognized esophageal intubations, which is the shocking part.
> 
> ...


hmmm 1 in 3 chance that he might have a failed airway, vs a 98% chance of dying when his airway swells shut and you are digging for an emergency surgical airway.....  which would you prefer?



FLEMTP said:


> The ER later complained that intubation was inappropriate as they felt the airway did not have sufficient edema or swelling.


hindsight is always 20/20.  They are forgetting the whatif factor; whatif the swelling increased, then what do you do in the field?   this isn't an ER, with lots of docs, lots of nurses, resp, anesthesia, light and space, all who can be waiting for you when for when you walk in the door.


FLEMTP said:


> I was called on the carpet to explain my "actions" and I wanted to make sure I was not alone in my choice to be aggressive with this particular patient.


ehhh, getting called on the carpet isn't too bad, assuming you can defend your actions.  Based on what you said, I would say your actions were in the best interests of the patient.  and if someone disagrees, just ask: if the swelling got worse, and we couldn't intubate, then what?


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## usalsfyre (Oct 7, 2010)

FLEMTP, who is calling you on the carpet? Is it the ED, or your medical direction. We have a local facility that does not like EMS doing pre-hosiptal pain control and/or sedation. For anything, at all. You could have a femur sticking out of your thigh and the physicians and nurses will give you a hard time  for an appropriate opiate dose and complain to the medical director. Our medical direction tells them politely to $crew off and the cyle is repeated. Unless my medical director or clinical education team is hassling me, I pretty much ignore it.


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## usalsfyre (Oct 7, 2010)

DrParasite said:


> hmmm 1 in 3 chance that he might have a failed airway, vs a 98% chance of dying when his airway swells shut and you are digging for an emergency surgical airway.....  which would you prefer?



While I agree intubation was approprite here, I'm not sure I agree with this statment. This is not a case where the cric kit can stay in the bag, a choice of last resort. Even though I know the sucker is 100 bucks plus, you better believe before I attempt to maniplulate this airway the ability to do a surgical airway will be out, ready and the skin over the neck preped. I've been lucky and haven't had to do a cric. I've been present for two, both in the ED, and both were faster than a conventional orotracheal ETI attempt. Hopefully some people who have done surgical airways for real can confirm or deny. 

An additional consideration is if I don't have paralytics or surgical airways. I'm not 100% on initially paralyzing this guy, but my Rocc would be ready to push in case I encountered or caused layrengospasm (one of the few cases where I would prefer succs, as the onset is slightly faster). As mentioned before, I'd be ready to do a surgical airway as well. If I can't do either one, I'm hauling *** to the closest facility that will accept me, espically if I think there is  anesthetists in house, as most facilties would have during the day or if they have OB services. I would notify the facility very early with what I had, and let the place that has the meds, equipment and training to deal with a potentially unstable airway take care of it.


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## FLEMTP (Oct 7, 2010)

usalsfyre said:


> FLEMTP, who is calling you on the carpet? Is it the ED, or your medical direction. We have a local facility that does not like EMS doing pre-hosiptal pain control and/or sedation. For anything, at all. You could have a femur sticking out of your thigh and the physicians and nurses will give you a hard time  for an appropriate opiate dose and complain to the medical director. Our medical direction tells them politely to $crew off and the cyle is repeated. Unless my medical director or clinical education team is hassling me, I pretty much ignore it.




Neither.. its our agency administration. They promoted a friend of our chief from a road paramedic to captain in charge of QA/QI issues. He has been with our dept about a year or so, tops. He was hired with a sense of entitlement because he is friends with the Chief, and seemed to exude the attitude that he should have been hired directly into a command position and becaues he wasnt, he now has a chip on his shoulder. He has character issues, and its nothing but rude and condescending to people when he "discusses" a call with him... its more or less him saying "this is not how *I* would have handled the call, so you're going to change your behavior.

 If you challenge him, his ideas, or his "authority" at all, then he takes measures to have you clinically restricted in your practice as a paramedic.  He has also taken to referring to our guidelines (which are just that.. guidelines) to protocols, and he can't seem to get through his head that we have always been encouraged to think outside the box, and to do what is appropriate for the patient vs what the book says. 

He was told by the last agency he worked at that it was time he retire before they assisted him with his moving into retirement.

He needs to go. He's been in EMS 30+ years and that's always his rationale for why he is right. 

If something isnt done soon, our agency is going to lose some good people.. myself included.


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## usalsfyre (Oct 7, 2010)

FLEMTP, without knowing how involved your physician medical director is, or how well you know him, is there anyway to get him involved in this case? Overzealous, disciplinary QA/QI is a fast road to no good, including poor retention of medics and inaccurate (read, lying so you don't get hassled) doccumentation. I very seriously doubt he would support this. Of course this may also paint crosshairs on your back. 

Remember folks, 30+ years in EMS could mean an experinced 30 year medic, or a medic with 1 year of experince, 30 times...


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## FLEMTP (Oct 9, 2010)

usalsfyre said:


> FLEMTP, without knowing how involved your physician medical director is, or how well you know him, is there anyway to get him involved in this case? Overzealous, disciplinary QA/QI is a fast road to no good, including poor retention of medics and inaccurate (read, lying so you don't get hassled) doccumentation. I very seriously doubt he would support this. Of course this may also paint crosshairs on your back.
> 
> Remember folks, 30+ years in EMS could mean an experinced 30 year medic, or a medic with 1 year of experince, 30 times...



I have a meeting with our medical director on Monday, a one on one. Im going to voice my concerns with him then. Our MD is a very reasonable and very understanding guy...but he also expects you know your job and do it appropriately. 

I will be bringing this up. The higher ups look at more QA/QI as a good thing.. but the problem is, if its not the way THEY would have ran they call.. the pull you in for a meeting. Not everyone practices medicine in the same way.. and micromanaging a paramedic on a medical treatment level isn't going to go over well... and its just not going to work. No 2 medics run the same call the same way. 

I really like your statement at the end of your post. Im going to thieve that for future use!B)


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## rhan101277 (Oct 9, 2010)

FLEMTP said:


> I have a meeting with our medical director on Monday, a one on one. Im going to voice my concerns with him then. Our MD is a very reasonable and very understanding guy...but he also expects you know your job and do it appropriately.
> 
> I will be bringing this up. The higher ups look at more QA/QI as a good thing.. but the problem is, if its not the way THEY would have ran they call.. the pull you in for a meeting. Not everyone practices medicine in the same way.. and micromanaging a paramedic on a medical treatment level isn't going to go over well... and its just not going to work. No 2 medics run the same call the same way.
> 
> I really like your statement at the end of your post. Im going to thieve that for future use!B)



My company can have meetings with me all day long.  It is like you said every paramedic will treat every call differently.  That does not mean you made bad decisions on your call.  If the patient was treated appropriately that should be all that is needed to be known.  I know some medics that don't take vitals until patient is in truck.  I like to get mine when I lay eyes on the patient.  It only takes a couple minutes. 

Trauma patients are different ABC's.  Do they have a radial pulse etc.


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## firetender (Oct 9, 2010)

*Sorry; GROSS overtreatment!*



FLEMTP said:


> 21 yo male with facial burns
> 
> He *states *his face burns.
> 
> ...



#1. *Mechanism of injury;* _*blast *_of steam to the face from a radiator of a car that had ALREADY COOLED DOWN for 1/2 hour. No prolonged exposure, not a direct hit into mouth/trachea

#2. Alert, conscious, _*talking 1/2 hour AFTER the fact*_, *Minimal visible signs of injur*y, only complaint of pain...AROUND THE EYES!

#3. Time elapsed w/o incident; at least 40 minutes from time of incident until medic feels need to take action

#4. chief complaint of patient? "states he is scared"

*Where in the protocols does it say "intubate for fear"?*

_*No kidding, I'm sorry...ALL OF YOU, this is absolutely ridiculous*_ 
and shows WHY everybody is watching and waiting for you to screw up and is ready to pounce when you do!


You DO NOT get a 45 minute DELAYED REACTION from burns (with negligible signs of trauma) that would come close to warranting _*SEDA**TION and INTUBATION *_in a case with such a limited impact.


*The patient had NOTHING to warrant intervention other than taking the time to provide reassurance and support during a time when he was alarmed.*

What you did was not really intervention; it was placing the patient at risk. To be blunt, you made such poor judgment on this one, I'm amazed you didn't screw up the sedation/intubation. Your safety net was less than 10 minutes away, my friend for a patient that was in ZERO danger, as evidenced NOT ONLY by subsequent examination, but by the very case you presented. 
*
FIRST WORK WITH YOUR PATIENT!* You missed the most important thing and it really could have cost this patient his life.

Here's where you get to really learn. This suggests to me you need to take a real good look at what you know, what you don't and why you jump to extreme paramedic/Doctor when being a humble EMT would suffice.

Please, look at this all carefully. Good luck on your review, but I wouldn't advise resistance.


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## medic417 (Oct 9, 2010)

Fire this could be a chemical reaction as much if not more than a steam burn and thus could be slower in developing the edema in the airway or worse fluid filling the lungs as a reaction to the toxins.  

Don't blindly say over treated.  To many possibilities that could make this nothing but a panic attack or an actual death eminent call.


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## Veneficus (Oct 9, 2010)

Firetender,

I have the highest respect for your opinions and input, but I respectfully disagree this time.

I think early intervention in the form of RSI was absolutely the best choice and I would have done the same.

From the initial discription I think due caution and an attempt to go without the advanced airway was properly made. Upon reassesment of the patient, and the potential for a catestrophic decompensation, which may have required a surgical airway, which may have been too little too late anyway, the decision to intervene was the only logical one.

In addition to the rather minor burn, it is importsnt to remember in the oral cavity, there are microbes that that potentiate an inflammatory and immune response which would cause additional swelling.

I would rather err on the side of intubating an not needing it in this case than not being able to intubate later or making it considerably more difficult.

Just my take on it.


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## MrBrown (Oct 9, 2010)

We had a guy like this the other week who had a face full of second degree burns.

He had no signs of any difficulty in breathing, increased work of breathing, normal breath sounds, no soot in the mouth, throat or nose, no singed nasal hairs or really anything that wpuld be problematic other than he was in a lot of pain.

Neither us nor the hospital intubated him (we did call for an RSI capable Intensive Care Paramedic) but the ICP gave him a lot of ketamine and we went off into space on what was hopefully a nice journey.


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## Akulahawk (Oct 9, 2010)

Just remember, this was a steam event, not a flame event. You won't see singed hair or soot because nothing was on fire.


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## dmiracco (Oct 10, 2010)

RSI absolutely


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## Smash (Oct 10, 2010)

Akulahawk said:


> Just remember, this was a steam event, not a flame event. You won't see singed hair or soot because nothing was on fire.



Water also holds and transmits thermal energy more effectively than gas/air, so one must assume that the potential for lower airway injury would be greater.


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## firetender (Oct 10, 2010)

Veneficus said:


> I think early intervention in the form of RSI was absolutely the best choice and I would have done the same.



I'm thinking I'm so damn old that I'm the only one who remembers that cars used to have fragile radiators that boiled over and it was COMMON for people to get 2nd degree burns exactly as the victim of the OP got!

Vene, it was a radiator-boiling over FLASH of steam, NOT prolonged causing MINOR irritation to the eye area which, clearly, took the HIT. In the absence of the pt. directly INHALING the steam blast, his eyes would have to have been bubbling mush before his airway would be affected.

One fatal flaw in the narrative, which now makes me wonder how legit the post is, _*when was the last time you got a conscious patient to okay you to intubate him?*_

*Let me make it perfectly clear to all of you, Under NO circumstances will you intubate me while I'm conscious and can keep enough air moving to stay conscious. Got it?*

How did the OP talk this guy into getting tubed? Answer me that, and then, I'll ask you another question.


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## Veneficus (Oct 10, 2010)

firetender said:


> One fatal flaw in the narrative, which now makes me wonder how legit the post is, _*when was the last time you got a conscious patient to okay you to intubate him?*_



Actually it has been a while, but I did have a frequent flyer asthma patient that when she would go into extremis she would actually ask to be intubated and tell us if it didn't happen she would crash. Which was actually true.

Aside from that, people get knocked own and intubated all the time in same day surgery.

Patients in extreme pain are intubated in order to be able to better control the pain. Most patient requests are denied, but it does happen.



firetender said:


> How did the OP talk this guy into getting tubed? Answer me that, and then, I'll ask you another question.



I can't answer that for him, but I can offer how I would have approached it.

"Sir, there is the possibility that you suffered an injury and the effects of such that may compromise your airway which will leave you unable to breath. Should that happen it maybe difficult to insert a breathing tube if not impossible. If that happens we may need to cut a hole in your neck in order to make sure you can breath."

"I would ask your permission to give you some medication to knock you out and insert a breathing tube now. The procedure is not benign and there are several complications that may result. These include infection, damage to the airway/vocal cords, medication reactions, and can possibly result in a longer hospital stay or even death."

"In my opinion, inserting the breathing tube is the best option right now to both manage your airway and relieve your pain. However you are free to choose to permit me to do this, refuse to have this procedure, or tell me what you would like and if possible I will do my best. At anytime prior to the procedure you may change your mind. Howver, once we give you the medication you will be unable to convey your wishes."

"How would you like to procede?"


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## firetender (Oct 10, 2010)

Veneficus said:


> "Sir, there is the possibility that you suffered an injury and the effects of such that may compromise your airway which will leave you unable to breath. Should that happen it maybe difficult to insert a breathing tube if not impossible. If that happens we may need to cut a hole in your neck in order to make sure you can breath."
> 
> "I would ask your permission to give you some medication to knock you out and insert a breathing tube now. The procedure is not benign and there are several complications that may result. These include infection, damage to the airway/vocal cords, medication reactions, and can possibly result in a longer hospital stay or even death."
> 
> ...



Honestly? If I was still alive by the time you got to the end of your pitch, I'd know I'd last long enough to get to the hospital without you messing with me. And Jesus! Quit talking and get me there.

*And Vene, Really, a simple steam burn?*


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## Veneficus (Oct 11, 2010)

firetender said:


> Honestly? If I was still alive by the time you got to the end of your pitch, I'd know I'd last long enough to get to the hospital without you messing with me. And Jesus! Quit talking and get me there.
> 
> *And Vene, Really, a simple steam burn?*



"5-10 minutes into transport *he begins to complain of shortness of breath*, and you notice he is *coughing quite a bit.* You note his Sp02 is now 95% on room air, and when *he coughs he has a slight barking quality to it.* His respirations are now 28, and he does appear to have some mild difficulty breathing. He is becoming anxious, but has no history of anxiety, and states he is *scared because he cannot breathe." *

Barking, usually describes the *upper airway obstruction* of croup. So it sounds as if there is some sort of inflammatory process going on in the upper airway.

There is no way for either of us to know just how much of an inflammatory response there will be. 

What happens if I intubate and I am wrong? The tube gets yanked in the ED and the drugs wear off.

What happens if I don't intubate and I am wrong? I lose the airway or such a sizable portion of it that it is no longer patent. Now I have to cut with a knife. 

Despite the fact I like cutting, and I am always happy to get a chance, my favoritism is not always best for the patient. Sometimes decisive surgical intervention is the proper/only treatment, but if it can be reasonably avoided, why shouldn't it be? If a properly timed intervention could potentially stop the use of a knife, why shouldn't it be used?

It all boils down to potential and risk stratification. Your assumption is that the patient will not deteriorate. My assumption is it could stay the same or get worse. 

I am not really a fan of Spo2, I find its usefulness rather small, so the number doesn't really concern me. But a patient getting anxious because he feels like he can't breath and a barking caugh.

I am sure we have both on many occasions seen patients who appear stable with a sense of impending doom just prior to things taking a turn for the worse. 

I cannot explain how they have this forsight, or wavelength, but experience has taught me to take it very seriously.

Might the RSI be an over reaction, sure, but with the info presented here, I would do it.

As an alternative, perhaps some albuterol or some recemic epi. But I think if EMS is trying to reduce inflammaton on a burn victim, the question becomes "why didn't you intubate?"

Having the pt tubed and mechanically ventilated can also protect the airway and take away pain/anxiety until some longer term anti inflammatory treatment can  be performed.


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## Charmeck (Oct 14, 2010)

Worse case, You can always call the bird.  I dont know of any flight services that dont have advanced airway abilities and a vent.  This is of course, if you dont have the ability to procure any advanced airways.


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## Akulahawk (Oct 15, 2010)

Charmeck said:


> Worse case, You can always call the bird.  I dont know of any flight services that dont have advanced airway abilities and a vent.  This is of course, if you dont have the ability to procure any advanced airways.


Charmek: I wouldn't call the bird. Why? The closest ED is about 7 minutes away, the L2 Trauma Center is 15 minutes away and the Helo is 10 min away. The Helo crew is NOT going to be able to just hop out and drop a tube. You go to the pad to wait for them, when they land, they still have to gather their equipment and exit the ship, walk over to your ambulance and begin doing their assessments. Then you still have the transport decision: air or ground and you're no closer to the ED than when you first started, and probably "further" as you'd still have to load the patient into the helo if air transport was chosen, even though flight time would be short: maybe 2-3 minutes.

While it's a great asset, in urban areas, a helicopter _usually_ does not make sense. 

At least the ED (any of them) would be able to have some kind of pre-arrival warning of a patient that may be in dire need of a surgical airway and be ready for your arrival.


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## Veneficus (Oct 15, 2010)

Charmeck said:


> Worse case, You can always call the bird.  I dont know of any flight services that dont have advanced airway abilities and a vent.  This is of course, if you dont have the ability to procure any advanced airways.



??? I am lost.

The OP was presenting a case in which he was faced with the decision to RSI a patient or not. The OP also has a circ away available.

What is the point of calling a helo or how did a discussion on this develop from the post?


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## Akulahawk (Oct 15, 2010)

Vene: in the original post, there was mention of a helo being available in 10 minutes and an LZ 5 minutes away (you go there, you wait 5 more minutes for the helo...) Nice asset, but the nearest basic ED is about 7 minutes away. Real difficult failed airway decision... ED or Helo...


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