# Trismus Intubation



## Rangat (Oct 21, 2007)

Hey all

So what are your opinions on a PVA pt with a clenching jaw and a GCS of 5?

What happened was after 20mg of Morphine and 20mg of Midazolam he was unconscious, but still clinching too much to get a proper view of the cords.

A good candidate for blind nasals, i know.

So would you give him even more sedation until you can intubate him, or turn lateral until they can RSI him in the ER?h34r:


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## Ridryder911 (Oct 21, 2007)

The problem is he had a sedative, not a paralytic (which would had reduced muscle tension). Whenever 20mg of Morphine is given, I would wonder about the dangers why, anyone would administer such a high dose with associated Versed. 

Face it, you are not going to knock them down if M.S. (10mg) and especially Versed (20mg). Now, you might have a potentially dangerous situation with lowering the blood pressure (since both will), potential bradycardia and inducing coma state unnecessary. 

This part of the problem with partial RSI or induced medicated intubation techniques. I would say the paramedic should had protocols permitting paralytic (muscle relaxer) such as succinylcholine or another; but judging by the amount or sedatives given, I can see why. As well, it is now being demonstrated induced narcotic unresponsiveness has a higher percentage of laryngospasms, and inability to intubate. Thus, the reason I will no longer use just pharmacological methods for < LOC without paralytics. 

There are tons of articles in regards to this type of scenario. 

R/r 911


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## Flight-LP (Oct 21, 2007)

3 words............Etomidate and Succinylcholine................Problem solved!


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## Hubbie (Oct 22, 2007)

Flight-LP said:


> 3 words............Etomidate and Succinylcholine................Problem solved!



I have to agree with you on that one, give those two drugs and your pt will clentch no more!


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## eggshen (Oct 22, 2007)

4 words 'round here. BNTI. At least for those of us that learned how to do it.

What is PVA?

Egg


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## Rangat (Oct 22, 2007)

PVA- Pedestrian Vehicle Accident

What is BNTI? Another word for RSI?



I agree that paralytics or inducers are the way to go. And luckily when I graduate in 2 years Ill have paralytics on a stand alone protocol.

I deduct from you guys that you wouldn't give more sedatives coz of the side effects? So turning lateral until hospital was ok?


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## Ridryder911 (Oct 23, 2007)

I am supposing Blind NasoTracheal Intubation.. which could be considered, but if you are going to sedate, then one might as well paralyze. My view point is if you trust your medics to intubate and administer sedatives, one might as well give authority to paralyze. 

Bil-lateral NPA's with normal suctioning and removing of secretions PRN. Sure, laying lateral is okay, but now you have probably knocked down some of the respiratory rate.. Closely monitor and assist ventilation's PRN with BVM, etc. 

R/r 911


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## Flight-LP (Oct 23, 2007)

RSI vs. blind nasal intubation has been shown to be safer, more successful, and quicker. Not to mention the possible ramifications of sticking an ET tube up someones nose with a potential closed head injury. BTNI was great in its day, but now has really fallen to the wayside with the progression to NMBA induction.


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## Rangat (Oct 23, 2007)

OK well an OPA was in place and he was still breathing at a good depth and rate.

Advice appreciated.

Thanks


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## eggshen (Oct 26, 2007)

What I would give for RSI. One would think that it simply does not exist in the EMS realm here. Granted, we have a very high success rate w/ nasal intubation but what a drag. I got got my practice and got it out of my system and now wish we had something else. BNTI is not fun (to say the least) for your pt. 

Egg


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## Grady_emt (Oct 26, 2007)

We dont have RSI in GA, at least for street level medics.  Flight Medics can, but no EMS system that I know of allows it.

As for BNTI, we had it up until this summer, but our Medical Directors in all their insightfulness removed that protocol from our skill set.  They said that it caused too much naso-pharengeal trauma when not done properly.  Also, supposedly we were sitting on scene too long instead of trying to get to the ER for definitive tx.  To that degree I can understand as our average Emer. transport time is 5-6 minutes, but there are however a few areas of our zone and MA response area that are 20+ minutes emergent drive from an ER. 

 We are only allowed to call the whirleybird if we are way-way-way out and the pt is a pediatric pt.  That just started being allowed about 4 months ago and no crew that i know of has utilized it yet.


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## eggshen (Oct 27, 2007)

This is something that I am rather torn about. I dislike BNTI but I think there may be a place for it. I feel that under the right circumstance it is a good thing but without practice on real people you can never really become good at it. I also think that you should not practice it on real people. So where do we go from here? Last year we kicked down a study going on about how great we are at dropping nasal tubes. Big deal, I kinda thought the more progressive systems are into the RSI thing. If you are face to face with a silent chest I think being able to drop a nasal tube smartish is a real good thing. However I say this having NO experience with RSI in the field. I will steer off for a moment and thank the inventor of CPAP. Anyway, not having experience with RSI and having more than enough with BNTI I think you should have at least one of the two. Why would your boss doc not give you either (not sure how GA rolls)? Long story short I am glad I can nasally tube most if I have to but I would love to have a much better option at hand. 

Another option would be to do as your "Gaurdian" would do. Chuck your "common sense" and maybe get a real detailed hx on that silent chest and them come up with 19 things for your diff/dx (never mind the 1 word dyspnea, that would imply using common sense). After that you may want to consult with your partner for a spell if you are still unsure about the etiology of the s/sx (god forbid you act like a "cowboy" and move fast on this one). Some time after that you might wish to state "Holy S**T!!!! I am way out of my league and should just flake out and let someone with some idea of how to manage a call take this person to the hospital". Goodness!!! I am sorry for that! A bit childish eh? So sorry. Really I am. Just kinda thought that if I am to be called a b**ch on the PM maybe I should respond in kind here. 

A bit of advice for new medics that do BNTI.
DO NOT tell your pt. that there will be some "pressure" in their nose or something along those lines.
DO NOT tell them it will be "uncomfortable". 
In fact DO NOT tell them ANYTHING short of "it is terrible and you will hate me and ALL paramedics after this".
I used to say these things, things that I heard other medics say. This was until I was told these things prior to ME "buying plastic".
It is nothing short of a very bad thing to endure. 

Egg


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## Grady_emt (Oct 27, 2007)

eggshen said:


> This is something that I am rather torn about. I dislike BNTI but I think there may be a place for it. I feel that under the right circumstance it is a good thing but without practice on real people you can never really become good at it. I also think that you should not practice it on real people. So where do we go from here? Last year we kicked down a study going on about how great we are at dropping nasal tubes. Big deal, I kinda thought the more progressive systems are into the RSI thing. If you are face to face with a silent chest I think being able to drop a nasal tube smartish is a real good thing. However I say this having NO experience with RSI in the field. I will steer off for a moment and thank the inventor of CPAP. *Anyway, not having experience with RSI and having more than enough with BNTI I think you should have at least one of the two. Why would your boss doc not give you either (not sure how GA rolls)? *Long story short I am glad I can nasally tube most if I have to but I would love to have a much better option at hand.
> 
> Egg



Well I looked at the protocol again, and we still technically have BNTI, but we have to call and get orders.  Isked our training guru yesterday and they said only one person has called and asked for orders and it was denied (not sure on circumstances) in the 4 months since it changed.  She said prior to that we were doing 10-15 or so a month as an agency (300 employees, 100k calls annually).

We do have CPAPs coming hopefully faily soon, once some financial issues are cleared up with the parent hospital.  It will be great once they are all up and going.

As for GA, we are just a**backwards when it comes to lots of things.  Still dont have a regulated/funded statewide trauma system.  One of the level I trauma centers is $50million in the hole, and scheduled to start cutting services after Thanksgiving barring and infusion of cash.  Two of the other three Lvl I centers are contemplating dropping trauma status.  No RSI for street medics.  NREMT-I85 not I99 level...the list goes on


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## ccfems540 (Oct 27, 2007)

What is NMBA?  I have never heard of it.


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## Flight-LP (Oct 27, 2007)

Neuro-Muscular Blocking Agent.............


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## Flight-LP (Oct 27, 2007)

Grady_emt said:


> Well I looked at the protocol again, and we still technically have BNTI, but we have to call and get orders.  Isked our training guru yesterday and they said only one person has called and asked for orders and it was denied (not sure on circumstances) in the 4 months since it changed.  She said prior to that we were doing 10-15 or so a month as an agency (300 employees, 100k calls annually).
> 
> We do have CPAPs coming hopefully faily soon, once some financial issues are cleared up with the parent hospital.  It will be great once they are all up and going.
> 
> As for GA, we are just a**backwards when it comes to lots of things.  Still dont have a regulated/funded statewide trauma system.  One of the level I trauma centers is $50million in the hole, and scheduled to start cutting services after Thanksgiving barring and infusion of cash.  Two of the other three Lvl I centers are contemplating dropping trauma status.  No RSI for street medics.  NREMT-I85 not I99 level...the list goes on



That is horrible that you have to call and ask someone if you can secure a patient's airway! I truly hope things better for you................

And don't hold a lot of hope on CPAP. Everyone is lovin' the CPAP and most are giving it at the wrong time! Think about this for a minute. You generally have three types of pts. medically that you would need to intubate; Asthmatics, COPD'rs, and CHF'rs. The CHF'rs will benefit from CPAP, but did you know that in "dry" pts. i.e the other two, CPAP is actually contraindicated? All too often I see pts. brought into ER's from other services with their Asthma pts. being CPAP'd instead of being intubated. They find out quickly that they have wasted their time and possibly worsened their pts. condition.

You have to have something available for these pts. to secure their airway and get them to ventilate. RSI, PAI, BNTI, something. But CPAP is not the answer.


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## ASTMedic (Oct 27, 2007)

I have one very quick question:

How were the pt Sa02 on a NRB mask to start with? Did they need to be intubated? I know it's a more secure airway but did they NEED it?



> OK well an OPA was in place and he was still breathing at a good depth and rate.



Again SaO2?

I agree with Egg, Load'n Go. (Or call for Air if you need to)

I tell my students all the time BLS before ALS.


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## Flight-LP (Oct 27, 2007)

ASTMedic said:


> I have one very quick question:
> 
> How were the pt Sa02 on a NRB mask to start with? Did they need to be intubated? I know it's a more secure airway but did they NEED it?
> 
> ...




Acute traumatic injury with altered mentation reducing the GCS to a 5, and a clenched jaw. He needs to be intubated, period. SPO2 is irrelevant.  The question here is more the methodology associated with the intubation. Perfect example of when RSI is indicated.


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## Ridryder911 (Oct 27, 2007)

ASTMedic said:


> I have one very quick question:
> 
> How were the pt Sa02 on a NRB mask to start with? Did they need to be intubated? I know it's a more secure airway but did they NEED it?
> 
> ...



I hope you tell your students it is SpO2, not arterial saturation, and that one should be *treating the patient, NOT the monitor*. Personally, I could care less what the SpO2 numbers say! 

Are you going to await to secure an airway on a patient with a "clinched jaw"? Allowing aspiration and hypoxia to occur before you take action? Remember, it may take up to 3-4 minutes of hypoxia before the tissues start to desaturate. If the patient has already desaturated, and you awaited for the numbers to fall, your NEGLEGENT. 

As well WHY DOES THIS PATIENT NEED AIR TRANSPORT? What does an aircraft have to do with any treatment?  Why is this a common response? It has been proven air transport does not change outcomes, unless one is very rural > 30 minute transport time. Sorry, if you are able to provide ALS and did not, your negligent in care. 

You describe Load-n-Go.. again why? Yes, do not delay transport, but take care of the patient. This patient needs an secure airway. 

Administer some Versed nasal, then intubate them. If the trismus has decreased and has relaxed and if one is able to place an oral airway in, one should be able to intubate. If you can't; then place an alternative airway.. i.e. combitube. 

Now, I have not read of the detailed assessment, but this is a trauma patient? Is there facial fractures, or potential palatine fractures blind nasal intubation is contraindicated. Again, if they have a GCS of 5 and they are able to communicate and are alert enough to fight, we have a problem. Either because the medic does not know how to calculate a GCS appropriately, or the patient is not as represented with "clinched jaws". 

One better decide which airway (such as BNI) way before administering narcotics, which decreases respiratory drive. Ever BNI a non-breathing patient? Especially trauma without manipulating the neck? I have and it is HE*L! Yes, it can be done but very tricky!  

I suggest that many read current literature on airway management and if possible take a course such as SLAM to be proficient. 

R/r 911


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## ASTMedic (Oct 28, 2007)

Ok sorry about the spelling (SaO2) I was writing that after a 13hr day. FYI I'm writing this on my iPhone at work so you might want some of that nasal Versed cus i may have made some spelling errors.

Whoa guess I hit a hot subject for someone! Also when did i say sit and do nothing. You keep using the neglegent statement. Some of us in the world cant give medication to allow for intubation. None Nada Zip Zero! I was making a loose statement and not writing protocols here. So are you saying that I should BNI this pt? A trauma pt with poss fractures? Or stick a little straw in their neck and hope that does the trick?

I will answer this in parts:

Load and Go- What is the point of sitting on scene just to provide ALS care. I'm 4 min from the hospital. Do I sit on scene to do ALS care or load the pt with a BLS airway, drop a line enroute, and get to the hospital where 10 times the hands are ready with 20 time the tools? It used to be done ALL the time. 

Air ambulance- You must work in an area that has short transport times or a nice scope. I am anywhere from 5-90 min from a level 3 that wants nothing to do with a head injury that has a GCS of 5. So I have two options: 1) Load and Go and make a 30-45min drive to one of the two closest level 2 or 2) Think ahead and call for an air ambulance to take the pt to one of those two hospitals. An air ambulance that can also RSI and I can't.


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## eggshen (Oct 28, 2007)

_And don't hold a lot of hope on CPAP. Everyone is lovin' the CPAP and most are giving it at the wrong time! Think about this for a minute. You generally have three types of pts. medically that you would need to intubate; Asthmatics, COPD'rs, and CHF'rs. The CHF'rs will benefit from CPAP, but did you know that in "dry" pts. i.e the other two, CPAP is actually contraindicated? All too often I see pts. brought into ER's from other services with their Asthma pts. being CPAP'd instead of being intubated. They find out quickly that they have wasted their time and possibly worsened their pts. condition_

We CPAP asthmatics using in line nebs. Can you hook me up with the info somewhere stating that it is a bad idea. We have been doing it for about 18 months or so and I have seen more than one asthmatic turn around. Anything I can find regarding this would be terrific.

Egg


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## Mr. Anderson (Oct 28, 2007)

Ridryder911 said:


> One better decide which airway (such as BNI) way before administering narcotics, which decreases respiratory drive. Ever BNI a non-breathing patient? Especially trauma without manipulating the neck? I have and it is HE*L! Yes, it can be done but very tricky!
> 
> 
> 
> Huh? I'm assuming by BNI you are refering to blind nasotracheal intubation. If that's the case, I'm eagerly awaiting the story behind how you did this with a non-breathing patient.


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## Ridryder911 (Oct 28, 2007)

Simple, one introduces into the trachea without the aid of respiratory movement. One can feel tautness, and "pop" as it goes through the glottic opening. Just blind intubation. 

Like I described not easy, but can be accomplished. 


R/r 911


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## eggshen (Oct 28, 2007)

I have done it a few times. Not easy but it can be done. Where nasal intubation in a breathing pt. is a combination of skill, technique, finesse and cooperation of the pt. the same in an apneic pt. is mostly luck and some decent anatomy.

Egg


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## Flight-LP (Oct 28, 2007)

eggshen said:


> _And don't hold a lot of hope on CPAP. Everyone is lovin' the CPAP and most are giving it at the wrong time! Think about this for a minute. You generally have three types of pts. medically that you would need to intubate; Asthmatics, COPD'rs, and CHF'rs. The CHF'rs will benefit from CPAP, but did you know that in "dry" pts. i.e the other two, CPAP is actually contraindicated? All too often I see pts. brought into ER's from other services with their Asthma pts. being CPAP'd instead of being intubated. They find out quickly that they have wasted their time and possibly worsened their pts. condition_
> 
> We CPAP asthmatics using in line nebs. Can you hook me up with the info somewhere stating that it is a bad idea. We have been doing it for about 18 months or so and I have seen more than one asthmatic turn around. Anything I can find regarding this would be terrific.
> 
> Egg



Yea, I'm trying to find a study I read recently...........I'll get back to you.

The issue that I have and the view of our medical director is that Asthma being an obstructive issue vs. an air exchange issue would be better served by focusing on the inflamation (i.e. steroids, b2 agonists), instead of increasing the probability of barotrauma. If they are going into failure and are inflammed, CPAP will do nothing for the inflammation. Therefore, do you really believe it will help slow their breathing to the point where they can control their respiratory cycle? More often than not, the answer is no. In fact the mask itself usually produces further anxiety. If it hits that point, they need to be intubated. They need to give their lungs some much needed rest. CHFr's onn the other hand can and usually do show an immediate improvement to the forced opening of the alveoli. Thats our take on it anyways..............

We do inline treatments through the BVM. Usually works wonders.................


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## eggshen (Oct 29, 2007)

Eagerly awaiting.

Thank you
Egg


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## natrab (Nov 23, 2007)

In respect to RSI, I wish we had it.  The patient described is exactly who needs it.

As a fellow California medic, I understand the air ambulance thing.  Let me explain.  I work on the coast and my transport time by ground to a trauma center is about 30-50 minutes.  Granted, it usually takes an air ambulance 20 minutes to get to scene (and for some stupid reason the auto-launch protocol is not being followed in comm.), 10 minutes to load, and 20 minutes back to the trauma center.  With this pt in particular, I would wait the extra 10 minutes for the air ambulance simply because they can RSI and protect the pt's airway and it will happen in 20-30 minutes rather than at the end of the golden hour when we finally get to the hospital.  I think it's ridiculous that we're forced to think that way (who wants to sit on scene or at an LZ with a severe trauma pt?), but they just don't allow us to RSI.  Typically we'll get the equipment set up, a nurse from the chopper will jump in with a drug bag and do the RSI before loading up.  Could have happened 10 minutes ago and we'd have beat them to the trauma center anyways.

I don't mind if they put limitations on RSI, but please give us the option so I don't get stuck watching my patient lose their airway on a winding road in the mountains on the way to a hospital.


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## burntbob (Nov 23, 2007)

*blind nasal*

As they always say, BLS first-- good airway, 02, careful ventilation, cautious suctioning  and good C spine control. Last thing you want is an airway full of blood and a vomiting patient.
Then ALS--If you don't have  an ALS  backup  Plan B  for when you've snowed them and taken away their breathing centre you better be good at BLS airway. 

Blind nasal is contrindicated up here for traumatic head injuries due to the risk of cranial intubation ......It's still a great skill and useful when you need it, we still get the old CHF'ers who point at their nose when you come in since they know what will  buy some time  when they are all tired from fighting the fluid in their lungs.
theres a neat gadget that fits on the tube and whistles when you get into the trachea called the BAM. Some guys here swear by it.


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## emtd29 (Nov 24, 2007)

Grady_emt said:


> We are only allowed to call the whirleybird if we are way-way-way out and the pt is a pediatric pt.  That just started being allowed about 4 months ago and no crew that i know of has utilized it yet.




OK I know this is off topic but...

WHAT?

OK let me get this straight...

you're way way way ( ie  20 miles the other side of nowhere ) out with an adult pt that would more than likely benefit from air transport vs. ground, you CANNOT call for a bird???

However, if you have a kid in the same situation, you CAN call for the bird??

I don't get it.


Something fishy there....


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## Ridryder911 (Nov 24, 2007)

burntbob said:


> .
> theres a neat gadget that fits on the tube and whistles when you get into the trachea called the BAM. Some guys here swear by it.



I posted a training video, that uses the "whistler" used to be known as the BAM. 
http://www.youtube.com/watch?v=HXjPdNSL96c



> Grady: "We are only allowed to call the whirleybird if we are way-way-way out and the pt is a pediatric pt."



That is a * dangerous* movement. Age discrimination is definitely noted, if you recognize the reason is needed for rapid transportation to a more definitive center. I highly suggest, that the EMS and Hospital legal team review this policy. It is a setting time bomb, one I would not want to be involved in. 

R/r 911


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## natrab (Nov 29, 2007)

I'm hoping he meant _or_ the pt is a pediatric.  That would make more sense in both trauma and medical scenarios.  It would make no sense to require a long ETA _and_ the pt to be pediatric.


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## pa8109 (Dec 8, 2007)

I know that this is a late post, but reading about a pedestrian struck with a GCS of 5 and a clenched airway I had a few things come to mind.  PA does not allow ground units, except a select few, to carry paralytics.  Some services carry Etomidate which it sounds like that in this case would work perfectly.  Now I realize that every patient is different, and its easy for one to sit and discuss how to treat a critical patient after that fact.  I was just suprised to hear that in regards to the increase risk of intracranial trauma from BNTI that no one mentioned a surgical airway.  If there was any doubt that a BNTI would cause more harm than good because of head/facial trauma, why not perform a cricothyrotomy?  Maybe I may have misread a thread or two, but I got the impression that this patient had some pretty severe head/facial trauma.  If it was my last resort, I'd look at a surgical airway.

In regards to the CPAP on "dry" patients, i.e. COPD patients, I find it interesting that there is debate about this.  I understand both sides of the arguement.  Our statewide protocols place strict warning on intubating patient with exacerbations of asthma and COPD without attempting CPAP first. I will quote, not to say its right or wrong but this is straight from the book "WARNING: Although sometimes needed, intubation further narrows the airway restriction in a severe asthma exacerbation, and this may worsen some cases.  Aggressive use of bronchodilators is generally the most important therapy for severe asthma exacerbation"  I have used CPAP on several asthma patients with in-line albuterol treatments and found marked improvement.  Every patient I've known to have been intubated has died.  Not to say that I've completed a research study on it, but in this area CPAP is beggining to take precedence over intubation in severe COPD exacerbation.  Any thoughts?


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## bonedog (Dec 15, 2007)

Intubation of asthmatics is great as long as you pay strict attention to your e time. Having the ability to recognize the patient that needs it is the biggest key. Any decreased LOC or tachypnea with a unexpected CO2 level points that way. Personally I have tubed a few, proper sedation and as stated careful attention to e time and mechanics, and fortunately have yet to have a morbid outcome. I have heard of a few though, usual cause is iatrogenic barotrauma. Acidosis is not to be feared in these broncho spastic patients, also with intubation, suctioning is targeted to the airways, as mucous can be half the problem.

CPAP is great for CHF.

Also as a great intensivist once told me, I'd rather Roc than suc.....


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## MSDeltaFlt (Dec 20, 2007)

Back on track with the original post, also.  A clinched jaw, a GCS=5, and appartently no paralytics available but you could get an OPA.  I'm hoping that you have another aiway option on the truck:  as in Combitube or King LT.  That will provide at least some airway protection.

GCS=5 and dropping with clenched jaws is an airway problem plain and simple.  Be aggressive.  And, in the immortal words of Snoop Dogg, "Drop it like it's hot!"


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## paramediclori (Dec 22, 2007)

Wow, I couldn't even finish reading all of the responses, I was getting so mad.  You have a person that was in an MVA, and you are giving them high doses of morphine?  Maybe it's just where I live, but has anyone thought about the fact you don't give that drug to someone who has any possible bleed or a head injury, which sounds like this patient had a very good possibility. :unsure: The fact that you gave THAT MUCH of seditives blows my mind.  I absolutley would have tried a nasal intubation, and OPA, NPA, Combitube.  Where I work, we do not do RSI do to the dangers of it, which I absolutly agree with.  I don't think we are ever in a controled enough enviorment to preform that.h34r:


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## Ridryder911 (Dec 22, 2007)

paramediclori said:


> I absolutley would have tried a nasal intubation, and OPA, NPA, Combitube.  Where I work, we do not do RSI do to the dangers of it, which I absolutly agree with.  I don't think we are ever in a controled enough enviorment to preform that.h34r:




Wow! You would nasal intubate a head injury, but NOT perform RSI? 

Nasal intubation should be used very, very cautiously in those with traumatic head injuries if ever. Personally, I find nasal intubation much more risky and dangerous than any assisted or even RSI procedure. If the patient truly does have clinched jaws, it is obvious that one cannot assess for internal maxillo fractures. As well, RSI has a double beneficial effect of lowering ICP in head injuries and is highly recommended per neuro's.  

Personally, if one cannot control airway enough for RSI, then one should not even be able to intubate. RSI, if properly educated and controlled is the *best* and least traumatic to an already traumatized patient. Apparently,  you never have seen a palatine fracture with the ETT going into the brain stem, then you would change your mind. 

Time to step up and increase the education level.... 

R/r 911


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## paramediclori (Dec 22, 2007)

HAHA, ok good point and thanks for making  me eat my words,... I guess I wasn't thinking about that, I got side tracked with frustration you would give so much Morphine to a possible head bleed, or even internal bleed, and you are right, I would not do a nasal intubation in that situation.  I guess as far as RSI, it really isn't done in the field in the state of michigan.  I have always been taught more the dangers of RSI then the benifits, not to mention I have watched an ER doc do an RSI, things went bad and ended up with alot more problems.  Maybe the education I recieved about RSI could use some improvment, but like I said, I have always been taught the downfalls and dangers.


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## Ridryder911 (Dec 22, 2007)

The problems with RSI is not the procedure, rather the persons performing or using it incorrectly. The main problem now, is Paramedics abusing it. 

I have been performing RSI since the late 80's in the field, so I don't see the big deal. For as your ER Doc, sounds like it either was an airway from he*l or they need to review. If one cannot tube, either ventilate with BVM, combitube, or crich them... again, no big problem. 

We RSI at least weekly here, and in ER usually at last every other day (and its a rural/urban ER). It is not uncommon to knock someone down for respiratory disorders (COPD, CHF-although CPAP has reduced our #'s) and definitely head injuries. 

Let me ask, how do you control respiratory patterns such as in head injuries, COPD or combative TBI patients?  Even non head injury combative patients?

R/r 911


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## paramediclori (Dec 22, 2007)

I can see people abusing it, and as far as the ER doc, she did crich.  Well in a combative I will take a few extra FF's with me for extra hands, we have restraints.  As far as if I need to intubate right away and need some way of knocking them out, then I would use MS for pain, and Versed as sedation, which is what our locol protocols call for.  If at all possible though, I try to hold off on intubations IF i can, and hope they can hold out for cpap.  No I do not depend on it, and I will and have intubated when needed.  I hope this answered your quetion, I wasn't 100% sure the specific of you quetion.


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