# When to intubate



## mindspade (Sep 16, 2011)

Hi all, I understand the concept of intubation, My issue is the fine line when you jump from BVMing a pt and intubating them. I understand when the pt cant control their own airway and what not but how and a COPDer or a bad asthmatic who is still talking to you, When is the point you decided to intubate or use RSI? Thanks


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## bigdogems (Sep 16, 2011)

I personally am not agressive with intubation. The only time I would be is burns to the airway. Its like anything ALS. Your going to have that small group that will have the "I did it because I can" thought process. I will always try CPAP first on a COPD or CHF pt. Once you decide to tube them its a :censored::censored::censored::censored::censored: for the hospital to get them off the vent. If a pt with asthma is still talking to you give the meds a chance to work and use a BVM for a few minutes to see if they improve.


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## Shishkabob (Sep 16, 2011)

It's not a decision to be taken lightly in the least, especially when you're first starting out as an advanced provider and the sole one responsible for making the decision.  To put it simply, if you've tried every other non-invasive measure first, and they're not improving, or actually getting worse, and you don't believe it can wait till the hospital, that's when it's possibly time to move on.


I can tell you my first RSI was a patient with asthma/COPD/CHF where walking in and just looking at the patient I knew something had to be done.  My second RSI?  A little tougher to make the decision to go that route, but I could still defend it.  But I also have the luxury of the excuse of being 45 minutes from a hospital, so it's a bit easier to defend the "It couldn't wait" aspect.    When I was working closer to a hospital (15minutes) I deferred RSIing 3 patients until we were at the hospital, and each of the 3 were RSId on arrival.  




If you can't defend your decision when asked by a peer (doctor, RT, other medics... only the ones that have to decide to RSI too), it's probably not the right decision.


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## mindspade (Sep 16, 2011)

Thanks for the advice guys. As a pretty new paramedic a question is always in the back of my mind weather or not i should tube some one or not. I am not incredibly aggressive in airway management and always attempt oxygen and medications for thinking about tubing or even putting a pt on CPAP. The only pt i have ever tubed in the field was a pt who i constantly had to remind him to breath. Im sure not all of the pts that i will have to tube will be that easy determine, but any advice helps, thanks again.


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## usalsfyre (Sep 16, 2011)

Generally if they require mechanical ventilation (including BVM), may require one in the future, or are so monumentally unconscious/altered that there is a risk of losing the airway then they are going to need a tube. The REAL question is should you be doing it prehospitally or not. And the answer is...it depends.

First and foremost, is the patient a good candidate for intubation? If the I have a patient that's a b!tch to ventilate and looks like they're going to be even harder to tube then you can bet I'm seriously evaluating whether we can make it to the ED where there's a ton more space, light, help and usually toys to help the process. Another thought is as above, do you need to wait to see if other options start to take effect? Do you have access to NIPPV and is that a better option for the conscious patient? 

All this must be balanced with the understanding that RSI done early generally goes smoother than RSI done late in the game. 

So in the end I don't have a good answer. It's one of those things you have to learn by doing. Just hope you don't futz it up too monumentally.


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## usalsfyre (Sep 16, 2011)

Just noticed you said your not aggressive with CPAP. Be VERY aggressive with CPAP. You'll save a lot of patients from tubes that way.


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## bigdogems (Sep 16, 2011)

mindspade said:


> Thanks for the advice guys. As a pretty new paramedic a question is always in the back of my mind weather or not i should tube some one or not. I am not incredibly aggressive in airway management and always attempt oxygen and medications for thinking about tubing or even putting a pt on CPAP. The only pt i have ever tubed in the field was a pt who i constantly had to remind him to breath. Im sure not all of the pts that i will have to tube will be that easy determine, but any advice helps, thanks again.



There is nothing wrong with being agressive in airway management. But you have to understand that agressive airway management DOES NOT mean intubation


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## mindspade (Sep 16, 2011)

The few times that i have used CPAP i have loved it. A lot of times i find myself doing nebs first since my first service was not big into CPAP, and i have just stared with a service that uses CPAP regularly. Must of the times when i ask medics here about uses they just tell me that ill know when i need it. That doesn't really help since the teacher on CPAP in school in a complete joke.


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## Iceman26 (Sep 16, 2011)

CPAP is wonderful. Where I worked before they didn't have it prehospital but where I'm at now they do and it's just a great tool to have. Utilize it, because as others have said, that can cut down quite a bit on the act of having to tube someone, let alone other issues it alleviates while being much less invasive. 

I like the other answers I've seen on here...and being a newer medic (I'm still newer myself) this is a great question to ask. I have nothing to add further because anything I would've said has been said i.e try all the meds first barring them totally crashing in front of you, CPAP, take into account distance/time from the hospital,etc.


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## NomadicMedic (Sep 16, 2011)

As you consider a drug facilitated intubation, you should ask yourself three questions...

1) Can this patient protect and maintain their airway?

2) Is there a deficiency in oxygenation or ventilation?

3) Is intubation anticipated in the clinical course? 

If you answer no to the first and yes to the second two, you're heading down the road to a DFI.


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## usafmedic45 (Sep 16, 2011)

> Once you decide to tube them its a for the hospital to get them off the vent.



Eh....that's a very broad statement.  Granted it's much better to non-invasively ventilate them (BiPAP) but it's not THAT difficult to wean most CHFers one you get past the initial crisis. 



> Just noticed you said your not aggressive with CPAP. Be VERY aggressive with CPAP. You'll save a lot of patients from tubes that way.



What he said. 



> As you consider a drug facilitated intubation, you should ask yourself three questions...
> 
> 1) Can this patient protect and maintain their airway?
> 
> ...



4.  Am I certain that I can secure his airway?
5.  What am I going to do if I give the drugs and then can't intubate?

If you don't ask those two questions along with the first three, you're heading towards a lawsuit.


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## usafmedic45 (Sep 16, 2011)

> If a pt with asthma is still talking to you give the meds a chance to work and use a BVM for a few minutes to see if they improve.



If they are talking to you, you're probably not going to be bagging them.


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## NomadicMedic (Sep 16, 2011)

usafmedic45 said:


> 4.  Am I certain that I can secure his airway?
> 5.  What am I going to do if I give the drugs and then can't intubate?
> 
> If you don't ask those two questions along with the first three, you're heading towards a lawsuit.



Agreed, but this is not the answer to "when to intubate", the question the OP asked. These are the questions you ask yourself once you've decided that you've going to head down the DFI road. And let's be totally honest, it's a foolish provider that doesn't set himself up for success. 

The answer to the questions that USA asked should be, "Yes, I'm sure I can secure the airway, if not with an ETT, then with a supraglottic rescue airway such as a Combi-Tube or a Cricothyrotomy. If I push the drugs and can't secure the airway with an ETT, I'll move right to the failed airway plan."

Every practitioner that even thinks about DFI should have a failed airway plan, with the rescue airway out and available.

When I do a DFI, and I'll admit, I've only done 7, I always have all of the tools I may require to secure the airway out and ready for use. That includes a bougie, a combi-tube, the Quick-Trach kit, a different blade, a size smaller tube, the suction on and the catheter at the ready...

A DFI isn't anything to be taken lightly... luckily I haven't had an airway prove to be so difficult that I can't manage it... yet. I'm sure that day will come, and every time I start to consider a DFI, I wonder if this will be the one that I can't get and will have to cut. 

I am a firm believer that if I can manage the airway without a DFI, I will. Close proximity to the ED or an airway that looks very difficult after a LEMONS/BONES eval will give me pause. However, if the PT needs that tube, I'll do what needs to be done, knowing that I've got a couple of backup plans if things start to go sideways.


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## mindspade (Sep 17, 2011)

Thanks for all the advice guys. I actually had a CHFer last night at work who i put put on CPAP even thought the thought of intubation quickly went through my mind. His stats went from the eighty's to ninty-five percent and his work of breathing became a lot easier. I definitely going to consider CPAP on lots more pts i wish all of the cases where so cut and dry for the need of CPAP or intubation.


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## MSDeltaFlt (Sep 17, 2011)

The answer isn't as complicated as one might think.  There are two diagnoses: Respiratory Distress and Respiratory Failure 

Respiratory Distress does not require intubation. Respiratory Failure does.  They both have different clinical manifestations and should be listed in your protocols. Go by those guidelines.


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## mindspade (Sep 17, 2011)

That might be somewhere i am tripping up. I obviously know a pt who needs to be intubated because they don't have an airway or i don't think that they can maintain it them selves. The same thing goes with cpap. I obviously know the CHFer who is talking to me but having a hard time breathing could benefit from it.  Being a brand new paramedic, i appreciate all of the help and hints.


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## Katy (Sep 17, 2011)

mindspade said:


> His *stats* went from the eighty's to ninty-five percent


Do you mean his _sats_, as in oxygen saturation ?


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## MasterIntubator (Sep 17, 2011)

When the answer is not clear of when to intubate, this is where experience and good assessment skills will be your guide.  It is the nature of the beast, and unfortunately... the training offered and opportunities to get that experience can be tough to get.  The lack of said training will ultimately be the demise of in field intubation.  Those passionate about it, need to be proactive and get together with experienced folks and train.  Get the training dept involved and get yourself in a hospital that offers you the hands on.  A training hospital should be used to the requests, and anesthesiologists tube people every day... get on the inside track and hang out with them, see what they see, smell what they smell, feel what they feel, learn.. ask questions.
Yeah, it takes time and some sacrifice.... but the benefits will be great!!


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## Akulahawk (Sep 17, 2011)

usalsfyre said:


> Just noticed you said your not aggressive with CPAP. *Be VERY aggressive with CPAP*. You'll save a lot of patients from tubes that way.


About 10 years ago (or so) when I was first learning about CPAP, the RT's that were doing that portion of the airway lecture made that point very clearly and strongly. CPAP wasn't yet an option out here back then... but they were very passionate about it. Those guys were also very into mixed-gas use with certain patients as well. 

I like to be very aggressive with non-tube options, but sometimes your best option is to simply intubate. We just don't have many good options for a failed airway... and Facilitated Intubation of any variety is not an option.


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## medicsb (Sep 18, 2011)

MasterIntubator said:


> the training offered and opportunities to get that experience can be tough to get.  The lack of said training will ultimately be the demise of in field intubation.  Those passionate about it, need to be proactive and get together with experienced folks and train.  Get the training dept involved and get yourself in a hospital that offers you the hands on.  A training hospital should be used to the requests, and anesthesiologists tube people every day... get on the inside track and hang out with them, see what they see, smell what they smell, feel what they feel, learn.. ask questions.



I don't think paramedics should rely on hospitals for ETI experience.  Medic training programs have a hard enough time as it is.  Trying to get practicing medics in to the OR on top of medic students, med students, EM residents, anesthesia residents, and CRNA students is going to be near impossible for most EMS systems.  Ultimately, a sea-change in who intubates is required (i.e. it should be a limited skill).  The "field" should provide the experience, which it can, if allowed.


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## MasterIntubator (Sep 18, 2011)

Well... hospitals offer a controlled arena with mega-experience watching, mentoring and giving you the tricks of the trade.  Not to mention, you should be able to get as many intubations in hospital in a good clinical setting as one would need to feel comfortable enough in the field.  Field medics are in great need of this training, and the field is not adequately providing it.  The numbers show it, we see it and it is going to hurt us.  Unless you are on a small grouped critical care service, a new medic probably won't get the experience they initially needs. 
Tubing the plastic head just does not cut it for experience.
But I do agree that the field is the best area for it, but we need the future medics to graduate having live intubations done and confident/proficient in it.


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## NomadicMedic (Sep 18, 2011)

Luckily, our service has an agreement with the local hospitals and our medics are encouraged to visit the OR often for tubes to maintain proficiency and confidence. 


Sent from my iPhone.


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## MasterIntubator (Sep 18, 2011)

n7.... thats awesome!!  I wish so many more jurisdictions had it set up like that.


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## medicsb (Sep 18, 2011)

MasterIntubator said:


> Well... hospitals offer a controlled arena with mega-experience watching, mentoring and giving you the tricks of the trade.  Not to mention, you should be able to get as many intubations in hospital in a good clinical setting as one would need to feel comfortable enough in the field.  Field medics are in great need of this training, and the field is not adequately providing it.  The numbers show it, we see it and it is going to hurt us.  Unless you are on a small grouped critical care service, a new medic probably won't get the experience they initially needs.
> Tubing the plastic head just does not cut it for experience.
> But I do agree that the field is the best area for it, but we need the future medics to graduate having live intubations done and confident/proficient in it.



I didn't say the OR shouldn't be used during initial training, just that for continuing contact, the working paramedic shouldn't expect to get experience in the OR.   Further, medics, as a whole, shouldn't expect anesthesiologists to open up to working paramedics.  If someone is going to intubate, they need to have frequent experience.  The overwhelming majority of EMS systems are set up so that the average medic does NOT get frequent experience.  EMS system stake-holders need to find ways to reduce the number "intubators" so that the intubators that do exist can get the number needed to be proficient.  Otherwise, the system is set for failure.


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## NomadicMedic (Sep 19, 2011)

medicsb said:


> I didn't say the OR shouldn't be used during initial training, just that for continuing contact, the working paramedic shouldn't expect to get experience in the OR.   Further, medics, as a whole, shouldn't expect anesthesiologists to open up to working paramedics.  If someone is going to intubate, they need to have frequent experience.  The overwhelming majority of EMS systems are set up so that the average medic does NOT get frequent experience.  EMS system stake-holders need to find ways to reduce the number "intubators" so that the intubators that do exist can get the number needed to be proficient.  Otherwise, the system is set for failure.



How many tubes did you have to place before you were good at it?

5? 10? How many did you paramedic class require?

Numerous studies have been conducted on students learning how to intubate. One I like to quote used statistical models to show that the average number of intubations to become baseline competent, that is, correctly placing the tube 90% of the time without asking for help, is 47. I don't know about you, but my paramedic class didn't require anything like 47 tubes. It was 10 to graduate. Nowhere near the number I needed to become competent.

So, who cares if it's the field or not? Get to the OR and practice. The opportunity to place tubes in the field is dwindling. It's just common sense, the more tubes you can put into a real head vs. a plastic one can only serve to build your skills.

Laryngoscopic Intubation: Learning and Performance
Anesthesiology: 
January 2003 - Volume 98 - Issue 1 - pp 23-27


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## LondonMedic (Sep 19, 2011)

Is this a question about intubating or anaesthetising?

It might take 50 tubes to be really competent to intubate but how many anaesthetics do you reckon you have to give to truly know what you're doing with that?


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## rhan101277 (Sep 19, 2011)

I am not aggressive with intubation.  I have managed problems like CHF with CPAP.  I have yet to intubate someone who was not in cardiac arrest.  They have not deteriorated to the point where I thought bagging was in-effective.  Once you intubate someone mortality goes up, so its a big decision.  If you think death is imminent if an airway is not secure then by all means do it.


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## medicsb (Sep 19, 2011)

n7lxi said:


> How many tubes did you have to place before you were good at it?
> 
> 5? 10? How many did you paramedic class require?
> 
> ...



The opportunity to place ETTs in the field is dwindling because there are too many paramedics allowed to intubate.  It is not because the number of patients requiring intubation is dwindling.  If one can get to an OR for practice, then great.  But that is extremely difficult if not impossible for most EMS systems.  You are extremely privileged to have the opportunity to go to the OR.  Your system is an exception.  

As far as number needed to become proficient - the data varies.  One says 17
(Med Educ Online. 2011;16. Endotracheal intubation skill acquisition by medical students.), another indicates between 15-25 (Defining the learning curve for paramedic student endotracheal intubation. Prehosp Emerg Care. 2005;9(2):156–62).  There was another study that said >20 prehospital ETIs for a 1st pass success of 90% (Prehosp Emerg Care. 2010 Jan-Mar;14(1):103-8).  

I'd like to point our that 1st pass success of 90% in the prehospital setting is unlikely to be obtained by anyone.  When one looks at studies involving physicians in the prehospital setting (including anesthesiologists), 90% has never been demonstrated (one example: Resuscitation. 2006 Aug;70(2):179-85.   Prehospital airway management: a prospective evaluation of anaesthesia trained emergency physicians.)  

Even in the ED, in the US, it has not been demonstrated (Ann Emerg Med. 2005 Oct;46(4):328-36. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts.)

It would probably be best to aim for a 75-80% 1st pass success rate with an overall success of 95%?  (I don't know what would be best, hence the question mark.)

Again, reduce the number on intubators/paramedics, you increase the frequency of the procedure bythose who can intubate.  It's simple, really.

Now, as London Medic asks, how many anesthetizations (RSIs) does it take to become proficient at using the drugs?  Who knows?  This is something where simulation and training is probably just as good as hands on experience as it requires more cognitive ability than motor skill.   I'd guess that the learning curve, as far as "hands on" experience goes, isn't as big as it is for the actual skill of intubation.  I imagine londonmedic will disagree.


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## jjesusfreak01 (Sep 19, 2011)

While everything that Medicsb says makes sense, you can't just decrease the number of medics allowed to intubate and expect better outcomes, because you can't choose which medic arrives onscene, and you can't know if a call is going to need intubation before you get there. With the introduction of CPAP and reliable BIADs, the need to intubate has dropped through the floor, so even reducing the number of providers allowed to intubate from 100 in a system to 30 doesn't guarantee that each one of those 30 gets one a year. If we truly believe its a useful skill that belongs in pre-hospital medicine, then we need to focus on continuing education to keep the providers proficient, whether that means practicing on airway dummies or shouldering up next to the anesthesiologist in the local OR.


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## LondonMedic (Sep 19, 2011)

medicsb said:


> Now, as London Medic asks, how many anesthetizations (RSIs) does it take to become proficient at using the drugs?  Who knows?  This is something where simulation and training is probably just as good as hands on experience as it requires more cognitive ability than motor skill.   I'd guess that the learning curve, as far as "hands on" experience goes, isn't as big as it is for the actual skill of intubation.  I imagine londonmedic will disagree.


Of course. 

I think you're right, it is a cognative skill. But that doesn't just mean that you can recite the drugs and the doses. I think it means that you've anaesthetised enough people in enough ways that you understand the different drugs that are available to you and can make an informed choice about what the most suitable technique is, you can recognise, identify and respond to the different side effects and complications that occur, you know how deep your patients are when to lighten or deepen and perhaps most importantly you can recognise when there's a need for intubation and when the risk is too high.

Pushing the drugs in and getting the plastic tube between the flaps is the easy bit.


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## LondonMedic (Sep 20, 2011)

jjesusfreak01 said:


> While everything that Medicsb says makes sense, you can't just decrease the number of medics allowed to intubate and expect better outcomes, because you can't choose which medic arrives onscene, and you can't know if a call is going to need intubation before you get there.


The way that this has been talked about in the UK, and not just with intubation, is to get various advanced paramedic types to respond to selected calls on a car to back up the techs or paras already assigned. That may not be practicable in large rural areas but should be readily achievable in high-call-density metropolitan areas.


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## tssemt2010 (Sep 20, 2011)

intubating will always be a last resort in my opinion, if the person can tolerate a BVM then so be it, i would much rather insert an OPA (if they tolerate it) or an NPA and bag them on the way to the hospital than insert a laryngoscope into their mouth and cause trauma and damage. airway burns is also a situation where i would always intubate the patient, i would much rather intubate a patient before their airway swells than have to do a surgical crich or needle crich to keep a patient alive, that is one skill we do not use enough and i would not feel very comfortable doing it in any situation


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## the_negro_puppy (Sep 20, 2011)

tssemt2010 said:


> intubating will always be a last resort in my opinion, if the person can tolerate a BVM then so be it, i would much rather insert an OPA (if they tolerate it) or an NPA and bag them on the way to the hospital than insert a laryngoscope into their mouth and cause trauma and damage. airway burns is also a situation where i would always intubate the patient, i would much rather intubate a patient before their airway swells than have to do a surgical crich or needle crich to keep a patient alive, that is one skill we do not use enough and i would not feel very comfortable doing it in any situation



The problem is, an OPA and BVM provides little airway protection and poor technique risks forcing air into the oesophagus. ETTs are used as a gold standard for airway protection and control due to the protection they provide and more efficient ventilation. There are inherent risks with laryngoscopy and intubation, but these must be weighed up against risks such as the patient aspirating on vomit or passive regurgitation. Not to mention drugs can also be administered via ETTs,


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## LondonMedic (Sep 20, 2011)

the_negro_puppy said:


> There are inherent risks with laryngoscopy and intubation, but these must be weighed up against risks such as the patient aspirating on vomit or passive regurgitation.


What about the risks of anaesthesia which are arguably more serious and more common than both laryngoscopy and intubation combined?




> Not to mention drugs can also be administered via ETTs,


I'd hope you'd put a cannula in before anaesthetising someone...


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## the_negro_puppy (Sep 20, 2011)

LondonMedic said:


> What about the risks of anaesthesia which are arguably more serious and more common than both laryngoscopy and intubation combined?
> 
> 
> I'd hope you'd put a cannula in before anaesthetising someone...



In my post I was talking generally about intubation in an unconscious patient with absent jaw tone/airway reflexes rather than intubation as part of anaesthesia/RSI. Although this thread is more about when to conduct RSI I was answering with respect to intubation in general as an advanced airway.

 I am not trained in intubation nor will I be, however I was just correcting tssemt2010's assumption that OPA + BVM will always suffice rather than attempting intubation due to the risks involved. By their post he/she seemed to discount the added benefits of using advanced airways

In regards to administering drugs via ETT I was referring to situations such as cardiac arrest etc where perhaps difficulty in obtaining IV access may exist. Though with rise if IO devices i'm sure this method is probably already outdated.


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## Katy (Sep 20, 2011)

tssemt2010 said:


> into their mouth and cause trauma and damage


This isn't always the case. Successful intubation techniques and safely placed ETT's will not cause trauma and damage in most cases.


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## LondonMedic (Sep 20, 2011)

Katy said:


> This isn't always the case. Successful intubation techniques and safely placed ETT's will not cause trauma and damage in most cases.


Around _half_ of people who are electively intubated for theatre by an anaesthetist will have a sore throat subsequently.


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## Katy (Sep 20, 2011)

LondonMedic said:


> Around _half_ of people who are electively intubated for theatre by an anaesthetist will have a sore throat subsequently.


Yes, I know that. I didn't say all would be without trauma or injury, just not all.


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## LondonMedic (Sep 20, 2011)

Katy said:


> Yes, I know that. I didn't say all would be without trauma or injury, just not all.


Just not all?



			
				Katy said:
			
		

> Successful intubation techniques and safely placed ETT's will not cause trauma and damage *in most cases*.


In an optimal environment intubation done by airway 'experts' with the benefit of proper planning and preparation causes some trauma in around half of all cases, do you think pre-hospital intubation by paramedics in sub-optimal environments done in a hurry is better or worse?


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## Katy (Sep 20, 2011)

LondonMedic said:


> Just not all?


Yes, the user I quoted said basically any time intubation is done, that airway trauma and injury happens. I wanted to correct that assumption, considering not every one does cause those injuries. 



LondonMedic said:


> In an optimal environment intubation done by airway 'experts' with the benefit of proper planning and preparation causes some trauma in around half of all cases, do you think pre-hospital intubation by paramedics in sub-optimal environments done in a hurry is better or worse?


Worse, of course. But, does that mean all of them will have side-effects, no. Is the percentage higher for such injuries? Yes, but still, that doesn't mean every one will have trauma.


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## usalsfyre (Sep 20, 2011)

I would bet >90% of patients sustain some sort of airway trauma from prehospital intubation. Does that mean they're all significant? No. 

That said, I'd also be willing to bet if we looked at the rate of significant injury from paramedic, and even ED intubation we'd find it unacceptable. I've seen some hack jobs with a laryngoscope.


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## Handsome Robb (Sep 29, 2011)

tssemt2010;338500[B said:
			
		

> ...[/B]i would much rather intubate a patient before their airway swells than have to do a surgical crich or needle crich to keep a patient alive, that is one skill we do not use enough and i would not feel very comfortable doing it in any situation



I'm going to assume that you have training beyond EMT-B since your talking about your comfort level with cricothyrotomy, either needle or surgical. 

This is my opinion and am more than willing to listen to your input/critism/downright 'your a dumbass' comments. 

I have never done a crich on a live patient. I've done a few on cadavers, lots on sheep tracheas and a few on high-fidelity manikins but that's about it, but I have tubed a live patient. Personally I feel that a cricothyrotomy is easier than an endotracheal intubation in equivalent patients from an airway standpoint. That's not including patients with extreme obesity and/or disfiguration, although a cadaver I cric'd was extremely obese (read 200+ kg) and after following my instructors advice to keep on cutting through the fatty tissue, the cric was easier to place than the ETT. I agree we don't use crichs very often but personally I would feel more comfortable doing a crich after a year without training or performing over doing an ETT after the same amount of time.


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