Airway Management and Intubating without Drugs

RocketMedic

RocketMedic

Californian, Lost in Texas
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So as I contemplate a possible CA move, I have a question: I see a lot of folks on the forum seem to intubate fairly frequently (more than I do at least) but not necessarily with traditional RSI protocols. This led me to a follow-on question: how are y’all managing unresponsive, obtunded and respiratory failure patients in terms of airway management. I’ve looked at a lot of the protocols for states like NM, CA, PN, etc, and I see there’s still references to intubation, but how are y’all facilitating and intubating those patients? I’m not thinking so much the completely-unresponsive patient, I’m thinking more along the lines of “unresponsive but (inadequate) breathing” or peri-arrest patients or those with rapidly-progressing respiratory failure or trauma.

Also, what gear/approach do y’all have?
 
I remember the early days where all of us, including ED Physicians did mostly nasal intubations on these patients. I remember lots of vomit, blood, aspiration etc. In the late 80's early 90's Succinylcholine started getting used around here. Usually with no sedatives or pain control. The way we used to manage airways was absolutely barbaric. It's sad that it's still fairly close to this in many communities. Yes you can sedate the **** outta someone and cram a tube in them but it's this practice that keeps our profession from being a respected profession in the medical community. If you are going to pass an endotracheal tube through a persons cords you should have every tool in your tool box to be successful, including all the RSI drugs and rescue devices. AND you should be required to maintain proficiency at the skill by passing at least 12 ET's a year with complete documentation of the procedure including airway grade, number of attempts, ETCO2 etc.

If you don't have ETCO2 and full RSI protocols with the ability to do it A LOT you probably have no business doing it.

My opinion.
 
In my experience, in CA, when I had a patient that required RSI you either called a helicopter or the patient suffered. Those were my options. I distinctly remember a traumatic head injury patient who had snoring respirations and a a significantly reduced GCS. Vomiting was a concern due to the TBI, but he and I had to deal with an OPA and a NRB for about 45 minutes until we got to the hospital. I was not allowed to give any medication to facilitate intubation.
 
NPO said:
In my experience, in CA, when I had a patient that required RSI you either called a helicopter or the patient suffered. Those were my options. I distinctly remember a traumatic head injury patient who had snoring respirations and a a significantly reduced GCS. Vomiting was a concern due to the TBI, but he and I had to deal with an OPA and a NRB for about 45 minutes until we got to the hospital. I was not allowed to give any medication to facilitate intubation.
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In CA this is how it works. Either your patient is able to accept a tube because they are extremely unresponsive or you just have to manage BLS until they become that far gone and then you can tube.

Got a facial burn patient with stridor? Can’t do anything on the ground until they become unresponsive. You either have to get a HEMS unit to you where we can RSI or do a surgical cric or get to your closest ED ask they can RSI and then probably fly the patient to a burn center.
 
I don't. Maybe I could get a doc to buy off on Fent/Versed if I felt it was that bad. Usually though I just toe the line on acceptable to CPAP, bag them, or just have the NRB/NC running hard.

Burn patients? Short scene time, drive fast.

Head injuries? Same.

Our higher ups still preach the "you're 7 minutes from a hospital". While I agree with this in surgical interventions and stuff, I think it encourages lazy practice when it comes to treatments we can appropriately do that are right for this patient. They focus in on the 7 minutes to transport and ignore the 5-7 minute response, x minute assessment and extrication, x minute assessment and treatment in the truck, 5-9 minute transport, 5 minutes to turnover and docs start assessing, then however long it may take to finally do the things we could have done.

Although my thoughts on this aren't limited to airway. I wrote a Hyperkalemia protocol a year ago and we still haven't implemented one despite a recent protocol "update" (not a good description of it).
 
California still has needle crimes, right? Is that like the State-endorsed Control-Alt-Delete for these questionable airways?

I mean, I know what I’d like to do and how I’d practice, but if I do move back, I’ve gotta adjust to the ways of the locals.

Personally, I think all intubation should be done with VL with DL backup, monthly competency trainings and checks and real, effective meds and tools, but that’s not the case everywhere.
 
RocketMedic said:
So as I contemplate a possible CA move, I have a question: I see a lot of folks on the forum seem to intubate fairly frequently (more than I do at least) but not necessarily with traditional RSI protocols. This led me to a follow-on question: how are y’all managing unresponsive, obtunded and respiratory failure patients in terms of airway management. I’ve looked at a lot of the protocols for states like NM, CA, PN, etc, and I see there’s still references to intubation, but how are y’all facilitating and intubating those patients? I’m not thinking so much the completely-unresponsive patient, I’m thinking more along the lines of “unresponsive but (inadequate) breathing” or peri-arrest patients or those with rapidly-progressing respiratory failure or trauma.

Also, what gear/approach do y’all have?
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Is nasal intubation with a trigger tube and BAAM device not a thing there? Not a fan of DAI personally. Either you have the full toolbox or you don't.
 
CANMAN said:
Is nasal intubation with a trigger tube and BAAM device not a thing there? Not a fan of DAI personally. Either you have the full toolbox or you don't.
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Nasal intubation is not a thing in California.

Also keep in mind, as far as DAI, ketamine is still not a thing in most places in California. Sedation is limited to Versed and fentanyl.

Edit: perhaps it's in the state optional scope. It was removed from my scope when I was there.
 
@NPO NTI is still in a handful of CA protocols, IIRC.

With the advent of CPAP, on the ground in most CA services’ coverage areas, it’s seldom needed. I had at least 5-8 in my pre-CPAP days. When used right, it was efficient.

That said, I don’t know how often they’re left in due to infection risks. I saw one doc give me accolades, and another scoff and remove it posthaste.

@RocketMedic, in short most ground services here are as described. There is some wiggle room in Kern Co. with regards to post-ETI management in, say, an arrest/ peri-arrested patient and delivery of sedation and pain management.

But again, we’re talking about a very small population. And considering it seems (to me at least) that most of my ground co-workers refuse to catch up with current practices in prehospital airway management, they’re lucky they’re still allowed the privilege of handling a BVM.
 
VentMonkey said:
@NPO NTI is still in a handful of CA protocols, IIRC.

With the advent of CPAP, on the ground in most CA services’ coverage areas, it’s seldom needed. I had at least 5-8 in my pre-CPAP days. When used right, it was efficient.

That said, I don’t know how often they’re left in due to infection risks. I saw one doc give me accolades, and another scoff and remove it posthaste.

@RocketMedic, in short most ground services here are as described. There is some wiggle room in Kern Co. with regards to post-ETI management in, say, an arrest/ peri-arrested patient and delivery of sedation and pain management.

But again, we’re talking about a very small population. And considering it seems (to me at least) that most of my ground co-workers refuse to catch up with current practices in prehospital airway management, they’re lucky they’re still allowed the privilege of handling a BVM.
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Well that's not fantastic. I take it "patient comfort" is pretty far down the list of things cared about in a peri-arrest/unresponsive ETI?
 
RocketMedic said:
Well that's not fantastic. I take it "patient comfort" is pretty far down the list of things cared about in a peri-arrest/unresponsive ETI?
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Depends on the provider. Personally, I could muster up enough to be “within protocols” while still caring for these patients if they’re in front of me sans my flight nurse.
 
VentMonkey said:
Depends on the provider. Personally, I could muster up enough to be “within protocols” while still caring for these patients if they’re in front of me sans my flight nurse.
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It does suck that NTI isn't a thing anymore and that ketamine isn't available. I reckon Versed and Fentanyl work decently well though.

I do think that RSI is a good thing in abstract to have, but keep in mind that I work at a service that is terrible at it and doesn't really have he structure, organization, talent or training desire to improve as a system. My prior system was extremely 'good' at intubating because who was able to do it was very limited to seasoned providers only, but that solution wouldn't work outside of a compact area and had plenty of its own problems.
 
I think the advent of CPAP has helped tremendously. As I can't RSI/DSI at my full-time place, I am more inclined to stick with CPAP if the patient remains hemodynamically stable with a decent respiratory drive even if they are somewhat more obtunded than perhaps the book teaches as acceptable. We are in at least a 1:1 provider/patient ratio here so I feel that there is adequate "reaction time" to a loss of airway reflexes.

I could also attempt to hurricane spray the crap out of someone, that seems like a bad choice. At the very worst, surgical crics are in the standard scope for every Colorado paramedic.

I am still happy that we will have a Ketamine/Roc RSI guideline by the end of the year. I was hoping we could carry over the "Ketamine facilitated airway management" guideline from previous/now PRN spot but alas...
 
As a ground medic in Vegas we always used etomidate/versed via standing order for intubation. Also, fentanyl for pain control. It worked well as I recall. In 2018 ground units got ketamine, but not for induction.

When I got on at a HEMS outfit in Vegas we had the full kit and caboodle of critical care interventions and medications. If they had a pulse, they got a full compliment of RSI drugs.
 
VentMonkey said:
But again, we’re talking about a very small population. And considering it seems (to me at least) that most of my ground co-workers refuse to catch up with current practices in prehospital airway management, they’re lucky they’re still allowed the privilege of handling a BVM.
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Not all of us are that bad, but the amount of times I have heard the phrase, "Bougies are for people who can't intubate" or "Why would i ever use suction?" Is pretty high. Curious if we are going to get the DeCanto suction though. That said, there isn't much incentive to improve aside from your own desire to better the patient, and you know how most of our co workers are.

In response to the thread, you basically have two options, be a bad medic and force the tube then sedate, or manage with a BLS airway and advise the hospital to have RSI ready. Had it happen to me earlier in the week, GCS of 7 with strong localization, and it's a choice of either doing something without the right equipment and medication, or manage the airway with an OPA and BVM.

As a side note, in general I feel frustrated more than satisfied in a lot of ways, we had a protocol update a year prior that never went into effect, still no official sepsis protocols, and a disincentive to using EtC02 for anything but pure respiratory reasons. I could list the things that frustrate for a while, but I'm starting to realise that the only thing I can do is improve my own practice as best I can.
 
Well that’s disappointing.
 
In PA we had "sedation assisted intubation", a fancy name for hoping that etomidate alone would be sufficient to intubate a non-unresponsive patient. I've seen it work once, on a burn victim, and fail twice on traumas who eventually got RSIed by the flight crew. It's a ****ty way to intubate. Either have medics trained to RSI or don't intubate alive patients--there are a very small subset of patients who can't be temporized with CPAP/BLS airways but still have airway reflexes, the vast majority of them being traumas--and you need experienced providers who have the yearly numbers and training to do those intubations safely. If you're only doing a small handful of RSIs per year, and/or you're not getting consistent training in the procedure and in pre/post intubation management, you're probably harming more patients than you help.


I'm not 100% convinced that urban areas with consistently short transport times will see any benefit from ground EMS RSI, even if implemented well, but maybe that's just from my experience (bias) working in systems that never had it.
 
rescue1 said:
In PA we had "sedation assisted intubation", a fancy name for hoping that etomidate alone would be sufficient to intubate a non-unresponsive patient. I've seen it work once, on a burn victim, and fail twice on traumas who eventually got RSIed by the flight crew. It's a ****ty way to intubate. Either have medics trained to RSI or don't intubate alive patients--there are a very small subset of patients who can't be temporized with CPAP/BLS airways but still have airway reflexes, the vast majority of them being traumas--and you need experienced providers who have the yearly numbers and training to do those intubations safely. If you're only doing a small handful of RSIs per year, and/or you're not getting consistent training in the procedure and in pre/post intubation management, you're probably harming more patients than you help.


I'm not 100% convinced that urban areas with consistently short transport times will see any benefit from ground EMS RSI, even if implemented well, but maybe that's just from my experience (bias) working in systems that never had it.
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I don’t think you’re wrong at all.
 
rescue1 said:
I'm not 100% convinced that urban areas with consistently short transport times will see any benefit from ground EMS RSI, even if implemented well, but maybe that's just from my experience (bias) working in systems that never had it.
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I agree with you 100% The majority won't see much benefit due large in part to the majority of places doing it wrong! If you don't have total buy in and total program oversight by Physicians that support it you are doomed from the get go. We have some very short transports in parts of King County and some very long ones as well. We RSI every single patient that needs it. Our past and present Medical Directors are all in agreement and have been for the past 50 years. We will occasionally sit on the ramp of an ED and RSI the patient before taking them inside the hospital and our Doctors appreciate it. They know we do it a lot and it typically makes their job a lot easier if we just handle it.
 
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