Airway Management and Intubating without Drugs

[DesertMedic66]

Nope!

A study is getting ready to kick off using both transport vents and CPAP. ALNW has it on their choppers, we use them for the long distance stuff.

How on earth do you not have CPAP? Even the super crappy systems in CA have CPAP haha

 

[KingCountyMedic]

How on earth do you not have CPAP? Even the super crappy systems in CA have CPAP haha

We know how to take care of sick people. I’d wager we have more Physician involvement than just about any other system in the country, especially California! Our Docs haven’t seen a need for it in our first 50 years of our program but we are going to start a study and see if it’s worth adding it to our rigs. One of our main medical directors is a world renowned pulmonary critical care Doc and he hasn’t felt a need for us to use transport vents so that’s good enough for me.

 

[Peak]

I don't think a 911 system needs a transport vent, but I'm surprised you don't have flow inflating bags or those cheap disposable CPAPs. The local 911 service rarely has transports over 10 minutes and they carry them, and have definitely kept patients from getting tubed, and they pride themselves on being a bit of the EMS cowboys.

 

[Tigger]

Nope!

A study is getting ready to kick off using both transport vents and CPAP. ALNW has it on their choppers, we use them for the long distance stuff.

What do you need to study? Pretty sure that Washington state is not a vortex in which evidence based practice does not apply somehow.

 

[FiremanMike]

Nope!

A study is getting ready to kick off using both transport vents and CPAP. ALNW has it on their choppers, we use them for the long distance stuff.

Holy cow.. that honesty surprises me..

I’m guessing you guys still regularly RSI your CHF patients then? That probably explains why your system has so many intubations these days..

 

[rescue1]

We know how to take care of sick people. I’d wager we have more Physician involvement than just about any other system in the country, especially California! Our Docs haven’t seen a need for it in our first 50 years of our program but we are going to start a study and see if it’s worth adding it to our rigs. One of our main medical directors is a world renowned pulmonary critical care Doc and he hasn’t felt a need for us to use transport vents so that’s good enough for me.

I would argue that knowing how to take care of sick people includes the ability to put people on CPAP, which has been standard of care for quite some time and can avoid a significant amount of intubations. It’s been a BLS skill in most places since like 2014.

 

[CANMAN]

Yeah, sorry, my point was "you're likely going to drop the pressure regardless of what you do, so don't think that using ketamine is going to save your patient who is hypotensive". Like you said, some drugs will drop it more than others, but you should always anticipate the hypotension.

Glad someone gets it... While Ketamine has been all the rave lately in many organizations, it certainly isn't a fix all medication like some believe. We implemented it pretty heavily a few years ago and you will get plenty of hypotension in very sick and/or catecholamine depleted patients. I am trying to push a shock index assessment prior to any RSI our program does in our next protocol update.

 

[FiremanMike]

Glad someone gets it... While Ketamine has been all the rave lately in many organizations, it certainly isn't a fix all medication like some believe. We implemented it pretty heavily a few years ago and you will get plenty of hypotension in very sick and/or catecholamine depleted patients. I am trying to push a shock index assessment prior to any RSI our program does in our next protocol update.

Even at lower doses (1mg/kg)? I'm not doubting you, I just haven't seen it myself..

 

[CANMAN]

Even at lower doses (1mg/kg)? I'm not doubting you, I just haven't seen it myself..

Have never administered a 1mg/kg dose for RSI so I'm not sure if you would get the same effect Our protocol was 1.5mg/kg and that was plenty to see hypotension in certain patient populations.

 

[FiremanMike]

Have never administered a 1mg/kg dose for RSI so I'm not sure if you would get the same effect Our protocol was 1.5mg/kg and that was plenty to see hypotension in certain patient populations.

Our RSI protocol right now is 1mg/kg ketamine and 1mg/kg rocuronium.. Works well and we've not seen any hemodynamic issues with it

 

[CANMAN]

Our RSI protocol right now is 1mg/kg ketamine and 1mg/kg rocuronium.. Works well and we've not seen any hemodynamic issues with it

911 or IFT service?

 

[FiremanMike]

911 or IFT service?

Municipal 911, will do local ER to ER IFT in an emergency and no privates available, but it's extremely rare..

 

[GMCmedic]

Have never administered a 1mg/kg dose for RSI so I'm not sure if you would get the same effect Our protocol was 1.5mg/kg and that was plenty to see hypotension in certain patient populations.

We regularly cut the dose in half to 1mg/kg in really sick patients. We still see hypotension in some patients but achieve adeqaute sedation.

 

[KingCountyMedic]

Holy cow.. that honesty surprises me..

I’m guessing you guys still regularly RSI your CHF patients then? That probably explains why your system has so many intubations these days..

Nope, we don't RSI many CHF patients at all. We use Nitro and good BVM "Firefighter CPAP" you could say. Love us or hate us we have never done anything without running studies first to see if it is something we need to do as a county wide system. Our Medical Directors make the decisions with input from the field Paramedics and local ED Physicians. Major changes have to be agreed upon by all Directors and then we also implement it into our Paramedic Training Program at Harborview. Our system has so many intubations due to the fact that we have a small amount of Paramedics seeing a large volume of sick people and our Doctors support and encourage us to be aggressive in airway management.

 

[SandpitMedic]

If the patient has not intact gag reflex, why the RSI medications? Hopefully the dosing was at least lessened for the difficult to resuscitate patients.

As in if the pt needs to be sedated/paralyzed.
Yes, if they are obtunded and they have no gag the full RSI is unwarranted.

 

[FiremanMike]

Nope, we don't RSI many CHF patients at all. We use Nitro and good BVM "Firefighter CPAP" you could say. Love us or hate us we have never done anything without running studies first to see if it is something we need to do as a county wide system. Our Medical Directors make the decisions with input from the field Paramedics and local ED Physicians. Major changes have to be agreed upon by all Directors and then we also implement it into our Paramedic Training Program at Harborview. Our system has so many intubations due to the fact that we have a small amount of Paramedics seeing a large volume of sick people and our Doctors support and encourage us to be aggressive in airway management.

I don’t mean to direct any hate towards you, but king county is considered to be a Mecca for paramedics.. To think that you need to go through some extensive T&E before implementing a BLS procedure that is the standard of care across the nation for at least 5 years now just floors me.

I mean, CPAP isn’t some obscure treatment that may help, it fixes CHF exacerbations nearly every time and it works in under 60 seconds..

 

[Tigger]

Nope, we don't RSI many CHF patients at all. We use Nitro and good BVM "Firefighter CPAP" you could say. Love us or hate us we have never done anything without running studies first to see if it is something we need to do as a county wide system. Our Medical Directors make the decisions with input from the field Paramedics and local ED Physicians. Major changes have to be agreed upon by all Directors and then we also implement it into our Paramedic Training Program at Harborview. Our system has so many intubations due to the fact that we have a small amount of Paramedics seeing a large volume of sick people and our Doctors support and encourage us to be aggressive in airway management.

It’s not above loving or hating the system, it’s about doing what’s right for the patient. C/BiPAP prevents intubation in a variety of settings, both in and out of the hospital. I’d rather be intubated in an ED than an ambulance but most of all I’d like to avoid intubation unless there isn’t another option.

It seems exceptionally likely to me that many of the system’s intubated patients buy a tube because that’s one of the few tools available to provide positive pressure. “Firefighter CPAP?” This isn’t the 80s anymore. You might be getting by, but improvements have actually occurred in the last two decades. Perhaps firefighter CPAP and/or intubation adequately manages the patient, but why must the patient receive a higher risk intervention when we know that lower risk interventions are equally, if not more effective?

Something about if your only tool is a hammer...

 

[KingCountyMedic]

It’s not above loving or hating the system, it’s about doing what’s right for the patient. C/BiPAP prevents intubation in a variety of settings, both in and out of the hospital. I’d rather be intubated in an ED than an ambulance but most of all I’d like to avoid intubation unless there isn’t another option.

It seems exceptionally likely to me that many of the system’s intubated patients buy a tube because that’s one of the few tools available to provide positive pressure. “Firefighter CPAP?” This isn’t the 80s anymore. You might be

I don’t mean to direct any hate towards you, but king county is considered to be a Mecca for paramedics.. To think that you need to go through some extensive T&E before implementing a BLS procedure that is the standard of care across the nation for at least 5 years now just floors me.

I mean, CPAP isn’t some obscure treatment that may help, it fixes CHF exacerbations nearly every time and it works in under 60 seconds..

Our system is far from perfect. I wouldn’t say it’s a Mecca for Medics but it’s a million times better than most private or fire based agencies. We have been in the stone ages in a lot of ways ( WWI splints, glass bicarb bottles, etc) but we have also wrote the book on resuscitation. Our CABS study is why the world knows what’s good and bad for you. Everything the AHA and the world does with cardiac arrest starts here. I agree that CPAP is a good tool to have. I manage many patients with a little ALS and good BLS and get them to the ED without intubating them. We will notify the ED Doctor that we will be there and to have RT set up with B/C PAP. I enjoy the exchanges here but I’m always wary to get involved as there is a lot of internet clinicians ready to pounce on anything related to my system. I’m proud of where I work. I’m proud that we don’t stick IV’s in BLS patients all day and then bill them for it. I spent a decade in the private sector with vents, CPAP, and worthless doctors that collected a paycheck and would never lower themselves to speak to a medic. I’ll take my current gig with Doctors that answer their personal cell phone in the middle of the night if I need them. And the 6 figure income is also wonderful. Peace!

 

[VentMonkey]

I am trying to push a shock index assessment prior to any RSI our program does in our next protocol update.

I’d be interested to know how this pans out for you and your program. It’s such a simple calculation, and I think it’d help keep things like resuscitation prior to induction and it’s ok to take a minute if it will save you several post-induction in the back of the providers minds.

 

[Tigger]

Glad someone gets it... While Ketamine has been all the rave lately in many organizations, it certainly isn't a fix all medication like some believe. We implemented it pretty heavily a few years ago and you will get plenty of hypotension in very sick and/or catecholamine depleted patients. I am trying to push a shock index assessment prior to any RSI our program does in our next protocol update.

That was a huge part of our RSI/DSI update this year, I think it's going to make a big difference. That along with the new but not new adage of "resuscitate before you intubate" which mostly just re-emphasized the utility of push dose pressors and a really solid pre-ox regimen.