Shishkabob
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Why is blind before digital?
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Anyone Nasally intubate anymore?
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8jimi8
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So you don't get bit?? They don't have RSI/DAI
reaper
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Digital is a form of ETI. If they bite you, then they are to alert for that procedure.
Shishkabob
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If they bite the ET tube during blind insertion, they're just as alert...
8jimi8
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So that must be why blind before digital... No?
Doesn't anyone test for gag with an OPA before trying to intubate anymore?
abckidsmom
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No, not ever. Why would we waste any time with BLS airway maneuvers while planning or prepping for intubation?
I don't really consider placing an OPA as testing for gag, more like just placing an OPA to manage the airway, however temporarily.
reaper
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I just tell them to suck it up, it will be over in a minute!
8jimi8
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When we are talking about being so far down the list of interventions tried and failed that we are going for digital intubation, i don 't know if i'd stop to keep repeatedly putting the OPA back in, is that what you meant? Is that something i should consider?
If I made a 30 second attempt to intubate and failed, how long should I preoxygenate before attempting again? Long enough that I should throw the OPA back in?
If I made a 30 second attempt to intubate and failed, how long should I preoxygenate before attempting again? Long enough that I should throw the OPA back in?
testing for gag can be done with a tongue depressor.
It was this dual role I was trying without success to point out. While you are setting up your intubation gear, somebody is bagging, a perfect time to "place an adjunct" which in addition to being helpful to maintain the airway also has a diagnostic property of testing for gag.
Dominion
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I'll be honest I don't know why blind before digital but I would assume it'd be due to possibly getting bit. Any time I've heard of the airway priority being challenged usually the medic in question skipped blind and digital and called for orders to needle chric. It doesn't come up that often really.
8jimi8
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I know that repeated attempts can cause someone to vagal down, but could it cause a spontaneous return of consciousness?
OP
OP
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OPA has taken a back step for me, its NPA for everything airway needing... or diagnostically reducing dopehead siezure fakers, etc. NPA for all my basic needs.
Although... OPAs make a great bite stick tube protector next to the ETT.
Digital.... was popular in the 80s in my area, as it was considered a coordination skill for small hand folks, and a mad trick for big hand people. Had one incident where it worked in a MVC with entrapment, window access, fingers in mouth to the palm and tube in and confirmed ( I used a cork screw bend in the tube with a lightly lubed stylus ). When the pt is flacid, it is easier... and oral secretions do make it a bit easier. That was 15 some years ago.... and that novelty of me putting my valuable digits in a mouth has worn off. The person would have to be dead before I attempt that. One siezure... one wrong muscle spasm... one neurological fubar... and fingers will be injured. We have much better tools to shove in the mouth at any angle, any position to get a tube in ( fiberoptics and such ). Loosing a non-attached instrument will hurt me less. Buuuuuuuuut.... it is a knowledge skill in the tool bag for that one special moment.... and I just might slide a bite stick between the molars before I go fingering someone. But that is just me.....
Now... if you were not able to intubate in 30 sec, do just what the class taught you. If they did not teach you... try it without the OPA. If you shove a NPA in, you won't have to worry about an OPA. If you have a relatively uncomplicated airway without an OPA, why not just BVM the pt without the OPA? Does is work well? Many have for me. Just remember, BVM skills are not taught very good, lack lots of hands on and can be improved, we need to strive to be BVM experts. If it does not work well, shove a NPA in ( or OPA ).
Desaturation.... another thing not taught very well. If you have someone that has been properly ventilated, for... lets say 2 minutes, and the SaO2 is phenominal... banging 99% and stuff... you have 2-3 MINUTES ( or more depending how balsy the doc is... ) before the pt desaturates and the body starts thinking about anoxia probs.
But... then if 3 minutes is up and you are still screwing around... you'll be behind the ball and playing catch up with oxygenation... right? That can be debated, studies have shown that healthy folks desaturate somewhere around 5 minutes. Ventilate the pt, and try again or think of another tool.
Maybe they choose not to teach this in field... but the point is, don't get too pressured into rushing to beat a clock. 30 seconds is a safe cutoff for all critical patients who may desaturate faster than the average non-complicated pt. Most of this relates to elective intubations, most our pts are already behind the ball and traumatized, soooooo speed is of the essence, but once you have them well oxygenated... game on. Question is.... can you get them oxygenated without a secured airway of some kind?
You also have to follow your own protocols on it, cause in the end... that is what they QI. Outside of that... have a sound and reasonable reason why you deviated.
Good lord... I think I rambled on wayyy too much...
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OP
OP
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Nice!!!
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I used to. If/when I get back out on the bus again, I'd continue doing precisely that. Why? A couple reasons. One: I can grab an OPA and get to using the BVM faster than I can set up my ETI stuff. Two: in the process, it lets me know the patient has a gag reflex, and if present, I might then consider an NPA and just using a BVM while considering OTI or NTI. Three, if the patient has been intubated orally, the OPA makes a great bite block (or chew toy) and it's right there for me to place as such.
This discussion makes me think back to the days of the oral screw... something I've never had to use.
nti
We used to do it here alot, before we got RSI 10 years ago. I still remember the last one I did. A man in his 80's, consolidated. He was getting fatigued, but didn't want to be RSI'd. I explained NTI to him, did it in just a few seconds. We would keep a couple of tubes curled around on themselves, with the tip inside the 15mm fitting, along with a small tube of fun jelly and a BAM in a small ziplock bag. I got 'talked to' about it. "we have a kinder and gentler intervention now" It stayed in the protocols until just recently. I think they realized that nobody teaches it anymore (around here). That and we have a really high intubation success rate. Higher than in Seattle (I forgot the name of that service).
We used to do it here alot, before we got RSI 10 years ago. I still remember the last one I did. A man in his 80's, consolidated. He was getting fatigued, but didn't want to be RSI'd. I explained NTI to him, did it in just a few seconds. We would keep a couple of tubes curled around on themselves, with the tip inside the 15mm fitting, along with a small tube of fun jelly and a BAM in a small ziplock bag. I got 'talked to' about it. "we have a kinder and gentler intervention now" It stayed in the protocols until just recently. I think they realized that nobody teaches it anymore (around here). That and we have a really high intubation success rate. Higher than in Seattle (I forgot the name of that service).
I'll wager you are referring to us, if so that is indeed a rumor. If you're not, I am dying to hear who has gained a rep for doing it more than we did. Yes, we still do it but since the advent of CPAP it is used far less than it used to be. I can't tell you the numbers off the top of my head, but the procedure has decreased in use dramatically. For the most part the only ones doing it are those that were around when it was the only tool we had to manage the tired, profoundly dyspneic pt. that was not responding to pharmacology. Sure, it was great back in the proverbial day (my record is 3 in a 10hr shift, all legit) but I am glad we have gotten away from it. Though I still see a use for it in a system that does not RSI, I am glad it's not the only tool in our toolbox.
Jeff
TransportJockey
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My short stint with ACA had me thinking you guys do it all the time, but it was some older medics talking about it.
Out here, it's still pretty common to for services to have protocols for NTI. I've attempted it twice in medic school internship and got one of them. Most trucks carry a bam, neosynephrine and lido-jelly, along with some services actually carry endotrols.