Assisting paramedic with intubation

[NomadicMedic]

Not so much a no-no as "not routinely recommended." That's for BVM ventilation, not to assist with visualization during laryngoscopy.

Just a point of order: Cric pressure isn't to "assist visualization during laryngoscopy". It was designed to compress the esophagus and prevent regurgitation. Bimanual manipulation or the BURP maneuver is what you should be using to assist with visualization.

Some infor for the new guys here:

http://www.airwaycam.com/bimanual-laryngoscopy.html
http://nmcp-anesthesia.net/subspeci...iatric-airway/cricoid_pressure_indication.pdf

 

[Carlos Danger]

Negative, close but a bit drawn out. If it were roc (~60-90s onset of action), this would be close if "several minutes" was 2 minutes. With succ it is BVM -> sedative -> continue BVM ~30 seconds -> succ -> continue BVM ~30-60 seconds more -> clear to tube. With an NC on it is much closer to 30s or less as they are persistently 99-100%.

Providing PPV to a non-NPO patient unnecessarily (i.e. a patient who is not hypoxic) is a dangerous practice. The whole reason that RSI was developed was to prevent having to do that.

I understand the thinking behind Dr. Weingart's "delayed sequence intubation" thing, but I believe the rationale is somewhat flawed and not applicable for most prehospital situations.

It may make sense in a small subset of patients (those who you know have little FRC and who you expect to be a difficult intubation and who are not cooperating with pre-oxygenation efforts), if you are in a hospital where you have plenty of help - and if you have ketamine available, which maintains the patient's protective airway reflexes. Even then though, I don't think it makes a whole lot of sense, because you still have other options.

The entire premise behind the DSI technique is that it supposedly allows you to avoid having the patient "crash" on you. Well, fortunately, that doesn't usually happen. And if it does, THAT is when you provide PPV and/or quickly place your supraglottic airway.

It just doesn't make sense to intentionally expose the patient to a known hazard in order to mitigate a potential hazard.

 

[Brandon O]

Just a point of order: Cric pressure isn't to "assist visualization during laryngoscopy". It was designed to compress the esophagus and prevent regurgitation. Bimanual manipulation or the BURP maneuver is what you should be using to assist with visualization.[/url]

That may be a bit strong. Applying cricoid pressure isn't "designed" for anything, per se. It's been used for several purposes, or at least with several theories behind it. Occluding the esophagus to reduce the lumen size to both insufflated air and regurgitated stomach contents is one use. But it's also been used for a very long time to assist with laryngoscopy.

Whether it works well for any of these purposes is another matter. I would counter your point of order, however, by noting that BURP is essentially a specific form of cricoid pressure.

 

[Christopher]

Providing PPV to a non-NPO patient unnecessarily (i.e. a patient who is not hypoxic) is a dangerous practice. The whole reason that RSI was developed was to prevent having to do that.

Agreed, and if they are taking adequate tidal volume breaths on their own prior to RSI they'll just get NPA+NC+NRB. If they do not have adequate tidal volume/rate, they'll need some form of PPV or PEEP depending on a number of things. Routine application is not necessary unless the patient is hypoxemic prior to initiation. Besides, if you go to rescue ventilation during the apneic period it will be with a BVM anyways, and studies into aspiration during this have shown it to be rare and likely present prior.

(The nice thing about the onset of paralysis is that it improves BVM ventilation. If given an opportunity to improve oxygenation prior to your intubation attempt you should take it.)

Perhaps I'll be more specific when describing this in the future, but I don't think we're far off. I was describing a setup for BLS to assist in an intubation, not necessarily one done as an elective RSI. Nor was this a description of DSI, as that goes a bit differently in practice (and we don't have ketamine with which to utilize this).

It just doesn't make sense to intentionally expose the patient to a known hazard in order to mitigate a potential hazard.

I believe the known hazard, as found in the literature, is an excursion down the dissociation curve into critical hypoxia. To your point, the other known hazard is excessive tidal volume during PPV and that is a problem with BVM usage prehospital and inhospital alike.