Bad Practice in the ED

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DPM

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Good evening all!

I work in California, where we have no RSI, but that is not the debate. Frequently I will have a Pt who you can predict is going to be getting an RSI upon arrival to the ER. To best prepare these patients, and to generally protect them the best I can, I will usually begin pre-oxygenating them en route if I think an RSI upon arrival is likely. Unfortunately I often find myself in situations where the receiving ED team doesn't know what I'm up to, and then ignores my reasoning.

An example from the other day. I had a 40's female Pt with MS, who was quadriplegic and in respiratory distress, with an SPO2 of 81% on 3 liters of home O2. My partner and I got her sat up to 95% after getting her onto our tanks, and by putting an NRB over her NC, which we cranked up to 10. Mildly unpleasant for the Pt's 10min ride to the ED, but her breathing improved massively. ED staff decided that they wanted to RSI, and promptly removed the NC and removed the NRB (so they could use the wall O2 source for a BVM) and laid the PT flat. Within a minute she as back at 83%, so they began bagging her (while stile supine) at about 20/min. SPO2 hit 85% and they went ahead with the RSI. Pt regurgitated her gastric contents upon introduction of the laryngoscope, which promptly filled the airway. Suctioning happened quickly, and the tube was in place shortly after with an SPO2 at 78%. This is one example, but quite illustrative of my problem.

I was taught hi-flow NC with NRB over the top for pre-oxygenation, and to leave the NC on during intubation. I was also taught that elevating the head of the bed 30-45* greatly reduces the likelihood of complications during intubation.

How can I better explain myself to my interdepartmental peers? It's somewhat disheartening when the whole room looks at you like you're the idiot while the evidence supports you.
 
You may be an early adopter of certain techniques and it takes quite some time for majority of practitioners to catch on, if ever. I would gladly engage in a conversation about it if asked why I am doing things a certain way however I do not think it is personally my place to try to educate the ER staff and would be better handled by your Medical Director to the ER physician.
 
Why both a mask and a cannula?

If you deliver a patient with an Sp02 far better than you found them, you've done your job. If the ED staff seems amenable to education, take the opportunity. But if they aren't, don't worry about it. It sucks for the patient, but you can only do what you can do.
 
Couldn't have answered better than @Chase. This is probably thee best, and most logical approach.
 
DEmedic said:
Although I use an end tidal cannula under CPAP. :)
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We only carry side-stream ETCO2 on our CCT monitors since the X-series are setup for them, and the E-series we have aren't; the ALS ground side works off the E-series.

It almost never fails that I get a "wth is that?" look or question from either non-CCT crews, and/ or ED folks.

I use them frequently for my own personal trending, and have all but given up telling the receiving ED what their ETCO2 was, unless agter explaining what it is, and/ or why I thought of placing it on the patient (e.g., suspected met. acidosis, sepsis, pulmonary pathologies, etc.). It's just nice to have for the right patients.
 
Remi said:
Why both a mask and a cannula?

If you deliver a patient with an Sp02 far better than you found them, you've done your job. If the ED staff seems amenable to education, take the opportunity. But if they aren't, don't worry about it. It sucks for the patient, but you can only do what you can do.
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We are taught to place both a NC and NRB that way we are set up for apneic oxygenation and just remove the NRB and bump the NC to 10-15lpm for our intubation attempt. All our NC are ETC02 and it is encouraged to get a pre-intubation ETC02 as well.

OP; Is this a smaller facility? Your company/program could offer to teach a continuing education class with the ED. Some facilities are very receptive to this while others are not.
 
Chase said:
We are taught to place both a NC and NRB that way we are set up for apneic oxygenation and just remove the NRB and bump the NC to 10-15lpm for our intubation attempt. All our NC are ETC02 and it is encouraged to get a pre-intubation ETC02 as well.
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This was brought up on an EMCrit podcast I listened to recently. Start with the cannula, and if that doesn't work add the mask. If that doesn't work, BVM with 15 of PEEP. Apparently if the mouth is open the effects of 15lpm NC are somewhat negated.
 
I would also defer to your medical director for educating the ED staff. That said, we are also encouraged to use NC during intubation as Chase describes. I can't say I have always checked ETCO2 prior to intubation, but I do often slip a NC ETCO2 under the BiPAP mask when someone is still struggling and we suspect we will need RSI.
 
Apneic oxygenation is a foreign concept here.

But so is working a code on scene.

I take my small victories where I can find them. I just call the ED and talk to the doc when I've got a patient that needs tubed. They're ready for me when I get there.

A relationship with the ED staff goes a long way when you're working with restrictive protocols.
 
Remi said:
Why both a mask and a cannula?

If you deliver a patient with an Sp02 far better than you found them, you've done your job. If the ED staff seems amenable to education, take the opportunity. But if they aren't, don't worry about it. It sucks for the patient, but you can only do what you can do.
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The NRB alone doesn't really deliver 100% fiO2, so adding the NC bumps it up significantly. This also means your NC is in place for apneic oxygenation when the time comes. I would use a NC with the ETCO2 bits on it too, which is my practice for respiratory emergencies.
 
Handsome Robb said:
I'm just gonna leave this right here....

http://emcrit.org/dsi/

This one too...

http://txemsa.com/using-dsi-to-prevent-rsi-from-becoming-rsd/


Sent from my iPhone using Tapatalk
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Good stuff.

airway-innov.png


I love the idea of CPAP pre-oxygenation! I thought apneic oxygenation was standard practice, though.
 
Apneic oxygenation is only as good as the patient is healthy/young. As the age, weight (obesity), and co-morbidities increase the FRC decreases and at a certain point, once apnea occurs, little benefit comes of it. Results really vary. Just pointing that out in case someone would think they were doing something wrong when the sat tanks as soon as the muscle relaxant goes in and diligent efforts at pre-oxygenation and "AO" were being undertaken.
 
E tank said:
. As the age, weight (obesity), and co-morbidities increase the FRC decreases and at a certain point, once apnea occurs, little benefit comes of it.
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Totally, that being said, it doesn't not help - it just helps...less, right?
 
DPM said:
The NRB alone doesn't really deliver 100% fiO2, so adding the NC bumps it up significantly.
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A NRB doesn't deliver 100% oxygen, but it delivers a high enough concentration that adding more probably isn't all that helpful. I guess the way I see it is that If someone is breathing 80% oxygen, for instance, and their Sp02 is still on the low side, then they likely have a V:Q mismatch that is best addressed with something other than a higher Fi02.

E tank said:
Apneic oxygenation is only as good as the patient is healthy/young. As the age, weight (obesity), and co-morbidities increase the FRC decreases and at a certain point, once apnea occurs, little benefit comes of it. Results really vary. Just pointing that out in case someone would think they were doing something wrong when the sat tanks as soon as the muscle relaxant goes in and diligent efforts at pre-oxygenation and "AO" were being undertaken.
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I've said many times that the patients who need this to work the most are the very ones that it's least likely to have any effect on.
 
EpiEMS said:
Totally, that being said, it doesn't not help - it just helps...less, right?
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Right...don't not do it if there is time, but there are things to do that have been mentioned above that can mitigate to some degree the loss of FRC and maybe even recruit some back, albeit, very briefly. The big ones are sitting the patient up or reverse trendellenburg and some form of NIPPV before apnea. Not always terribly practical...
 
EpiEMS said:
Totally, that being said, it doesn't not help - it just helps...less, right?
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Well, atelectasis = shunt, and in principle shunt actually has no response whatsoever to changes in FiO2.

In reality shunt is rarely 100%, more of a spectrum of V/Q mismatch, but that would be the principle.
 
Brandon O said:
Well, atelectasis = shunt, and in principle shunt actually has no response whatsoever to changes in FiO2.
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edit for misread...irreversible shunt. Recruit atelectatic lung units with big breaths, CPAP and PEEP and more O2 will raise PO2
 
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