California Pediatric Intubation

Aren't most SGA's contraindicated in people under 16?

Also, what are you going to tell a parent when there is no flight medic or pre hospital RN available and the trauma center is >1 hour away in the rare cases where intubation is truly required? "Sorry you're kid is going to die and there is nothing I'm allowed to do about it" Talk about a scene safety issue developing
 
VentMonkey said:
On a related note, is anyone out there effectively using pediatric BVM’s to ventilate adults? I know there’s a push in some circles given the lower Vt’s.

Admittedly, I sometimes still catch myself having to imagine tying one arm behind my back when ventilating an adult with an adult BVM.
Click to expand...
I've debated bringing that into practice considering the regularity I am running arrests, it would give me one less thing to have to keep track of. I haven't personally tried it yet though.
 
vc85 said:
Aren't most SGA's contraindicated in people under 16?

Also, what are you going to tell a parent when there is no flight medic or pre hospital RN available and the trauma center is >1 hour away in the rare cases where intubation is truly required? "Sorry you're kid is going to die and there is nothing I'm allowed to do about it" Talk about a scene safety issue developing
Click to expand...

This is the 1st time that I hear about LMAs being contraindicated based on age subset. Just for the record, there are 16 y.o. (and younger) patients who are bigger than adults, and in their case the contraindication is morbid obesity, not their age. And even that can be accommodated with a sheet/towel roll between shoulder blades.

If I’ll ever have to work for a rural system with <1hr transport times and no HEMS div, I might as well carry a pepper spray. Or a tazer.
 
There are SGAs available for pediatric patients. They're just not commonly issued to us in the field because pediatric intubation is exceedingly rare.
 
StCEMT said:
I've debated bringing that into practice considering the regularity I am running arrests, it would give me one less thing to have to keep track of. I haven't personally tried it yet though.
Click to expand...

Interesting point. Adult BVM's are just manufactured too large, IMO. You could almost ventilate horses with them. That is something that manufacturers should re-examine. Smaller tidal volumes for lung protection aside, just the effect of big breaths on cardiac output should be enough for some introspection on the subject by all of us.
 
E tank said:
Interesting point. Adult BVM's are just manufactured too large, IMO. You could almost ventilate horses with them. That is something that manufacturers should re-examine. Smaller tidal volumes for lung protection aside, just the effect of big breaths on cardiac output should be enough for some introspection on the subject by all of us.
Click to expand...
I listened to Eric Bauer's podcast on this and that is what got me contemplating it. 1. for the cardiac output and 2. for lung protection. In hindsight, I've had some arrests in places that were not ideal and in the whole juggling act I've found little things I could have definitely done better. Being able to remove one variable (mostly) would be nice. I definitely think it is one part of how we manage airways that deserves more thought and attention, I've seen some pretty weird stuff with BVM's.
 
StCEMT said:
I listened to Eric Bauer's podcast on this and that is what got me contemplating it. 1. for the cardiac output and 2. for lung protection. In hindsight, I've had some arrests in places that were not ideal and in the whole juggling act I've found little things I could have definitely done better. Being able to remove one variable (mostly) would be nice. I definitely think it is one part of how we manage airways that deserves more thought and attention, I've seen some pretty weird stuff with BVM's.
Click to expand...
Well all things being equal, I'm less concerned about us and the way we hand ventilate than I am about folks that don't manage airways as a part of their job, whether that is a fireman, non CC RN or whomever. The bag is a liter and a half so that must mean I give liter and a half breaths...so goes the assumption...
 
vc85 said:
Also, what are you going to tell a parent when there is no flight medic or pre hospital RN available and the trauma center is >1 hour away in the rare cases where intubation is truly required? "Sorry you're kid is going to die and there is nothing I'm allowed to do about it" Talk about a scene safety issue developing
Click to expand...

Or, if you really had to go there at all - which of course you don't - you could at least be ethical and intellectually honest and tell the whole story, rather than just the part that paints the picture you'd like people to believe. "Sorry, your kid is going to die and there's nothing I'm allowed to do about it because the intervention that I have in mind has not been shown to improve outcomes and might cause even more serious harm to your kid".

Seriously though, why all the drama? Most of us will go our whole career without ever encountering a scenario where an ET tube is the difference between the life and death of a child. Why do we think it is makes sense to focus on the very rare (the times when intubation is really needed) and completely ignore the much more common (the times that pediatric ETI results in complications, or at least does not help)?
 
Last edited:
That brings up a pretty interesting ethical debate not just in this situation

If a patient is in extremis or already clinically dead; is it better to not do an intervention that has a risk of harm or no benefit or is it better to do the intervention on the .0001percent chance it would work.

Obviously is it out of protocol the decision is made, but what if the intervention was still in protocol?
 
Clinically dead? Why are you worried about intubation at that point anyway. There is a reason intubation keeps moving down the list in ACLS

We could go around and around with this. Should we resuscitate every traumatic arrest because it may save .001%? Field thoracatomy? I mean they are dead and it may help...

Sorry but that type of thinking is based off emotion and not evidence. At some point we have to play the numbers game and make decisions that don’t feel good but are the most logical. Even if it could have potentially saved a little kid that could grow up to cure cancer.
 
vc85 said:
If a patient is in extremis or already clinically dead; is it better to not do an intervention that has a risk of harm or no benefit or is it better to do the intervention on the .0001percent chance it would work.
Click to expand...

Here's another variable. What if the intervention is very expensive (or very cheap)? How does that change your willingness to do it?
 
EpiEMS said:
Here's another variable. What if the intervention is very expensive (or very cheap)? How does that change your willingness to do it?
Click to expand...

My guess is that cost is a very minor factor - if a factor at all - in the minds of most EMS providers.
 
Remi said:
My guess is that cost is a very minor factor - if a factor at all - in the minds of most EMS providers.
Click to expand...

Absolutely, if unfortunately, true.
 
Remi said:
My guess is that cost is a very minor factor - if a factor at all - in the minds of most EMS providers.
Click to expand...
It is a reason I dislike the "transport everyone, cuz liabilities." mindset. I get some people don't care since they really aren't going to pay anything. However I try to help the regular folks at least be aware of their options and a general idea of what they include.
 
EpiEMS said:
Here's another variable. What if the intervention is very expensive (or very cheap)? How does that change your willingness to do it?
Click to expand...

Sooner or later, training and experience needs to inform reasonable treatment decisions. It's a professional thing. Also, it begs the question as to the motivation of the person attempting futile effort.
 
E tank said:
Sooner or later, training and experience needs to inform reasonable treatment decisions. It's a professional thing.
Click to expand...

One would think, but healthcare workers perform all kinds of futile (or actively harmful) care, no?
 
EpiEMS said:
Not to mention...ETI doesn't demonstrate any patient survival advantage over BVM.
Click to expand...
Congrats on reading the abstract.

Gausche wanted to limit prehospital intubation and designed this study to fail, and how did she do it? By conducting it in one of the poorest clinically run EMS systems in the country. Yes, you guessed it, Los Angeles County. The same county had had adult intubation for less than 10 years prior to this study and has provider agencies who routinely “draft” people for paramedic school.

In her study she writes, “Paramedics were trained to mastery of all skills.” Do you know how long according to Dr. Gausche it takes to master pediatric ETI?

6 hours.

The icing on the cake, the instruction was led by RN’s. Not CRNAs, or Anesthesiologists, or Pediatricians, or ER MDs, but RNs.

*end rant*
 
Last edited:
aquabear said:
Congrats on reading the abstract. Gausche wanted to limit prehospital intubation and designed this study to fail, and how did she do it? By conducting it in one of the poorest clinically run EMS system in the country. Yes, you guessed it, Los Angeles County. The same county had had adult intubation for less than 10 years prior to this study and has provider agencies who routinely “draft” people for paramedic school.

In her study she writes, “Paramedics were trained to mastery of all skills.” Do you know how long according to Dr. Gausche it takes to master pediatric ETI?

6 hours.

The icing on the cake, the instruction was led by RN’s. Not CRNAs, or Anesthesiologists, or Pediatricians, or ER MDs, but RNs.

*end rant*
Click to expand...

^this. The study was never intended to be successful.
 
RocketMedic said:
^this. The study was never intended to be successful.
Click to expand...
Unfortunately this is the only major study on pediatric ETI and EVERYONE cites it as to why they don’t want prehospital pediatric ETI.

Ideally, it should be redone in a system with more experienced intubators, who have access to DSI/RSI, and modern equipment (VL, capnography, etc).

But I’m just a paramedic. What do I know???
 
You must log in or register to reply here.
Back
Top