Had a patient a couple day's ago with HX of alcholism and esophogial varices. Predicted difficult intubation. esophogial varices is a contraindiction for a combitube for my back up plan for establishing an airway. Airway was a grade 3 to 4 , used the bougie was able to get the tube first try, bougie's are inexpensive and can definataly aid you in a difficult situation. For nasal intubations I also use the ET tubes that have the ring with a cord attached to the distal end that allows you to move the distal end anteriorally when you pull the ring these also help when nasally intubating.
cardiac arrest tips and tricks you have learned along the way...?
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remote_medic
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If I can add a comment here...this is the most civil and intelligent thread I've read on here in a long time. No name calling, no education bashing...just good ole fashion discussion and experience sharing.
Lets see more topics like this please!!!
Chris
Lets see more topics like this please!!!
Chris
Multiple neurological conditions, such as peripheral neuropathy for example, can cause nerve impulse transmission delays or alterations. These can potentially cause an increased calcium influx into the cell due to inappropriate signals from the CNS and cause hyper-excitibility of skeletal muscles, thus causing rigidity. Think of it as a V-fib of the skeletal muscles in a way. It can also occur due to certain auto-immune issues. It can actually be common during the initial stages of an arrest as the brain is still being oxygenated by the body's reserve (3-4ish minutes).
Trismus itself can be caused by a multitude of issues. More commonly is a trigeminal nerve (CN V) deficiency. Also a common cause is excessive ecstacy use. Others include peritonsillar abscess and TMJ.
Keep something in mind though, we are no longer intubating first thing in a code. Wait a few minutes and use good ventilation with a BVM and OPA / NPA's. Give it a few minutes, if you are still working them, then drop the tube, they should be relaxed by then.
Trismus itself can be caused by a multitude of issues. More commonly is a trigeminal nerve (CN V) deficiency. Also a common cause is excessive ecstacy use. Others include peritonsillar abscess and TMJ.
Keep something in mind though, we are no longer intubating first thing in a code. Wait a few minutes and use good ventilation with a BVM and OPA / NPA's. Give it a few minutes, if you are still working them, then drop the tube, they should be relaxed by then.
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Wow thanks,
yeah thats what we did I tried intubating right when I got there because the fd was doing cpr and bagging for approx 3-4 minutes before we arrived.
Or we could just cut this one in a million son of a gun and go on with life. That’s what my gut is telling me at least. I think it would depend a lot on the provider and we have a long way to go to reach the kind of proficiency you’re advocating here. Anyway, I know this was as much theoretical as anything else, so good point.
djmedic913
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I have brought this idea to my education department and there was a discussion over it. They seemed intrigued. They are quite interested in the idea.
Have you ever done this technique? I have never nasally intubated anyone..never had a need, so not opportunities for me to nasally intubate ever presented itself.
Yeah and it had to happen to me as a new medic. This was my first code since getting my medic license...learn stuff everyday.
Just read the paper, guy ended up passing away 3 days later in the icu. :unsure:
The premise also extends into other, more common scenarios (i.e. COPDer in extremis, MDMA OD, APE advanced to resp. failure, apneic status seizure, metabolic coma, etc.), so it is something worth exploring further. I would imagine that the reason most protocols contraindicate NTI in apneic patients is that the writers assume that the procedure will be done in a specific fashion. Ideally, we'd be using a soft, trigger tube (Endotrol, et al.) with a BAAM whistle and be operating in a calm, quiet environment (hah!). The primary reason for advancing the tube during inhalation it to prevent damage to the vocal chords and to prevent any associated subglotic hematoma or stenosis, but let's face it, NTI is a messy process and if you're performing it, is likely a critical intervention. Obviously, a BAAM whistle is going to be useless if the person is apneic, but we've done NTI with a standard tube and no BAAM for years using only cric. pressure and silent prayers, so it is quite possible.
On a personal note, I hate using Versed to alleviate clenching. Anecdotally, it has failed for me more times than it has worked. In a situation where we are simply attempting to sedate someone to facilitate ETI, it's fine, but if a clenched jaw is the problem it's just not the right tool for the job. Until RSI is more mainstream, NTI will remain a necessary skill. With the addition of CPAP, I've seen my personal number of NTIs drop significantly (haven't nasally intubated a CHFer in the 6 months since we got CPAP). While that's certainly a good thing, it means that our proficiency as a group with nasal tubes is going to suffer. Like with other skills, it becomes easier and less intimidating with practice (things like properly positioning the tube once it's in the nasopharynx, applying the correct amount of cric. pressure, and knowing sensation of a tube passing through the crycoid membrane beneath your fingers, etc.), so manikin and cadaver training is a must.
It's interesting to hear about using a Bougi and the stethoscope trick. One of my complaints about the BAAM is that I have used it twice during extrications and couldn't hear a thing, so next time that scenario comes up I'll have to flip a coin and decide which alternative to try.
ResTech
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Since this has turned into a great airway discussion during arrests.... I was wondering if anyone runs at a service that uses the Glidescope and has any good patient uses to share? We were taught how to use the Glidescope in class and got to practice with it which seemed to be a very nice tool.
At the service I do my field clinicals, the EMS supervisor units each have a Glidescope... too expensive to equip 6 or 7 Paramedic ambulances.
At the service I do my field clinicals, the EMS supervisor units each have a Glidescope... too expensive to equip 6 or 7 Paramedic ambulances.
quewiwi
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Wow. Just joined the forum today and i have already learned a ton from this one thread, thank-you!
Now, my comments, lol!
I too was taught that apnea was a contraindication to NTI and our current protocol also states this. I greatly appreciate all the insight and info regarding alternate techniques. We will never have capnography or CPAP where I work so this has been helpful.
Also, as far as the discussion regarding continuing care and transporting the continually unresponsive code pt. vs. calling on scene; I also feel that as emergency medical professionals we have a responsibility to the public to act respectful and compassionate. Remember that the pt may be just another code to us but they are likely the world to the person standing by and watching you work them. We see death and hold it in our hands everyday, the average person never sees it, except on t.v.. Whatever you think that person standing by is already thinking about or already knows that the pt. is dead is irrelevant. They are watching everything and will process it all later. I feel it is our obligation to give them peace of mind that every possible thing was done to try and revive their loved one so that they may begin the grieving process fully and move on with their life.
I'll shut up now
Now, my comments, lol!
I too was taught that apnea was a contraindication to NTI and our current protocol also states this. I greatly appreciate all the insight and info regarding alternate techniques. We will never have capnography or CPAP where I work so this has been helpful.
Also, as far as the discussion regarding continuing care and transporting the continually unresponsive code pt. vs. calling on scene; I also feel that as emergency medical professionals we have a responsibility to the public to act respectful and compassionate. Remember that the pt may be just another code to us but they are likely the world to the person standing by and watching you work them. We see death and hold it in our hands everyday, the average person never sees it, except on t.v.. Whatever you think that person standing by is already thinking about or already knows that the pt. is dead is irrelevant. They are watching everything and will process it all later. I feel it is our obligation to give them peace of mind that every possible thing was done to try and revive their loved one so that they may begin the grieving process fully and move on with their life.
I'll shut up now
reaper
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If pt is viable! If they are dead, they are dead.
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I'm going to try to be as civil as possible, but...
If you are placing endotracheal tubes without continuous waveform capnography your service's practice is negligent. In this day in age with easily available, relatively inexpensive and reliable ETCO2 and/or extraglotic airways there's no reason to keep placing tubes without waveform capnography or eliminate them all together.
I understand we didn't use to have waveform capnography and we placed tubes. Cars also didn't have seatbelts at one point, does that mean we shouldn't utilize them? (and yes I put these on par with one another). I also understand the technology may fail. However, that should fall under the "extraordinary occurrence" category.
Transporting can interfere with the grieving process by giving false hope. Our FIRST responsibility to render the best care possible to the patient, which can't be done for a cardiac arrest in the back of a moving ambulance. I've been terminating resuscitations in the field for several years. I've never had anyone imply "everything wasn't done". I've usually seen this excuse used by medics who are uncomfortable with the notion of making death determinations and notifying the family of the patient's death.
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Shishkabob
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Don't know about your service, but I can do every single thing out in the field that a hospital can in a medical cardiac arrest.
I make sure that when I go talk to the family about calling it, I let them know that fact.
Sasha
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Always ask for a DNR
quewiwi
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>sigh<
I am not here to argue.
I am expressing my gratitude to the participants of this thread (up to this point) for providing so much information on these topics.
I work for a private ambulance company so you can preach to them about how inexpensive capnography is and make the case as to why they should invest in equipping our units. They are not very receptive to new ideas there, let alone any that would cost them money. I will, however, be bringin it up to them anyway.
As for declaring death in the field, I am not going to waste my time arguing the moot details of certain scenarios where it is and isn't appropriate, just expressing my opinion on the topic as a whole and one of the many considerations.
And Sasha, yes, thank-you, I always do.
...
I am not here to argue.
I am expressing my gratitude to the participants of this thread (up to this point) for providing so much information on these topics.
I work for a private ambulance company so you can preach to them about how inexpensive capnography is and make the case as to why they should invest in equipping our units. They are not very receptive to new ideas there, let alone any that would cost them money. I will, however, be bringin it up to them anyway.
As for declaring death in the field, I am not going to waste my time arguing the moot details of certain scenarios where it is and isn't appropriate, just expressing my opinion on the topic as a whole and one of the many considerations.
And Sasha, yes, thank-you, I always do.
...
A word of advice for this argument. One of the few true areas of legal liability for EMS is misplaced endotracheal tubes. See if you can find out how much equipping your services fleet with waveform capnography would cost. It shouldn't be too hard to find examples of judgements against services for misplaced ETTs. This kinda makes your argument for you.
The AHA has some pretty good literature on this, although I don't have it handy. Basically they have the same recommendations as what I stated above. There's more situations where it's appropriate than not. I have found many medics (myself included) are very uncomfortable with family notification initially, however it gets easier with experience.
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medicstudent101
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Standard of Care.
JPINFV
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