Fall from a roof

[Veneficus]

Dropping a tube with chest compressions going sounds like a rough skill to learn.

It is not as bad as it sounds. The nice thing about dead people is they have no muscle tone, so even with some very powerful compressions, there isn't a whole lot of movement in the head.

 

[Veneficus]

The only thing I can see I would have done is intubate rather than drop an OPA so I did not get behind the ball and have to drop a tube when I was too late. I know it is not clinically indicated by the book but the pt condition was not going to get any better in the field, your assessment shows he has the potential for airway compromise if not an actual compromised and no gag reflex.

Perhaps this and the associated citations may alter your decision.

http://www.ncbi.nlm.nih.gov/pubmed/15920406

"CONCLUSION: Prehospital intubation is associated with a decrease in survival among patients with moderate-to-severe TBI. More critically injured patients may benefit from prehospital intubation but may be difficult to identify prospectively."

 

[TransportJockey]

It is not as bad as it sounds. The nice thing about dead people is they have no muscle tone, so even with some very powerful compressions, there isn't a whole lot of movement in the head.

Or just, ya know, put a king in and don't bother with ETI

EDIT: Or combi since that's what I have for a backup down here. I wound up using it last night on a code after I tried twice for ETI and couldn't get it.

 

[MS Medic]

I don't know that I would use a combitube on this patient becuase of the potential for bulb to displace anything else that may be fractured. ICP is a concern, but if he is bleeding out the ears and nose there is somewhat of an "outlet" for the pressure. I would also be prepared to decompress that left side if he isn't getting better after being intubated.

I see your point on the combitube but that is the only back up airway on the truck.

 

[MS Medic]

Perhaps this and the associated citations may alter your decision.

http://www.ncbi.nlm.nih.gov/pubmed/15920406

"CONCLUSION: Prehospital intubation is associated with a decrease in survival among patients with moderate-to-severe TBI. More critically injured patients may benefit from prehospital intubation but may be difficult to identify prospectively."

Yea, another "medics should not be intubating study." This pt meets intubation requirements for my protocols and I have had to try and manage an airway on a person going down a county road once they started crashing before, so this guy would be getting a tube out the gate.

As far as these studies go, while I'm not a protect my access to a skill kind of person, I have rolled someone into the level 1 trauma center with a tube that I checked before I pulled them out of the truck and took all steps to protect the placement after that and the first thing the doc did without even listening for placement was call the tube misplaced and pulled it.
While I realize this is an apples and oranges type of thing, it makes me raise an eyebrow as to the data collection methods.

 

[Veneficus]

Yea, another "medics should not be intubating study." This pt meets intubation requirements for my protocols and I have had to try and manage an airway on a person going down a county road once they started crashing before, so this guy would be getting a tube out the gate.

As far as these studies go, while I'm not a protect my access to a skill kind of person, I have rolled someone into the level 1 trauma center with a tube that I checked before I pulled them out of the truck and took all steps to protect the placement after that and the first thing the doc did without even listening for placement was call the tube misplaced and pulled it.
While I realize this is an apples and oranges type of thing, it makes me raise an eyebrow as to the data collection methods.

So how many studies will it take on a decrease in survival in prehospital intubation of TBI specifically (I am not really concerned about the whole paramedics intubating or not argument) before people realize it may not be the best way to practice?

There have been several studies on this pathology done.

In all fairness, it is my thinking that the decrease in survival can actually be attributed to lack of familiarity with the skill creating prolonged scene time as well as excessive ventilation rate that may be responsible for the decrease since there are studies that are linked on that page showing an actual increase in survival for patients intubated by airmedical EMS. (Which are generally superior to a majority of ground EMS in the US)

 

[Akulahawk]

So how many studies will it take on a decrease in survival in prehospital intubation of TBI specifically (I am not really concerned about the whole paramedics intubating or not argument) before people realize it may not be the best way to practice?

There have been several studies on this pathology done.

In all fairness, it is my thinking that the decrease in survival can actually be attributed to lack of familiarity with the skill creating prolonged scene time as well as excessive ventilation rate that may be responsible for the decrease since there are studies that are linked on that page showing an actual increase in survival for patients intubated by airmedical EMS. (Which are generally superior to a majority of ground EMS in the US)

Over the years, the one thing that I keep reading over and over is that in major trauma, patients that are transported by BLS tend to do better than those transported by ALS crews. I think a lot of that comes from the fact that BLS crews don't have a lot of stuff they "need done" so they get off scene pretty quick. I tend to "think" like an EMT when it comes to trauma. I want to be headed towards the hospital yesterday. I don't want to sit on scene any longer than I must. I'd like to secure the airway (if necessary) on scene, but I'll do it during transport if I have to. Same with every other ALS intervention. For the "excessive ventilation" thing: it's natural to squeeze the bag at a faster rate than you realize...

 

[MS Medic]

thread hijacking

since this has been successfully hijacked let me go back to the OP and say that you did a good job, just see the first few replies.

 

[Veneficus]

For the "excessive ventilation" thing: it's natural to squeeze the bag at a faster rate than you realize...

Yes it is natural, it is also harmful.

The last numbers I saw (2 years ago) showed the average rate with BVM was 44 times a minute.

When these same providers were made aware to benefit the patient instead of just watching harm done to objectify the study, they slowed to 22 a minute.

Since in my experience most EMS providers do not see a lot of major trauma as individuals, so they often significantly over estimate severity. In the rare instances when they do see something severe, they are basically overexcited and on autopilot.

Hopefully what I have witnessed in the last few years both in person and in discussion here is not a global trend of EMS providers becoming more automated and making decisions (or not making decisions) based on being uncomfortable with trauma or outright fear rather than objectivity.

 

[Veneficus]

since this has been successfully hijacked let me go back to the OP and say that you did a good job, just see the first few replies.

Past the first page there really wasn't much to reply to.

 

[Akulahawk]

Yes it is natural, it is also harmful.

The last numbers I saw (2 years ago) showed the average rate with BVM was 44 times a minute.

When these same providers were made aware to benefit the patient instead of just watching harm done to objectify the study, they slowed to 22 a minute.

Since in my experience most EMS providers do not see a lot of major trauma as individuals, so they often significantly over estimate severity. In the rare instances when they do see something severe, they are basically overexcited and on autopilot.

Hopefully what I have witnessed in the last few years both in person and in discussion here is not a global trend of EMS providers becoming more automated and making decisions (or not making decisions) based on being uncomfortable with trauma or outright fear rather than objectivity.

That would make sense to me. And I agree that it's harmful to over ventilate the patient. 44 in a minute is a mite bit too fast. Heck, 22/min is probably too fast, but it's better...

 

[Smash]

I will see your retrospective Davis, and raise you a prospective Bernard:

Bernard et al. 2010 Prehospital Rapid Sequence Intubation Improves Functional Outcome for Patients With Severe Traumatic Brain Injury A Randomized Controlled Trial. Annals of Surgery. 252:6, 959-965

RSI isn't the bogeyman. RSI done badly (hypoxic episodes, hypercapnea, hyperventilation, hypotension) most certainly is.

 

[Veneficus]

In all fairness, it is my thinking that the decrease in survival can actually be attributed to lack of familiarity with the skill creating prolonged scene time as well as excessive ventilation rate that may be responsible for the decrease since there are studies that are linked on that page showing an actual increase in survival for patients intubated by airmedical EMS. (Which are generally superior to a majority of ground EMS in the US)

"RSI isn't the bogeyman. RSI done badly (hypoxic episodes, hypercapnea, hyperventilation, hypotension) most certainly is."

That was my conclusion from Davis.

Bernard was a good read to though

 

[MrBrown]

Most people just blindly squeeze the bag doing the good old ambo trick of "more is better" and universally ventillate too fast.

Think about each breath, squeeze the bag and in your mind say "release, release, release" then squeeze the bag again.

Hyperventilation for head injured patient fell out of fashion donkeys years ago or so Brown thought.

Brown would want to RSI this guy, ensure good oxygenation including chest decompression if required, whatever circulatory support is needed in the short term (maybe infuse a bit of fluid, conservatively), split and package and pop him in the big noisy machine the sky cowboys in thier "DOCTOR" jumpsuits swann down out the clouds in for transport to the hospital type deal.

Oh and Brown has serious methadological and confounding variable concerns about those Paramedics should not intubate studies .....

 

[Veneficus]

Most people just blindly squeeze the bag doing the good old ambo trick of "more is better" and universally ventillate too fast.

Think about each breath, squeeze the bag and in your mind say "release, release, release" then squeeze the bag again.

Gotta love anesthesia.

But not only do you have to say it, you have to be as calm when you say it as when you are sniffing your own gas.

Hyperventilation for head injured patient fell out of fashion donkeys years ago or so Brown thought.

For EMS.

Oh and Brown has serious methadological and confounding variable concerns about those Paramedics should not intubate studies .....

So do I. But I think that the major confounders of skill, experience, and oversight discrepencies demonstrate very well that subgroups of paramedics from selective services should not be intubating.

Globally saying "all paramedics" is one of those "extreme" positions that never seem to make mch sense.

 

[jjesusfreak01]

Most people just blindly squeeze the bag doing the good old ambo trick of "more is better" and universally ventillate too fast.

If only there were a device that could show us O2 saturation and % CO2 exhaled to allow us to correctly ventilate patients. It could maybe even do this in a waveform on some sort of video display, possibly in color. Alas, we'll just have to do without until such a thing is invented.

 

[Veneficus]

If only there were a device that could show us O2 saturation and % CO2 exhaled to allow us to correctly ventilate patients. It could maybe even do this in a waveform on some sort of video display, possibly in color. Alas, we'll just have to do without until such a thing is invented.

would be great if the device was inexpensive too though.

 

[MrBrown]

If only there were a device that could show us O2 saturation and % CO2 exhaled to allow us to correctly ventilate patients. It could maybe even do this in a waveform on some sort of video display, possibly in color. Alas, we'll just have to do without until such a thing is invented.

Waveform capnography is quite new here and has only been around for the last two or three years. It is only mandatory for use on RSI patients although we do have the colourmetric ETCO2 devices which you can attach to a bag mask.

 

[Handsome Robb]

Unlike Smash, I'm not as worried about an axial load problem on this guy's cervical spine. This patient still reportedly has good distal motor function (he's moving his limbs). The flail segment of the left chest tells me that he didn't land directly on the top of his head like the proverbial lawn dart. He probably landed on his left side, while looking to his left, trying to cushion his fall (and his head) with his right arm. In other words, looking at his injury pattern, I'm not seeing a mechanism that supports an axially loaded cervical spine upon impact.

I was a little unclear about his motor function. He had strong pulses and good cap refill in all extremities, but no real motor function, besides withdrawing from painful stimuli. The way you described his fall was pretty much the conclusion I came to as well. I don't want to be a protocol monkey with C-spine, but to me with the flail chest and especially the skull fx wouldn't that be a good indicator of possible spinal injury due to a lateral load on the cervical spine? I was under the impression that it is much harder to fracture your skull than it is to fracture your neck...but I may be completely wrong.

On the Philips monitors we use we have waveform capnography available to us, but I am a little fuzzy on if it is something that can be interpreted by an Intermediate. I know what the wave form is supposed to look for and I know that you are looking for between 35-45 mmHg but that is about the extent of my knowledge that I have of it, so I am not sure how comfortable I would be using it exclusively.

 

[TransportJockey]

I was a little unclear about his motor function. He had strong pulses and good cap refill in all extremities, but no real motor function, besides withdrawing from painful stimuli. The way you described his fall was pretty much the conclusion I came to as well. I don't want to be a protocol monkey with C-spine, but to me with the flail chest and especially the skull fx wouldn't that be a good indicator of possible spinal injury due to a lateral load on the cervical spine? I was under the impression that it is much harder to fracture your skull than it is to fracture your neck...but I may be completely wrong.

On the Philips monitors we use we have waveform capnography available to us, but I am a little fuzzy on if it is something that can be interpreted by an Intermediate. I know what the wave form is supposed to look for and I know that you are looking for between 35-45 mmHg but that is about the extent of my knowledge that I have of it, so I am not sure how comfortable I would be using it exclusively.

My service allows basics to use Capno, both cannulas and slipstream for MLAs. EMT-Is and medics here use it for the same thing, and also with ETI placement confirmation. If you know what it is, and how to use it I don't see how it would be wrong... But your mileage may vary