Intubation and Spontaneous Respirations

[LACoGurneyjockey]

Came across a scenario on a call earlier today that neither I nor my partner could come up with a clear answer to.
We got called to a single vehicle rollover at highway speeds. One patient DOA, one pinned in. He's got a strong radial pulse at 120 and labored, snoring respirations at 30/min, GCS of 5.
After he was extricated, packaged and loaded my partner went for the intubation. Tube went in fine, but when I went to confirm lung sounds the patient appeared to still be breathing on his own. I'd get lung sounds with the patients inspiration as well as with FD bagging.
My question, can this patient continue to breath spontaneously if the tube was in the trachea? Does his continuing to breath mean the tube was in the stomach?
Maybe 3-5 minutes later we started getting resistance with the BVM. The tube was found to be in the esophagus and we pulled it.
My partner visually confirmed placement thru the cords, and my partner and I both confirmed lung sounds immediately after the intubation. While getting the tube holder in place FD managed to jostle the patient quite a bit. Our thinking was this is when we lost the tube.
Any thoughts? The patient had spontaneous respirations from prior to intubation throughout until he was finally RSI'd by the flight crew.
Of note, in Kern County our only drug to assist with intubation is versed at 1mg, which was given.

 

[STXmedic]

Why would placing a tube in the trachea immediately take away their ability to breathe? All it is is an open airway. And 1mg of Versed? Seriously?

 

[LACoGurneyjockey]

I know I know, but not everyone gets to be an RSI badass in Texas... For being just outside of So Cal I can't complain.
So basically, if a patient was breathing inadequately before you tube them, they're going to continue to breath inadequately with the bag just improving volume?

 

[STXmedic]

I don't even have RSI at the moment. I'm just referring to the near worthlessly low dose.

It depends on why they're breathing inadequately. If it's an airway issue, you may actually make their breathing easier. If something else is causing the respiratory compromise, the ET tube will just provide you with an adequate airway. It shouldn't directly affect their breathing, though.

 

[Handsome Robb]

Search "SIMV". Not all agencies carry vents capable of SIMV in the 911 setting though.

 

[LACoGurneyjockey]

Ventilators cost money, right? Yeah, we don't carry those.
He was apneic until being extricated and an OPA got him breathing on his own. Followed up with the trauma center and apparently he had a brain bleed, cervical fracture (they didn't say which), and multiple breaks on his right arm. So I'm guessing his position in the vehicle was the airway issue, but I guess a C3 fracture or the bleed could definitely have contributed.

 

[Handsome Robb]

I'd be surprised if he had a fx in the C3-5 region and still had a respiratory drive due to the phrenic nerve exiting the spinal column, which is what controls your diaphragm. Also sounds like he may have been displaying an abnormal respiratory pattern, biots or cheyne-stokes both could fit what you're describing unless his rate become regular after correcting the airway obstruction.

Not to monday morning QB but why no OPA or at least an NPA in the car during extrication? Patient like that I'm gonna be in the car with them while fire cuts the car apart around us.

 

[VFlutter]

We had a doc that liked to put intubated patients on a T piece for weans. It is definitely possible to have adequate representations with an ETT, just tiresome without some pressure support.

 

[socalmedic]

yes, the patient can spontaneously breathe though the tube and BVM, there is a one way flutter valve in the bvm that allows the patient to breathe even when you are not actively bagging. so I would say yes it is possible that the patient was breathing in addition to your (the FD) ventilation with BVM.

I would say that while your partner saw the tube pass the chords it was pulled before the cuff was inflated leaving only the distal tip in the trachea and the cuff outside the trachea. one of the movements that you described re-positioned the tip from the trachea to the esophagus. It is hard to pull the cuff through the larynx if properly inflated which is why I say that it was probably only a marginal placement at best.

was waveform capnography used? if so what did the wave look like? if not, why wasn't it?

 

[medicsb]

Yes, as you now know, it is totally possible for a patient to breath with an ETT in place. I've seen patient 30+ minutes into cardiac arrest still breath through an ETT (yeah, seriously, it was bizarre), and plenty of RSI patients who resumed spontaneous respiration after the succs wore off. I used to do one of two things: squeeze the bag when they breath in or allow them to breath and give them a moderate to large squeeze a few times a minute between respirations.

 

[rmena]

Davis County Utah does has a special deputy sheriff paramedic position that does RSI. I think they are the only system in Utah that isn't a CC unit that does RSI.

 

[Handsome Robb]

I thought about applying to Davis County when my shoulder gets better. Wanna talk to someone who knows the system first though.

 

[Carlos Danger]

Came across a scenario on a call earlier today that neither I nor my partner could come up with a clear answer to.
We got called to a single vehicle rollover at highway speeds. One patient DOA, one pinned in. He's got a strong radial pulse at 120 and labored, snoring respirations at 30/min, GCS of 5.
After he was extricated, packaged and loaded my partner went for the intubation. Tube went in fine, but when I went to confirm lung sounds the patient appeared to still be breathing on his own. I'd get lung sounds with the patients inspiration as well as with FD bagging.
My question, can this patient continue to breath spontaneously if the tube was in the trachea? Does his continuing to breath mean the tube was in the stomach?
Maybe 3-5 minutes later we started getting resistance with the BVM. The tube was found to be in the esophagus and we pulled it.
My partner visually confirmed placement thru the cords, and my partner and I both confirmed lung sounds immediately after the intubation. While getting the tube holder in place FD managed to jostle the patient quite a bit. Our thinking was this is when we lost the tube.
Any thoughts? The patient had spontaneous respirations from prior to intubation throughout until he was finally RSI'd by the flight crew.
Of note, in Kern County our only drug to assist with intubation is versed at 1mg, which was given.

What most likely happened is that your partner tubed the goose, and the "good" breath sounds you heard were from the patients spontaneous respirations.

 

[LACoGurneyjockey]

His respirations went from apneic in the car initially, to rapid, shallow, and labored after we started to lift the car off him.
No real interventions in the car because he flipped a convertible mustang and was pinned between the car and the road, with both pillars almost entirely collapsed. And Monday morning QB away, I wouldn't post here if I didn't want to take something away from it...
All we have for ETCO2 is colorimetric which was used

 

[teedubbyaw]

He was apneic? Wait, I thought he had snoring resps on arrival?

It sounds like you were listening to him breath, and not necessarily the manual breaths. Plus, depending on where you're listening, that sound can transmission and be heard as respirations, even if the tube is placed in the esophagus.

Do you guys not have capnography? 3-5 minutes and just finding out the tube is incorrectly placed is completely unacceptable.

 

[rmena]

So was the thinking then that you were going to have a delayed transport/extrication time? was their blood/vomitus/other airway complications or you just wanted a more definitive airway?

 

[rmena]

the reason I ask is that I know there is quite a bit of grey area with intubation and the rule of thumb of sub 8 intubate on glassgow is a very sloppy rule

 

[rmena]

To clarify, I totally agree with the decision in this case I am just a newer medic trying to figure out when it is appropriate to intubate and when it isn't necessary.

 

[rmena]

Add to this list of indications they taught in class for ET intubation as opposed to King/LMA

1. Code
2. oral secretions in unconscious patient (i.e. blood, vomit, water)
3. long transport times to eliminate risk of filling stomach with air and aspirating a pt
4. swelling secondary to burns, acute epiglotitis/croup (like completely closed airway)
5. le forte II/III fractures to protect the airway and allow for better ventillation

Sorry, I know you guys think I am probably a moron but our medic class/preceptors pushed BLS airways to the max so intubation was kinda left sparse.

 

[medicsb]

Indications and method to intubate, realistically, is going to vary depending on your training and experience. An EM physician may intubate patients that you would not, an experienced anesthesiologist or CRNA will intubate some patients that an EM physician would not, and an otolaryngologist may be more comfortable securing an airway under certain circumstances than some anesthesiologists or CRNAs.

It will be better for you to simplify the indications according to difficult airway course teaching (not unique to them, but its where I first learned it):
1. Impaired protection or maintenance of the airway (e.g. the comatose patient)
2. Impaired respiration (e.g. the CHF'r, COPD exacerbation, etc.)
3. Anticipated course of disease/care (e.g. airway burns, expanding neck hematoma, the fatiguing respiratory patient, etc.)

You need to get to know your skill level. Being that you're out on your own, you should already have a pretty good idea. You also need to consider if you have back up (i.e. an experienced partner) and what do they feel comfortable with. If you only tubed a handful of patients during training, I would not make riskier attempts. If you do not have an experienced partner who can take over, I would not make riskier attempts (do not consider a partner experienced if he or she has 20 years experience but only intubating 1-2 patients per year for those 20 years).

Ultimately, good BVM technique (with an airway adjunct) or use of a supraglottic device may be your best choice.

Add to this list of indications they taught in class for ET intubation as opposed to King/LMA

1. Code
2. oral secretions in unconscious patient (i.e. blood, vomit, water)
3. long transport times to eliminate risk of filling stomach with air and aspirating a pt
4. swelling secondary to burns, acute epiglotitis/croup (like completely closed airway)
5. le forte II/III fractures to protect the airway and allow for better ventillation

Sorry, I know you guys think I am probably a moron but our medic class/preceptors pushed BLS airways to the max so intubation was kinda left sparse.