Intubation and Spontaneous Respirations

[rmena]

I like how that's broken down. makes more sense that way.

 

[kindofafireguy]

My current system pushes advanced airway management for anyone with anticipated clinical need. A person who has a GCS of 5 is someone who has serious potential for losing control of their airway. RSI would be utilized in this case.

 

[LACoGurneyjockey]

Let me clarify. He was apneic on arrival, with shallow, snoring respirations during extrication which improved slightly after OPA placement.
With the airship, ETA to a level 2 trauma center was roughly 50-60 minutes from our arrival on scene, plus snoring labored respirations and a GCS of 5 were our indications for ET.

Teletubby, we have colorimetric ETCO2, unfortunately no waveform. Medic visualized the tube thru the cords, good lung sounds, condensation in the tube, chest rise/fall, and colorimetric ETCO2 all indicated a successful intubation. Is there no possibility of a tube becoming dislodged after a successful intubation, particularly in a patient responsive enough to put up some resistance?

 

[STXmedic]

:rofl: at OP changing your name to teletubby [emoji1]

 

[LACoGurneyjockey]

Meh, close enough....

 

[Carlos Danger]

Let me clarify. He was apneic on arrival, with shallow, snoring respirations during extrication which improved slightly after OPA placement.
With the airship, ETA to a level 2 trauma center was roughly 50-60 minutes from our arrival on scene, plus snoring labored respirations and a GCS of 5 were our indications for ET.

Teetubby, we have colorimetric ETCO2, unfortunately no waveform. Medic visualized the tube thru the cords, good lung sounds, condensation in the tube, chest rise/fall, and colorimetric ETCO2 all indicated a successful intubation. Is there no possibility of a tube becoming dislodged after a successful intubation, particularly in a patient responsive enough to put up some resistance?

Certainly that is possible. But it is also quite possible that your partner was mistaken about seeing the tube pass the cords, and that the trachea was never intubated. Happens all the time to inexperienced folks, and occasionally to even very experienced ones.

Assuming that the ETT cuff was inflated and the tube was properly secured with tape or a commercial device, the latter possibility is much more likely, IMO. Especially if the patient was breathing spontaneously.

This case really underscores why waveform capnography is so important. If you don't have a tracing to prove the tube was in the trachea, then it wasn't.

 

[LACoGurneyjockey]

...and colorimetric ETCO2 indicated a successful intubation.

I get that it's not waveform, and this wouldn't be the first time our system takes 10 years to catch up, but we had positive color change on the end tidal co2 available to us.

 

[kindofafireguy]

It's possible to have positive color change on colormetrics even with an esophageal intubation. It's not common, but it can happen if they've recently consumed carbonation, CO2 is transported to stomach during bagging, etc. Just like you can get condensation in the tube from esophageal intubation as well.

http://www.mastertrain.8m.com/articles02/co2 and cpr.pdf

Here'S some supporting info.

 

[medicsb]

It's possible to have positive color change on colormetrics even with an esophageal intubation. It's not common, but it can happen if they've recently consumed carbonation, CO2 is transported to stomach during bagging, etc. Just like you can get condensation in the tube from esophageal intubation as well.

http://www.mastertrain.8m.com/articles02/co2 and cpr.pdf

Here'S some supporting info.

This potential confounder is why you keep the colormetric device on for at least 6-10 ventilations or keep an eye on the wave form and number. If it is in the stomach and there is CO2 in the stomach, you'll quickly blow it off. With each ventilation the number should come down precipitously to zero. The initial reading will often be remarkably high (>100mmHg). There have been a number of experimental studies with animals and different models that have been published on the topic.

 

[kindofafireguy]

True story. It's also a perfect example of why it takes multiple confirmation methods. And why End Tidal is where it's at.

 

[Rialaigh]

Just to pick apart another point, If the patient had no gag reflex and did have some respirations with an OPA in place. AND the airway appeared clear with no massive amounts of blood or other issues, I would feel a lot better bagging this patient, and calling for orders for a lot of versed prior to intubation, or if flight (with RSI capabilities) will be on the ground in 10-15, just supplement the patients breathing with a BVM and high flow O2.


Aside from the point of whether the tube was properly placed or not, Im not going to attempt this tube if the patient is breathing with a clear airway (at least semi adequately), I don't have RSI, and I can't get orders for a LOT of versed and probably some morphine. No reason you can't bvm till flight arrives. I'm not saying the patient didn't need a tube, I'm saying he didn't need a tube right then with the medications your able to give.


Where I am at we have RSI, and when we don't want to utilize that we can call the doc and get orders for just versed if we feel like it, usually 5-10 mg to start.

 

[Smash]

Where I am at we have RSI, and when we don't want to utilize that we can call the doc and get orders for just versed if we feel like it, usually 5-10 mg to start.

Why on earth would you choose just to use midazolam when you have the option of doing it properly?

 

[Rialaigh]

Why on earth would you choose just to use midazolam when you have the option of doing it properly?

Why is taking away someones airway who is breathing doing it properly. We have hashed the RSI/No RSI thing over and over in several other threads. If the patient has no gag reflex, and just needs some comfort and a bit of assistance to maintain a tube and will still maintain some of his own breathing I am all for that. My main concern with this patient would be proper sedation, nothing more, and by proper sedation I mean the absolute minimal to keep the patient comfortable and keep my tube safe.

 

[Carlos Danger]

Just to pick apart another point, If the patient had no gag reflex and did have some respirations with an OPA in place. AND the airway appeared clear with no massive amounts of blood or other issues, I would feel a lot better bagging this patient, and calling for orders for a lot of versed prior to intubation, or if flight (with RSI capabilities) will be on the ground in 10-15, just supplement the patients breathing with a BVM and high flow O2.


Aside from the point of whether the tube was properly placed or not, Im not going to attempt this tube if the patient is breathing with a clear airway (at least semi adequately), I don't have RSI, and I can't get orders for a LOT of versed and probably some morphine. No reason you can't bvm till flight arrives. I'm not saying the patient didn't need a tube, I'm saying he didn't need a tube right then with the medications your able to give.

I agree with your thought process here. Generally speaking, I think a few good guidelines for the prehospital realm are:

• Invasive interventions of any type really should be a last resort.
• Most airways can be more safely management with conservative techniques
• When intubation does need to occur, it should be done by the most experienced intubator. In many cases this will be the primary paramedic on scene, but if there is an ED physician 10 minutes away or a HEMS crew enroute, it may be better to defer to them.

This reminds me of an experience. On one of my last shifts before quitting work for grad school, we were requested to respond to an MVC in the county just south of yours. This county had recently "cleared" a handful of "RSI medics". As we were approaching the scene, we could see a second ambulance racing though the streets towards the scene. As we were on short final, maybe 100 feet or so AGL, this second ambulance screeched to a stop on the scene, with the two occupants quickly exiting the ambulance, look towards us landing, and then literally run to the ambulance that the patient was in. We entered the ambulance maybe 60 seconds later, just in time to see vomit spewing out of an ETT like a fire hose and the patient gagging violently. The "RSI medics" had been in such a hurry to beat us to the tube, that they hadn't even given the sux time to work.

Why is taking away someones airway who is breathing doing it properly.

Because plenty of research shows that it's easier, which translates into it being safer for the patients. RSI with NMB results in fewer intubation attempts and lesser incidence of aspiration than does sedative-only intubation.

A small dose of any sedative will preserve breathing and airway reflexes, but will do very little to improve intubating conditions. A large dose of any sedative will improve intubating conditions, but will also result in severely depressed respiratory drive and airway reflexes, with intubating conditions still being not as good as with NMB. So how is sedation only better or safer than NMB?

There are good reasons why even in the controlled environment of the OR, with little risk of aspiration and with extremely experienced people doing the intubating, NMB is still routinely used. There are times when intubating without NMB is the right choice, but it is more difficult to do safely, and the indications do not exist in the prehospital environment.

 

[NomadicMedic]

[*]When intubation does need to occur, it should be done by the most experienced intubator. In many cases this will be the primary paramedic on scene, but if there is an ED physician 10 minutes away or a HEMS crew enroute, it may be better to defer to them.

Just curious, how does the primary paramedic become the most experienced intubator if they're waiting for the helo... And how does the secondary medic get experience if the primary medic gets all the tubes?

And what is the bench mark for "most experienced"?

 

[FiremanMike]

Just curious, how does the primary paramedic become the most experienced intubator if they're waiting for the helo... And how does the secondary medic get experience if the primary medic gets all the tubes?

And what is the bench mark for "most experienced"?

Generally speaking, your lemon assessment should dictate who is going to tube. If you can predict a difficult tube ahead of time, it should go to the "strongest" airway person on the scene. This can be a scenario that leads to a lot of butt hurt, but it'd be nice to believe that everyone is mature enough to acknowledge who amongst the group is good at intubation and who isn't.

 

[NomadicMedic]

No, the LEMON assessment should determine IF you intubate.

 

[Carlos Danger]

Just curious, how does the primary paramedic become the most experienced intubator if they're waiting for the helo... And how does the secondary medic get experience if the primary medic gets all the tubes?

Not sure. Acquiring airway experience has been a big challenge since before I got into EMS, and I don't see it getting any easier in the future.

All I can tell you is that when you have a sick patient who needs to be intubated, that is not the time to practice or to let your ego influence the decision making.

 

[FiremanMike]

No, the LEMON assessment should determine IF you intubate.

Maybe on an in-betweener, but some people just need intubated..

 

[Rialaigh]

I agree with your thought process here. Generally speaking, I think a few good guidelines for the prehospital realm are:

• Invasive interventions of any type really should be a last resort.
• Most airways can be more safely management with conservative techniques
• When intubation does need to occur, it should be done by the most experienced intubator. In many cases this will be the primary paramedic on scene, but if there is an ED physician 10 minutes away or a HEMS crew enroute, it may be better to defer to them.

This reminds me of an experience. On one of my last shifts before quitting work for grad school, we were requested to respond to an MVC in the county just south of yours. This county had recently "cleared" a handful of "RSI medics". As we were approaching the scene, we could see a second ambulance racing though the streets towards the scene. As we were on short final, maybe 100 feet or so AGL, this second ambulance screeched to a stop on the scene, with the two occupants quickly exiting the ambulance, look towards us landing, and then literally run to the ambulance that the patient was in. We entered the ambulance maybe 60 seconds later, just in time to see vomit spewing out of an ETT like a fire hose and the patient gagging violently. The "RSI medics" had been in such a hurry to beat us to the tube, that they hadn't even given the sux time to work.



Because plenty of research shows that it's easier, which translates into it being safer for the patients. RSI with NMB results in fewer intubation attempts and lesser incidence of aspiration than does sedative-only intubation.

A small dose of any sedative will preserve breathing and airway reflexes, but will do very little to improve intubating conditions. A large dose of any sedative will improve intubating conditions, but will also result in severely depressed respiratory drive and airway reflexes, with intubating conditions still being not as good as with NMB. So how is sedation only better or safer than NMB?

There are good reasons why even in the controlled environment of the OR, with little risk of aspiration and with extremely experienced people doing the intubating, NMB is still routinely used. There are times when intubating without NMB is the right choice, but it is more difficult to do safely, and the indications do not exist in the prehospital environment.

Oh I agree with you here, however this patient in the scenario I would likely approach intubation without any NMB use and very minimal sedative use assuming there is truly no gag reflex at all.



And I agree that RSI with a NMB is easier, I however would be skeptical that it is safer in the prehospital realm. Given the high percentage of misses that EMS systems tend to have, an RSI may be easier to the tune of 10-15% but if your missing 20% of your tubes in spontaniously breathing patients, and now that 20% has 0 respiratory drive at all....

In a hospital setting with experience airway providers I 100% agree it is easier and likely safer.