Intubation

[MinnesotaMedicStudent]

I'm going to probably sound like an idiot, but please don't be too hard on me. It's my first time posting and I'm a relatively new medic student.

We have not covered intubation yet and I have some questions. I was doing some of my BLS rides (riding on an ALS rig but only being able to do interview, vitals and such) and my preceptor confused me. The call was for an overdose.

We get on scene to find an 84 year old woman unresponsive on the floor. She is breathing (R-14, SPO2- 95% on RA), has a GCS of 5 (E-1, V-2, M-2), and has bounding distal pulses (BP 112/64, P 60 regular). There are about 12 empty pill containers in the bathroom, husband states she takes her pills and goes to bed before him, he last saw her about 1.5 hours ago.

One of the bottles was for percocet, husband states he thinks that was already empty. Pupils dilated (equal at 4mm, reactive, round). Pt does not appear to have vomited, is not diaphoretic (warm to touch, skin appears normal), and has good cap refill.

She has snoring respirations that are easily corrected with a simple head-tilt. Here's where my question comes in. My preceptor was the attending and he elected to place a nasal pharyngeal airway and provide oxygen via mask. His partner appeared to think the lady should be intubated and after some not-so-subtle hints at such the preceptor attempted to place an oral airway and then said "not going to happen, she has a gag-reflex".

Should she have been intubated? I've read that a gag-reflex doesn't mean the patient is protecting her airway. If your service, like this one, doesn't have RSI, can you intubate a patient with a gag reflex? When you intubate someone who is breathing adequately, how do you bag them? Try to do it when they are inhaling but still only 8-10 times a minute, even if they are breathing faster (in this instance 14)? Do you try to sedate them with the drugs you have?

This service carries versed and morphine for controlled substances. No etomidate, vec, succ, or anythings like that.

Thanks for your help. Also, if you have any links to reading material that may help me it would be much appreciated. I apologize if I sound like an idiot.

 

[Sasha]

She was breathing fine on her own, so it seems. No need to intubate. If it's not broken, don't fix it!

 

[Epi-do]

First of all, you don't sound like an idiot. You are a student, therefore, you are building the foundation all other learning will build off of. I have only been a medic for a couple months and am still learning so much. It's almost like I am still in school because I have moved from a controlled environment to one that I have to control.

Based on the information you presented, I would not have intubated the patient. At the time, she was breathing adequately on her own. I agree with the NPA, and I would have continued to monitor her airway.

We do not have RSI, so I can't really comment on that. As far as intubating a patient with a gag reflex, I have only seen it done once. It was for an asthmatic that was teetering on respiratory arrest and was in the middle of respiratory failure. They had been tubed in the past and were begging us to do it again. The medic I was working with at the time did a blind nasal intubation on them.

Any sort of sedation of the patient you had would depend upon local protocol, but I would be hesitant to put any more drugs onboard if you are treating an overdose of multiple substances. At the very least, I would contact medical control before doing anything along those lines.

When you intubate someone who is breathing adequately, how do you bag them?

If someone is breathing adequately, I am not sure why you would intubate them, or bag them. Maybe one of the more seasoned medics can address this one better for you.

As for bagging a patient with inadequate respirations, if they are alert, I try to bag with their respiratory effort as long as it is within a "normal" range. Sometimes, they just aren't able to get the tidal volume on their own for whatever reason. You will also find that an alert patient may fight you when you try to bag them. Sometimes you can talk them through it, and they will relax enough to accept it. Othertimes, you just do the best you can.

For an unresponsive patient, I bag them at an appropriate rate. If they are breathing too slowly, I still try to bag when they are inspiring, but will put extra breaths in there as well. If they are breathing too quickly, I only bag them at around 10 breaths/minute to try and slow them down.

I personally don't have any links readily available for you, but if you do a search on the net I am sure you can find info. Good luck in school, and keep asking good questions of those around you.

 

[tydek07]

Hi,
It does not sound like this pt needed to be intubated. From what you have told us, I would not have intubeted this person... But remember, I was not there and do not know what all was going on.

Can you intubate someone with a gag reflex without RSI? Very rare that it would need to be done...

How do you bag them if they are breathing on their own? Lets say a person is breathing 6/min. and you are assisting them with ventilations. It helps that you find a rythym so when they take a breath, you are also giving them a breath... just find the rythym.

I used a resp. rate of 6/min. as if a person were "breathing adequately" (as you put it) there is no reason to assist ventilation, little own intubate the person.

Take Care,

 

[MSDeltaFlt]

I'm going to probably sound like an idiot, but please don't be too hard on me. It's my first time posting and I'm a relatively new medic student.

We have not covered intubation yet and I have some questions. I was doing some of my BLS rides (riding on an ALS rig but only being able to do interview, vitals and such) and my preceptor confused me. The call was for an overdose.

A medic student and doing BLS rides?!? I'm confused. If you're a medic student and not allowed to do medic stuff, why are you doing any rides at all?

We get on scene to find an 84 year old woman unresponsive on the floor. She is breathing (R-14, SPO2- 95% on RA), has a GCS of 5 (E-1, V-2, M-2), and has bounding distal pulses (BP 112/64, P 60 regular). There are about 12 empty pill containers in the bathroom, husband states she takes her pills and goes to bed before him, he last saw her about 1.5 hours ago.

One of the bottles was for percocet, husband states he thinks that was already empty. Pupils dilated (equal at 4mm, reactive, round). Pt does not appear to have vomited, is not diaphoretic (warm to touch, skin appears normal), and has good cap refill.

Doesn't sound like an overdose per se. At least not of narcotic origin. Narcs suppress. She'd more than likely be breathing slow and shallow; not 14/min with a RA SpO2 of 95%. Even though BP's not high, I'd be thinking CVA with BP normalizing. Semmantics, I know. But I digress.

She has snoring respirations that are easily corrected with a simple head-tilt. Here's where my question comes in. My preceptor was the attending and he elected to place a nasal pharyngeal airway and provide oxygen via mask. His partner appeared to think the lady should be intubated and after some not-so-subtle hints at such the preceptor attempted to place an oral airway and then said "not going to happen, she has a gag-reflex".

Should she have been intubated? I've read that a gag-reflex doesn't mean the patient is protecting her airway. If your service, like this one, doesn't have RSI, can you intubate a patient with a gag reflex? When you intubate someone who is breathing adequately, how do you bag them? Try to do it when they are inhaling but still only 8-10 times a minute, even if they are breathing faster (in this instance 14)? Do you try to sedate them with the drugs you have?


Yes, she should have been intubated. You are born with 3 holes that can accomidate an ETT. All 3 lead to the same trachea. If your pt has an intact gag, then oral intubation would prove to be counterproductive. Placing the blade into their posterior oropharynx can stimulate their gag reflex and cause them to regurgitate. Vomitting while intubating can cause aspiration. Aspiration automatically gives your pt a 50% mortality rate alone. Not good. Nasal intubation would be the better route

As far as assisting respirations on an intubated pt, just squeeze the bag when they breathe. If they're constantly fighting your assistance and their BP can handle it, sedate them. Don't squeeze too hard against them because you can drop a lung. It has been done before. Also not good

This service carries versed and morphine for controlled substances. No etomidate, vec, succ, or anythings like that.

Thanks for your help. Also, if you have any links to reading material that may help me it would be much appreciated. I apologize if I sound like an idiot.

Hope this helps.

 

[tydek07]

Oh, I forgot:

I'm going to probably sound like an idiot, but please don't be too hard on me. It's my first time posting and I'm a relatively new medic student.

Your not an idiot, you are a student Students are suppose to ask questions and learn...

There two types of students: 1) Students that ask question after question after question. 2) Students that do not ask questions and think they know it, or will learn it on there own.

Do you think students 1 or students 2 become better medics?

Take Care,

 

[MinnesotaMedicStudent]

Thanks for the replies. So for everyone who said she doesn't need to be intubated because I said she was "breathing adequately": What would you do if she was breathing at, say 4 per minute and SPO2 is 60 but still has a gag reflex. Would/do you nasally intubate? Do you keep the NPA in place and just bag her?

Thanks again all!

Also a few replies to questions/comments:

A medic student and doing BLS rides?!? I'm confused. If you're a medic student and not allowed to do medic stuff, why are you doing any rides at all?

The rides are the very beginning of our internship. We do 40 hours of "BLS" rides to get familiar with the service, get to know the preceptor so they can get comfortable allowing you to do things, and such.

Doesn't sound like an overdose per se. At least not of narcotic origin. Narcs suppress. She'd more than likely be breathing slow and shallow; not 14/min with a RA SpO2 of 95%. Even though BP's not high, I'd be thinking CVA with BP normalizing. Semmantics, I know. But I digress.

Yes, you are right that it wasn't narcotic. Of the 12 bottles, her husband thought all had pills EXCEPT the percocet. The rest were a combination of anxiety, depression, sleep, hypertension, and metformin. He was sure that those had pills, most of them had been filled in the last week.

 

[MinnesotaMedicStudent]

Oh, one other thing I forgot that added to my question was that the first thing they did on our arrival to the ER was intubate this patient, with RSI. I know we aren't the ED, but it just made the question stand out that much more.

 

[marineman]

I know MSDeltaFlt will probably have a bit of science to his answer but at my service we would probably ask med control but technically per protocol we are supposed to intubate anyone with a GCS of 8 or less. I know that's really an arbitrary number and two patients at 8 could be completely different than each other but that's what the guy with the license says to do that's what we do.

We usually clarify with online med direction before doing it in a borderline situation like that and in that case would probably depend on which MD is on duty that day.

 

[remote_medic]

I'm going to echo what others have said. Did this patient need to be intubated...yes. Did it need to be done prehospital by a service that does not do RSI (as evidenced by your lack of paralytics)...NO!!!

Attempting to intube a patient with a gag reflex should not be done with some exceptions (airway burns and asthmatics come to mind). If they hadn't vomitted before they most certainly will once you try intubating. The last thing this patient needed is an aspiration pneumonia on top of the polypharmacy overdose.

As for your questions, they are not dumb. They are very valid and I would encourage you to ask more as things come up. I'm pretty new around here myself but have learned a lot by reading what other experienced EMTs/medics/nurses/RRTs/Med students/etc have to offer. Some will be a bit more harsh then others but we should all have the same goal of bettering ourselves and our field.

 

[Epi-do]

A medic student and doing BLS rides?!? I'm confused. If you're a medic student and not allowed to do medic stuff, why are you doing any rides at all?

I don't think this is all that uncommon. (At least it isn't around here.) I know in my medic program we were required to have a certain number of BLS contacts. Similar to what MnMedicStudent said, it gave us a chance to get to know the preceptors and also gave them a chance to see how well we could evaluate a patient and make sure we had good BLS skills to build off of. Likewise, we did no ALS skills until second semester.

 

[el Murpharino]

Also you mentioned about a gag reflex not being an indication that your patient can maintain their airway. The ability to swallow is a better indication that your patient will be able to maintain their airway (don't take this as gospel, as it hasn't been adequately studied). Also, if you're testing the gag reflex to determine airway patency, you run the risk of aspiration (aspiration of gastric contents carries a 90%+ mortality rate). Nasal intubation is always a choice in breathing patients - if your area allows it.

A couple of other factors to think about: Transport time, anticipated clinical course of your patient, available help...and that's not even considering your patient. Are they going to be an easy tube, are there reversible conditions? Now granted this isn't as applicable for this patient as much as future ones, but there is a multitude of factors to consider before intubating a patient.

 

[Juxel]

This can be a complex case and many different sides can be argued. Does your patient need an airway? Yes. Does he or she need immediate field intubation (even with RSI)? Probably not. Transport time, the judgement of how difficult of an intubation the patient will be and many other factors will play a role in the decision. My service allows RSI but we are a dual-state service and if you are on one side of the river the law dictates that both medics or RN/medic must be at the patient's side for RSI. That also plays a factor in the decision.

In the described situation, if the service you are with does not have RSI and does not allow nasal intubation, or nasal intubation is unsuccessful, I would place the patient in the recovery position (with the O2 via mask and NPA) and have suction ready in the event she vomits.

A gag reflex does not indicate the airway is being protected. See:

Moulton C, Pennycook A, Makower A. Relation between the Glasgow Coma Scale and the gag reflex. BMJ 1991;303:1240–1241.
Bleach N. The gag reflex and aspiration: a retrospective analysis of 120 patients assessed by videofluoroscopy. Clin Otolaryngol 1993;18:303–307.
Davies AE, Kidd D, Stone SP, et al. Pharyngeal sensation and gag reflex in healthy subjects. Lancet 1995;345:487–488.
Chan B, Gaudry P, Grattan-Smith TE, et al. The use of Glasgow Coma Score in poisoning. J Emerg Med 1993;11:579–582.

 

[Flight-LP]

Lets look at the variable we know..........

12 empty pill bottles.

A strong historian (the husband).

A severly altered patient with relatively normal hemodynamics.

Way to many questions and not enough information immediately available to put 1+1 together.

In other words, she just bought herself an endotracheal tube. RSI would be ideal and would minimize potential risks associated with an intact gag, however if not available, there is this beautiful skill that many are afraid to do and many aren't even taught any more; that being nasotracheal intubation. The reality to this is that any competent physician will intubate this person upon arrival at the ER until he/she can get some answers. Having someone in that room constantly manually monitoring an airway is not practical, nor efficient; intubation and vent placement takes care of that problem for the short term.

Distance to ER is irrelevant. If something needs to be done, then do it. The 'pawning it off on the ER 'cause I don't feel comfortable with doing it' attitude and belief that diesel medicine is still appropriate is one major downfall of progressive EMS. This skill is well within a Paramedic's scope of practice, not doing it when needed is just negligent, sorry.

 

[Juxel]

Distance to ER is irrelevant. If something needs to be done, then do it...not doing it when needed is just negligent, sorry.

I disagree with this as a blanket statement. For example, let's say you are 3 minutes from definitive care, as can be very frequent in a large urban setting. Realistically, it's going to take you about 7-8 minutes to RSI someone when you combine starting the IV, monitor, preparing intubation equipment, drawing up meds, giving meds, tubing, verifying, and then moving from back of rig to front to transport.

If you call the hospital and say "I've got a 100kg male who is going to need to be RSI'ed as soon as we arrive" they can have all the equipment ready, the meds drawn up, and with the line you started during the 3 minute transport the patient can be intubated in a more controlled setting in the same amount of time it would have taken you to do it AND the patient is now at a definitive care site.

 

[triemal04]

I disagree with this as a blanket statement. For example, let's say you are 3 minutes from definitive care, as can be very frequent in a large urban setting. Realistically, it's going to take you about 7-8 minutes to RSI someone when you combine starting the IV, monitor, preparing intubation equipment, drawing up meds, giving meds, tubing, verifying, and then moving from back of rig to front to transport.

If you call the hospital and say "I've got a 100kg male who is going to need to be RSI'ed as soon as we arrive" they can have all the equipment ready, the meds drawn up, and with the line you started during the 3 minute transport the patient can be intubated in a more controlled setting in the same amount of time it would have taken you to do it AND the patient is now at a definitive care site.

Or you walk in and are met with a nurse who says "so what where you blabbering about on the radio?" and then proceeds to assess the pt, call the doctor who assess's the pt, calls for meds to be drawn up and respiratory to be called, sets up his equipment, waits for the meds to be drawn up, pushes them, and then intubates the pt. So at this point how long has the pt been waiting to be RSI'd from the time you did your initial assessment?

Point being that you might, might be able to get away with that sometimes but in all reality many times an ER will not be able to immedietly perform the procedure that you could have done when you walk in. It may work out sometimes, but others you will be left holding the bag. And hopefully will have to answer for your actions (pawning off the pt on someone else instead of treating them) Blanket statements like YOUR'S are not a good way to go.

Just bringing someone into the ER does not mean that they will magically be treated at the snap of your fingers; there will still be a time lag before anything happens. How much depends on where you are and what is wrong, but delaying your treatement because you are close is almost always a bad idea.

 

[Juxel]

Or you walk in and are met with a nurse who says "so what where you blabbering about on the radio?" and then proceeds to assess the pt, call the doctor who assess's the pt.

You guys must operate much differently than we do. We can call on the radio, "3 minutes out with a critical patient, need a doctor at *Insert hospital*" We'll have a doctor within seconds. The doctors are great and trust our field judgement. If you tell them someone needs something, it is ready when you get there.

I'm not saying you should "pawn" off care because you are lazy or not comfortable doing your job. However, I do believe there are times when a patient shouldn't be RSI'ed in the field, my above example being one of them, especially if you judge the patient to be a difficult intubation.

 

[MSDeltaFlt]

I disagree with this as a blanket statement. For example, let's say you are 3 minutes from definitive care, as can be very frequent in a large urban setting. Realistically, it's going to take you about 7-8 minutes to RSI someone when you combine starting the IV, monitor, preparing intubation equipment, drawing up meds, giving meds, tubing, verifying, and then moving from back of rig to front to transport.

If you call the hospital and say "I've got a 100kg male who is going to need to be RSI'ed as soon as we arrive" they can have all the equipment ready, the meds drawn up, and with the line you started during the 3 minute transport the patient can be intubated in a more controlled setting in the same amount of time it would have taken you to do it AND the patient is now at a definitive care site.

True. However, even with your knowledge, training, and experience, you know that a lot can happen in 3 minutes. Not just with hypoxia, but also with the increased ICP's associated with hypercapnia AND the cerebral ischemia associated with hypocapnia.

 

[VentMedic]

You guys must operate much differently than we do. We can call on the radio, "3 minutes out with a critical patient, need a doctor at *Insert hospital*" We'll have a doctor within seconds. The doctors are great and trust our field judgement. If you tell them someone needs something, it is ready when you get there.

That is the way many EDs and EMS teams work together.

However, there are those that prefer to sit in the hospital parking lot for 15 minutes while the ED staff is waiting and wondering if the truck broke down. We've even sent one of our LEOs (stationed in the ED) to check on them only to find the Paramedics were trying for the 5th time to get a tube because of someone's ego not letting them come into the ED without one.

If you can not maintain an airway on a patient that still has spontaneous respirations for 3 minutes as you pull into the ED you probably shouldn't be messing with RSI either.

 

[triemal04]

You guys must operate much differently than we do. We can call on the radio, "3 minutes out with a critical patient, need a doctor at *Insert hospital*" We'll have a doctor within seconds. The doctors are great and trust our field judgement. If you tell them someone needs something, it is ready when you get there.

I'm not saying you should "pawn" off care because you are lazy or not comfortable doing your job. However, I do believe there are times when a patient shouldn't be RSI'ed in the field, my above example being one of them, especially if you judge the patient to be a difficult intubation.

Sure, I can agree with that. And I love taking pt's to hospitals like the one you mention. Unfortunately I also take pt's to ones that are the exact opposite. This is where knowing your system and really thinking about what needs to happen and how long it'll actually take to happen if you don't do it comes into play. Even if you are right across the street, there are times when it'll still be better for you to do something versues transporting and waiting. And times when it won't.

And yeah, in the given situation, if the pt was say, 300+ pounds and 5'4", and the hospital was 3 minutes away (and the time away should always be measured from where you find the pt, not just drive time) then electing to not RSI, and give enough info to the ER before getting there to ensure that they were ready...good choice. But if the pt was normal sized...still have to go with RSI in the field.

Out of curiousity, what if this pt had vomitted, or been vomitting? Would you still transport without RSI, or perform it right then?