Intubation

[Ridryder911]

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

It is broken. Unresponsiveness = inability to control airway = high percentage of aspiration, hypoxia, anoxia, death.

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 patients side for RSI. That also plays a factor in the decision.

Just how long does it take for someone to blow chow and then aspirate? Transport time should never take precedence over ensuring a safe and effective airway. Again, just how long does it take to perform RSI? Remember, even in the ED setting it still will be another additional 3-5 minutes to have RSI performed in the best of the systems. So now, we are now looking at 10 minutes longer, when RSI should be accomplished in usually < than 3 minutes?

Use common sense. Judge wisely based upon multiple reasons.

Remember this thought, if you think of the possibility of intubation is needed, it was.

R/r 911

 

[VentMedic]

Just how long does it take for someone to blow chow and then aspirate? Transport time should never take precedence over ensuring a safe and effective airway. Again, just how long does it take to perform RSI? Remember, even in the ED setting it still will be another additional 3-5 minutes to have RSI performed in the best of the systems. So now, we are now looking at 10 minutes longer, when RSI should be accomplished in usually < than 3 minutes?

From the original post:

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?

Jumping to RSI is the easy solution. Of course every service has RSI ability.

If you are 3 minutes from the hospital, have a breathing patient that can be assisted and no RSI, how long do you want to stay on scene while attempting to intubate with the risk of aspiration?

In the ED, we can get an NG tube within the first minute and to suction if necessary while the airway is being maintained.

RSI can be done in 3 minutes by a very experienced Paramedic under ideal situations. Some Paramedics don't get enough intubations each month or in a year to get that efficient with or without RSI. You are also assuming every patient will react the same with the RSI recipe. Not all patients go down easy even with a drug OD on board.

 

[Ridryder911]

I understand and respect your opinion Vent, but here is my opinion. If you are unable to intubate a few times a year, privileges should be considered yet then again.... I know the majority of physicians never intubate that often and yet they are still able to.

In my opinion I have found intubating a patient is just as easier as placing a NG tube in and in some cases I have actually seen gastric tubes actually cause vomiting and aspiration, hence why many recommend securing the airway especially in drug induced and those that might have potential vomiting. I agree both should be used, dependent upon the case which I would perform first.

Point being, use common sense and the situation should be based upon each individual case. Some I might elect to intubate and some I may not; hence why I am a practitioner. The patient is breathing and you are comfortable assisting with and monitoring airway; so be it. Just remember the BVM does increase the risks of gastric distention and vomiting.

Again, alike any other scenario and situation(s) there maybe and usually are many approaches that could be considered right or wrong.

R/r 911

 

[VentMedic]

The patient is breathing and you are comfortable assisting with and monitoring airway; so be it. Just remember the BVM does increase the risks of gastric distention and vomiting.

And intubating without RSI may also increase the risks of intubation greatly. Correct BVM may have less risk. I emphasize correct BVM because without some comfort in that skill, again referencing to the initial post, you should NOT be doing RSI.

You must also work within what your system has to offer. If your system doesn't do RSI, you can talk about all the benefits of it you want but that ain't gonna help you out for that moment in time.

Placing an NG tube also takes experience and that is why those that do them the most do them the best.

 

[VentMedic]

Abstract from Prehospital Emergency Care.

Abstracts for the 2009 NAEMSP Scientific Assembly

www.naemsp.org

Link to Publications

Paramedic Endotracheal Intubation Experience Improves Patient Survival

Henry E. Wang, Goundappa K. Balasubramani, Judith R. Lave, Donald M. Yealy, Lawrence J. Cook, University of Pittsburgh

Introduction. The effect of paramedic endotracheal intubation (ETI) experience on patient outcomes is unknown. We evaluated the association between paramedic ETI experience and patient survival. Methods. Using 2000-2005 Pennsylvania statewide emergency medical services (EMS) data, we calculated total clinical ETI experience for each individual paramedic during 2000-2005, categorizing total (6-year) ETI experience as low (1-10 ETIs), medium (11-25 ETIs), high (26-50 ETIs), and very high (> 50 ETIs). Using multiple imputation triple-match algorithms, we probabilistically linked 2003-2005 (3 years) EMS ETI records to statewide death and hospital admission data, identifying the primary outcome survival on hospital discharge. We determined the association between patient survival and paramedic total ETI experience, adjusting for paramedic total clinical experience; patient age, Glasgow Coma Scale score (GCS), heart rate, systolic blood pressure, and major trauma; and EMS population setting. We separately evaluated cardiac arrest ETI and nonarrest ETI. We analyzed the data using multivariate random-effects regression, clustering by individual paramedic and combining imputed results using Rubin's method. Results. Across the imputed sets, we linked 25,718 (77.7% linkage rate) ETIs performed by 5,433 paramedics to patient outcomes. There were 4,835 (18.8%) by low-, 9,850 (38.3%) by medium-, 8,513 (33.1%) by high-, and 2,289 (8.9%) by very-high-ETI-experience paramedics. Survival was 17.4% (3,204/18,414) for cardiac arrest ETI and 68.2% (4,981/7,304) for nonarrest ETI. Adjusted survival was higher for cardiac arrest patients intubated by high-and very-high-ETI-experience paramedics; combined odds ratio (OR) (95% confidence interval [CI]) vs. low ETI experience: medium 1.04 (0.91-1.18), high 1.18 (1.01-1.38), and very high 1.29 (1.04-1.61). Adjusted survival was higher for nonarrest patients intubated by high-and very-high-ETI-experience paramedics; combined OR (95% CI) vs. low ETI experience: medium 1.05 (0.8-1.25), high 1.31 (1.07-1.60), and very high 1.59 (1.21-2.10). Conclusion. Increasing paramedic clinical ETI experience is associated with improved ETI patient survival.

 

[Flight-LP]

Sorry, but it takes less than 2 minutes to prep and slide an ET tube through someone's nasopharynx. The problem lies in (as usual) education and retention of practical knowledge due to disuse. I see medics that are petrified by the notion of performing a blind intubation. Yet they have no problem with their pt. getting aspiration pneumonia because the hospital "is so close". Too much can happen in an instant, much less several minutes. It would be nice to have the NBC "ER" version of care where the doc's meet you at the back door, but here in the world we call reality, that isn't the case. Even if they were ready and rearin' to go, what happens when the MI pt. they just brought back from triage decides to code 1 minute before your arrival??????

There will always be exceptions to the rules, but not providing a definitive airway based solely on the lack of RSI is absurd. Nasopharyngeal intubation, LMA, Combi-tube, and King LT, are all acceptable methods. But just bagging an altered pt is asking for trouble.

Treat your patients as you have been educated to do. Relying on others to provide accetable treatments that are available to Paramedics is negligent. Agree or disagree, thats my belief and I am sure the belief of many other professionals.

 

[VentMedic]

Sorry, but it takes less than 2 minutes to prep and slide an ET tube through someone's nasopharynx. The problem lies in (as usual) education and retention of practical knowledge due to disuse. I see medics that are petrified by the notion of performing a blind intubation.

Yes, nasointubation is an alternative and in 3 minutes at the hospital that tube will quickly be removed and O-ETI will be done.

I am not oposed to NTI in the field but it is not my top choice either especially if I am 3 minutes to the hospital. Blood aspiration and vomit run neck to neck for PNA.

Maybe you just want to stick a face mask over the end of that tube also instead of using the Bag-Valve.

Taken an ACLS class lately?

 

[Flight-LP]

I guess its a local thing for you, because I have rarely encountered an occurance where a patent ET tube has been replaced regardless of its entry point. Maybe instead of complicating a situation by removing the tube and replacing (risking the pts. condition even further), perhaps your physicians could verify placement, maybe confirm with radiography? That's what most physicians I worked with for nearly 2 decades have done. But if there is a trust issue with your local medics or just the need for a self servent feeling of superiority, maybe then your medics should not perform any invasive procedure. Then your physicians can do it all by themselves. Maybe diesel medicine is appropriate for your facility to ensure that no adverse issues ever occur and the allmighty ER staff can save the world.

I've had ER's kill more pts. than I could ever attempt to. While I value your opinions and highly respect your experience and knowledge, lately there seems to be a trend of "Vent and her facility right, everyone else wrong". Maybe its me, maybe I'm overtired, but it really gets exhausting after a while......................

I'm done with it, people can pick through the info posted and decipher how they wish. I'm through with hitting my head on a brick wall...................

p.s. I taught an ACLS class last week for any relevance that it may remotely have on this topic. Of course the day I rely on the AHA to provide me religious guidance on how to practice medicine is the day I retire~

 

[Juxel]

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

That changes it. If they have vomited or are actively vomiting with an altered LOC, they will get a tube even if we are one block from the hospital.

 

[VentMedic]

I've had ER's kill more pts. than I could ever attempt to.

How you alerted the Police for an investigation? Can you prove it? Or is this just because you as a TV quarterback could do it so much better? That is a serious accusation to make unless you have what it takes to follow through with your comments and file a formal complaint.

I rarely post here anymore because of the bashing. Some don't want to hear another way to do things or just think anything a hospital does is wrong because only those in EMS know how it really is mentality. Your way may not always be the most correct way either.

Haste also makes waste. Trying to do something too quickly because you are just 3 minutes from the hospital can also lead to poor preparation and a paralyzed but poorly sedated and poorly oxygenated patient getting tubed also.

 

[Ridryder911]

I am curious why anyone in EMS would have a displaced tube anymore. EtCo2 monitoring with waveform can verify as well as good assessment. Not having an ETT in the proper place is inexcusable and assuming that another airway is comparable is foolish and not true. Again, just because there is those that perform poor techniques is not a reason not to endorsethe most effective proper treatment, rather emphasis should be placed upon the problem... lack of and poor quality control of the performance of the personnel.

We have to be careful comparing EMS systems. For example in my area, the metro EMS has a >99% intubation rates all with confirmation upon arrival to ED. The reason is simple, evaluation of ETI was getting <95% and re-education with introduction of devices such as flex-guide and confirmation using EtCO2 immediately changed the outcomes.

Instead of making sacrifices to the patient care, we should focus upon the problem and source of the problem... poor or lack of education.

Should we abolish other care because certain areas of the country EMS perform poor skills or techniques? If there were EMS that administred NTG wrong, should other EMS stop administering it? The med is still needed, it still works yet should our treatment change because of ill prepared and monitored personell?

I realize Vent is frustrated with EMS programs. From reading posts from the nation I can understand why and as well upset too. Yet, we need to remember not all is created equal (thank goodness) and the majority of Paramedics can intubate effectively and there are thousands that perform RSI and even intubation more effective and faster than physicians in a ED. Again, it is how well one want to be proficient and knowledgeable in their profession.

R/r 911

 

[tydek07]

Oh my, this thread is getting to be a fighting ground

Everyone is going to have their own opinion(s) on how to handle situations like this. One medic will say intubate, the other will say don't intubate. It also depends on the area that the person is working. We do not do RSI and we are close the ER's (prob. max of 15 minutes in most cases)... Some of mentioned that you could nasointubate this pt if you do not have RSI, yes that is an option... but then again, it depends on the medic and what he opts to do.

Pretty much everything done in the field, can be handled more then one way...

Take Care,

 

[VentMedic]

I am curious why anyone in EMS would have a displaced tube anymore. EtCo2 monitoring with waveform can verify as well as good assessment.

What percentage of services have ETCO2? I would be happy if all could do a 12-lead but some still can not. I would be even more delighted if some of those doing 12-leads were not relying on machine interpretations.

I still live in one state that has over 50% of its Paramedics programs being unaccredited medic mills feeding the FDs.

I visit another state frequently that is still stuck in 1984 for advancements and that is the one where 12-lead EKGs are "science fiction" stuff.

People do need to know their options for any given circumstance and know that if they can not get a tube, they don't have to stay and play on scene just so they can save face at the ED. There is nothing worst than having a patient with multiple attempts at an IV or ETI arrive with vomit rolling out. The vomit is actually easier to deal with than the butchered cords and throat.

If one believes their patient can make it 3 minutes to the ED, they shouldn't be criticized for exercising their clinical judgement and comfort level to maintain an airway. Choosing not to intubate should also not be considered the sign of a poor Paramedic if you scored the patient as having the potential for problems. It is when an argument is presented as my way only and bashing those who dare to question you. I will try to provide my view without the use of slander and profanity to get a point across. I enjoy a good debate but not when it turns to personal attacks, personal bashing or bashing facilities and other professionals. However, this is a forum about EMS and those in EMS should be aware of the problems so hopefully the next generation can fix what we haven't over the last 40+ years.

 

[Juxel]

Our service has great ETI success rates and we have not had an unrecognized esophageal intubation in over a decade (not that it should have ever happened). We have a strict policy on continuous ETCO2 monitoring and every chart with an invasive airway (King, Combitube, or Endotracheal tube) is automatically audited for compliance in documentation.

We just had re-education on both skills and documentation because people were writing a blanket statement like "monitored ETCO2 and had good waveform throughout patient contact". We are required to document the numerical reading every 5 minutes and to document verification of lung sounds and waveform anytime the patient is moved.

Two employees were recently fired (after the educational sessions) for failure to properly document despite the fact that their tube placements were verified by chest x-ray upon arrival to ED.

 

[Ridryder911]

What percentage of services have ETCO2? I would be happy if all could do a 12-lead but some still can not. I would be even more delighted if some of those doing 12-leads were not relying on machine interpretations.

Again, we are discussing poor education. I am surprised how antiquated Florida must be in some areas. Even here is the boondocks all will have either colormetric and anyone that has a LP12 has switched to EtCo2 monitoring for assessment and documentation. Anyone here using the idiot box for interpretation would be laughed or riduculed into disgrace.

Alike what I said, one should not base treatment upon the adequacy or inadequacy of the system or lack of but on what is proper for the patient.

Let's not throw out the baby with the bathwater, instead of making excuses of not properly treating let us fix the problem.

R/r 911

 

[daedalus]

I find myself lucky to have CPAP, 12 lead, ETCO2, etc. I however do not have RSI (Medics have been known to rapidly push versed...). In the OP's situation, the patient requires ETI, there is no doubt in my mind. The patient also could have been managed effectively with a NPA and mask ventilation with a BVM until arrival at the ER, but I believe one should make an attempt at least to secure the gold standard in airway maintenance before transporting with a substandard method. While it may not be negligent it is certainly close.

Mommy and Daddy fighting again? It is okay, because they still love you children.

 

[emtjack02]

Just playing devils advocate so don't shoot. Personally I think that NTI would have been a good alternative but... NTI takes more skill and practice to do (so i've read, never had the chance) and if the medics are not well versed in intubating someone with a gag they, IMHO, should not be practicing on this pt.

 

[emtjack02]

I was also wondering what the standard def of definitive airway is...

 

[emtbill]

That changes it. If they have vomited or are actively vomiting with an altered LOC, they will get a tube even if we are one block from the hospital.

I'm not trying to bash you, but that criteria would be having a lot of my patients getting intubated when they don't need it. Are you going to RSI every drunk patient you get because they have an altered LOC and are vomiting from the EtOH? I can't imagine preforming RSI on a patient who is simply drunk...it has too many potential complications in this scenario. Since this hypothetical patient clearly has food in his stomach evident form his active vomiting, as soon as you push a paralytic he looses all airway protection. Although sellick's manoeuvre should prevent aspiration during laryngoscopy the chance of vomiting has increased significantly now that the patient is paralyzed. What if the patient is unable to be intubated? Sure vomiting threatens the patient's airway, but is it enough of a threat to preform a procedure that has inherent risks in itself? It's a judgment call you have to make yourself, but in my opinion it's not worth it. Would you be negligent for not preforming RSI on this patient? Probably not. Would you be negligent for bringing a paralyzed patient into the ER without an airway who has aspirated because you couldn't get him intubated? Absolutely. I have been doing EMS for going on three years now, and in my service that runs about 4,000 calls a year and I would have preformed RSI on two patients.

As far as the OP's original question goes regarding intubating a patient with a gag reflex: I wouldn't have tried it. In this given scenario the pt was ventilating adequately, and her airway was managed with BLS techniques. There was no indication for intubation to assist her ventilations, and if laryngoscopy was preformed in an effort to protect against possible vomiting, she very may well vomit from the laryngoscopy itself, and now you have a bigger problem on your hands. The patient would be better served by trying to identify the etiology of her altered LOC after her airway was managed with an NPA. If you can fix that, she can manage her airway on her own. If you have a patient with a gag reflex and who clearly needs intubation the next best thing to RSI would be nasal intubation.

 

[triemal04]

emtbill- small difference between someone who is drunk and vommiting and someone who's OD'd on meds, has a GCS of 5 and is vommiting (although there are people who get themselves drunk enough to buy a tube unfortunately). Save for a narcotic OD, you really aren't going to reverse anything in the field. What you need to do is treat your pt, which in this case would mean protecting the airway against further aspiration risks.

As far as not being ABLE to intubate...this is where properly assessing your pt prior to trying is important. What are the odds you will be successful? Good? Bad? Is this predicted to be an easy airway or is this the airway from hell where more than likely you will have to use a backup airway that will still not protect the trachea as well as an ET tube and potentially you will have to use a BVM to ventilate the pt which will also be very difficult? As said before, there may be times when it will be more appropriate to not attempt intubation, but there will also be many times when it is appropriate to tube someone in this situation, with or without vommiting. As with all medicine, you should have a good, appropriate and justifiable reason for doing, or not doing something.

Juxel- figured. Just had to be sure. B)