No more combitube?

[rescuecpt]

I just got a cryptic email from one of my Chiefs saying combitube is no longer in protocol in Suffolk County and they have all been removed from our ambulances. No explanation.

I know of one anaphylaxis case as a result of combitube use in the County, but that's all I've heard bad or good.

My medic is making some calls - I'm really curious now. I'll keep you all posted.

 

[vtemti]

Please do!!

At this time in Vermont, unless you are a p-medic, that is all we have for advanced airway management.

 

[TTLWHKR]

Someone must have killed a guy.

 

[Phridae]

Yeah, keep us updated. If they have a good reason for pulling them from the truck then its bound to spread.

 

[TTLWHKR]

There have been injuries reported due to over inflation of the Combi-Tube and improper sizing for the patient. I believe they only come in two sizes, 37Fr & 41Fr. The way we were taught to size them was to use the size of the backboard as a guide. Although we don't use them, we were taught to use them, just in case.

 

[Jon]

This is moronic. A combi-tube is usually used as a "back up" or "plan B" airway. if they pull the combitube, what else can you do in protocol other than a tube? EGTA/EOA??? LMA??? Intubating LMA? PTL? EOA-King or whatever it is?

Gee... you had an anaphalatic reaction to the latex cuff... boo-hoo... that is why god gave the medic EPI!!!

 

[TTLWHKR]

Originally posted by MedicStudentJon@Jul 30 2005, 02:39 AM
Gee... you had an anaphalatic reaction to the latex cuff... boo-hoo... that is why god gave the medic EPI!!!

Sense tells me that you would not notice anaphylaxis until it was too late. The patient is already in deep doo doo, otherwise you wouldn't be tubing him/her to begin with. The reaction will probably worsen the symptoms, there by causing injury when extubation is attempted.

Of course, would you not perform this life saving procedure if they had a latex allergy? They are already intubated, so you will have a patent airway. You could always secure command to administer .3cc of epi, just in case; or Benadryl IM. You would also want to act fast and get a line in, just in case anaphylactic shock leads to cardiac arrest.

 

[vtemti]

Originally posted by TTLWHKR@Jul 30 2005, 01:02 AM
There have been injuries reported due to over inflation of the Combi-Tube and improper sizing for the patient.

I wonder if that's the real reason or if the actual injuries come from improper removal at the ER?

 

[Flight-LP]

This is really simple. If properly placed, properly sized, properly inflated, and properly ventilated, then the Combi-Tube is an excellent adjunct whether used primarily or as a backup. I too would be interested to find out the logic for their removal and I would especially emphasize that if you utilize an RSI protocol that another adjunct be available if the Combi-Tube is removed.

 

[medic03]

a little birdie told me that they are relating 3 deaths in the county to the combitube. 1 was a trauma pt that survived his injuried but died from an esophageal tear and not sure about the other 2, but looking into LMA's now....

 

[DT4EMS]

Before we pull combitubes from the trucks we oughta do a study on how many die from improper ET placement or the too many attempts of proper placement................. :unsure:

 

[Flight-LP]

Originally posted by DT4EMS@Jul 30 2005, 07:04 PM
Before we pull combitubes from the trucks we oughta do a study on how many die from improper ET placement or the too many attempts of proper placement................. :unsure:

Good point to ponder............................

 

[rescuecpt]

Originally posted by medic03@Jul 30 2005, 03:04 PM
a little birdie told me that they are relating 3 deaths in the county to the combitube. 1 was a trauma pt that survived his injuried but died from an esophageal tear and not sure about the other 2, but looking into LMA's now....

A bigger birdie told me there were 2 esophageal tears and 1 subq emphysema as results of combitube use. Then there's also the anaphylaxis a friend of mine got to witness first hand. That's all out of 60 combi tubes used. Not a good rate, huh?

 

[Flight-LP]

Originally posted by rescuecpt+Jul 30 2005, 10:24 PM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>QUOTE (rescuecpt @ Jul 30 2005, 10:24 PM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-medic03@Jul 30 2005, 03:04 PM
a little birdie told me that they are relating 3 deaths in the county to the combitube. 1 was a trauma pt that survived his injuried but died from an esophageal tear and not sure about the other 2, but looking into LMA's now....

A bigger birdie told me there were 2 esophageal tears and 1 subq emphysema as results of combitube use. Then there's also the anaphylaxis a friend of mine got to witness first hand. That's all out of 60 combi tubes used. Not a good rate, huh? [/b][/quote]
Esophogeal tear = Improper over inflation of the proximal cuff. Despite the manufacturer recommendation of 85 - 100cc of air, it only takes 50cc to fill. When you add more, you increase the possiblity of esophogeal damage.

Sub-Q Emphysema = Overventilation!!!! Too many medics forget the basics. There is absolutely no need to bag a tidal volume of 800+. Just like dopamine, start low, titrate to effect!! Pump too much air into an esophogeal airway and you'll blow a lung!!!!

Anaphylactic reaction - Hopefully it would be possible to obtain allergies prior to an intervention. O.K. sometimes it not!!!!!! But as stated before, we have pharmacological agents that can be utilized to counteract a reaction (Epi, Decadron, Solu-medrol, Benadryl, Terbutaline, etc.) Also, I would think it would be difficult to have such a small amount of latex cause a fatal reaction quicker than a medics ability to intervene. But again, I have not seen the facts, so please do not take this as an objective questioning of any medics ability.

My basic philosophy to this is that sometimes we need to focus more on fixing a problem than implementing a quick way to avoid it........................

 

[rescuecpt]

Originally posted by Flight-LP@Jul 31 2005, 02:33 PM
Anaphylactic reaction - Hopefully it would be possible to obtain allergies prior to an intervention. O.K. sometimes it not!!!!!! But as stated before, we have pharmacological agents that can be utilized to counteract a reaction (Epi, Decadron, Solu-medrol, Benadryl, Terbutaline, etc.) Also, I would think it would be difficult to have such a small amount of latex cause a fatal reaction quicker than a medics ability to intervene. But again, I have not seen the facts, so please do not take this as an objective questioning of any medics ability.

My basic philosophy to this is that sometimes we need to focus more on fixing a problem than implementing a quick way to avoid it........................

Well, first, the County has decided to stop its use while they decide how to retrain or adjust the protocols to help avoid such problems. We didn't have combitube until Jan 1 of this year anyway... before that it was all tubes or OPA/NPA. Sometimes we as ALS providers forget that OPA is good enough if the patient is getting proper ventilations and you have a line in place.

Second, the anaphylaxis patient was a witness arrest, otherwise considered viable due to age, history, and time of CPR start/electrical interventions. With the anaphylaxis, in less than 3 minutes she went from looking normal to having her eyes swell to softballs, throat and mouth swell shut (luckily, or unluckily, the combi was already in place) and her face and head turned black from her nose up. I still can't figure that out, but the ED ruled it as anyphylaxis. Yes, epi is great, but the anaphylaxis epi is different than the cardiac epi, also that's a different protocol...and... by the time orders were obtained it was too late (you can only run in one protocol at a time under standing orders around here).

I think we need to get back to basics - like I said before many forget that the OPA/NPA exist and go straight to tubing when that's not necessarily the easiest nor least invasive way to achieve a patent airway.

 

[Flight-LP]

Wow, sounds like **** when south real quick. I am truly sorry that has happened to your co-worker and his / her patient. Am I correct in understanding that you have to have on-line medical direction for your anaphylaxis protocol? I understand medical directors' having an online program, but that would be one protocol that should not be on-line due to the time critical nature. Personally, and this is just my opinion, I would question the reasoning for the on-line requirement. If you don't mind me asking, what was the original presentation that necessitated the combi-tube? Was there anything in the original presentation that may have exacerbated the reaction?

 

[rescuecpt]

Originally posted by Flight-LP@Jul 31 2005, 05:47 PM
Wow, sounds like **** when south real quick. I am truly sorry that has happened to your co-worker and his / her patient. Am I correct in understanding that you have to have on-line medical direction for your anaphylaxis protocol? I understand medical directors' having an online program, but that would be one protocol that should not be on-line due to the time critical nature. Personally, and this is just my opinion, I would question the reasoning for the on-line requirement. If you don't mind me asking, what was the original presentation that necessitated the combi-tube? Was there anything in the original presentation that may have exacerbated the reaction?

She was in cardiac arrest, and a difficult tube (no go after 2 tries, per our protocol, and this provider is a great tuber), so the provider dropped a combi-tube.

No, our anaphylaxis protocol has standing orders for ALS, but you can only run one protocol under standing orders at a time. Since the cardiac arrest protocol was already being run, we technically need online permission to ALSO run the anaphylaxis protocol. However, our transport times can range anywhere from 4 - 12 minutes, and as I understand it this call was in the shorter end of that range, so by the time the reaction was noticeable, they were right outside the ED doors.

 

[usafmedic45]

Or look at the complication rate from overzealous ventilation following successful intubation. It makes 3 cases out of how (?) many seem paltry.

 

[Nikki320]

That's very interesting. On the other hand i have heard that paramedics aren't experienced enough and don't have enough training to perform endotracheal intubations (which is a crock, bc we probably do it more than the doctors who are b*tching), and that some people (i don't remember exactly who.. But i do know they are doctors) are trying to get us to discontinue use of the ET tube and start using just the combitube. Now if this ever happens, i don't know. This is just what i was told.