ROSC intubation scenario

TF Medic

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This is a call I am familiar with and it has brought up some discussion. Curious to hear other opinions.

Called for full arrest for 84 YOF.
Hx:
DM2, A-fib, lung cancer, chronic pain. Last seen normal last night.
Meds:
Coumadin, levothyroxine, fentanyl patch, unknown others (family doesn't have a list)

Family couldn't wake her around 10am. Pressed life alert button. Life alert asks if PT is breathing, family says no, life alert instructs to start compressions.

You arrive to find PT laying in recliner with family doing ineffective compressions. Skin is pale but not ashen, warm centrally, cool in extremities. No carotid felt on initial attempt. Pt moved to floor, compressions continued. After about five compressions spontaneous breathing noted, compressions stopped, carotid pulse is weak and irregular.

Partner now has monitor patches on showing a-fib. PT is breathing spontaneously around 6/min. Ventilations assisted by BVM while fire helps package, secure, and move pt to ambulance.

Vitals:
PT unresponsive to pain
139/51
BGL 133
HR 100-130 A-Fib
SPO02 up to 96% with BVM. Good compliance with NPA placed.

Transport initiated, IV established, 12 lead unremarkable, ETCO2 is easily managed around 40 with BVM. PT remains stable but unresponsive in transport. Spontaneous respirations improve to around 16 with BVM assistance, fall back to around 8 if BVM is withheld. Carotid pulse is now strong and irregular. Crew unable to find fentanyl patch. 2mg Narcan pushed, no changes.

Fire is driving. You have two medics in the back. Airway remains patent with good compliance on BVM ventilations. Intubation would require RSI protocol.

Unknown if PT ever fully arrested, general agreement is probably not. Transport to Level 1 is approx 15 min. Do you intubate enroute? Why or why not?
 

chaz90

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So this is really more of an RSI scenario than ROSC, but fair enough.

If this were my patient, I would not intubate her. We're already moving to the hospital, so by the time we've established these kinds of baselines, we're probably a few minutes into the 15 minute transport time. She's maintaining adequate oxygenation and ventilation status as measured by SpO2 and EtCO2, her heart rate doesn't seem to indicate dire distress, and her respiratory rate unassisted isn't even too bad.

Do her SpO2 readings change much if she's left on O2 and allowed to breathe spontaneously 8 times/minute without using a BVM? This whole call seems to be on an upward trend, and I'm reluctant to commit to intubation and ventilator usage when I'm not so certain she'll need it in another 10 minutes. If things don't improve or maintain well enough without a BVM, we can always go back to using a BVM as we have already shown it is perfectly feasible on this patient. With all vitals improving, is there any change to her mental status or purposeful movement? Gag reflex present?

This seems likely to be some kind of positional or opioid induced apnea that led to a decline in HR and BP. With improving oxygenation, she seems to be improving as well. Or of course, it could be any of a hundred other things and she may be intubated shortly after arrival at the ED. Either way, I'm confident I would not need to do this RSI pre-hospitally in the back of a moving ambulance with only two people.
 
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TF Medic

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So this is really more of an RSI scenario than ROSC, but fair enough.

Yeah. I posed it as ROSC since arrest protocols include advanced airways, and even though cardiac arrest is questionable, compressions were performed which makes this post-arrest in our protocols.

GCS remains 3, no purposeful movement. SPO2 falls when BVM stopped.
 
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NomadicMedic

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I'm at a service with no RSI now, so I'd be limited on intubation; it's only available if there was no gag or if I wanted to use a big dose of brutane. However, this is a patient that most likely needs a tube.

The bigger question is, do you REALLY feel that this patient won't need vent support in another 10 minutes? I'd guess that this patient would have been tubed shortly after arrival at the ED.

If you had the experience and protocol to intubate this patient, I would have done it prior to leaving.

BTW, my guess is CVA.
 

chaz90

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Yeah, I still don't know if I'd be completely sold on prehospital RSI here. This patient may not improve any more with EMS, but she has already gone from apneic with pulses too weak to palpate (or just not felt as the crew was conditioned to expect an arrest) to breathing spontaneously (albeit slowly) and with a stable HR and BP. With this transport time and the fact that we're already moving in the back of the ambulance, I don't think it would be unreasonable to continue with the BVM and advise the ED of a possible need for intubation shortly after arrival. I agree though that if the patient remains in this state at ED arrival she is getting intubated post haste.
 

teedubbyaw

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Low GCS, unable to effectively breath on her own, unknown etiology of AMS/unconscious. Is she protecting her own airway? Nope. Is her LOC improving? Nope.

I'm toobin her. +1 on probable CVA.
 

NomadicMedic

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Sure. You know I'm a fan of "just because you can, doesn't mean you should". Certainly nothing wrong with bagging this patient all the way to the ED, but I believe this patient DOES need ventilatory support and will continue to require it for the foreseeable future. Use a BVM and NPA for the short ride in (and be behind the 8 ball when she starts to vomit after all that BVM ventilation) or take another few minutes on scene and secure an airway for the transport and continued clinical course.

In all honesty, I dont think either path would be a QI red flag, as both positions are justifiable based on the experience and comfort level of the provider.
 
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TF Medic

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Thanks for the discussion guys, it mirrors the conversations we've had here about it. Anybody else with different input?

I'll post an update to this thread later this evening or tomorrow.
 

Carlos Danger

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If this were my patient, I would not intubate her. We're already moving to the hospital, so by the time we've established these kinds of baselines, we're probably a few minutes into the 15 minute transport time. She's maintaining adequate oxygenation and ventilation status as measured by SpO2 and EtCO2, her heart rate doesn't seem to indicate dire distress, and her respiratory rate unassisted isn't even too bad.

Do her SpO2 readings change much if she's left on O2 and allowed to breathe spontaneously 8 times/minute without using a BVM? This whole call seems to be on an upward trend, and I'm reluctant to commit to intubation and ventilator usage when I'm not so certain she'll need it in another 10 minutes. If things don't improve or maintain well enough without a BVM, we can always go back to using a BVM as we have already shown it is perfectly feasible on this patient

This.

The patient is managing just fine without intubation, and in fact seems to be improving.

Intubation & mechanical ventilation is not a benign procedure. It should only be done when really necessary.
 

MS Medic

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I agree that if there's no gag reflex, drop pvc. Unresponsive with inadaquete respiration. I've been on this type of call where I didn't tube the pt before Tx and things went sideways during transport. You can bank on the pt being intubated as soon as you get to the ED. There is no reason not to prehospital. Failing to do so actually neglects proper airway management in my opinion.

My qualifier here is that the pt doesn't have a gag reflex. I'm not saying to RSI.
 

NomadicMedic

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This.

The patient is managing just fine without intubation, and in fact seems to be improving.

Intubation & mechanical ventilation is not a benign procedure. It should only be done when really necessary.

I disagree. I believe in this case it is necessary. This patient had a respiratory rate of 8 when not being bagged, a GCS of 3 and was found peri arrest. I wouldn't want to ride for 15 minutes with a patient that didn't have a airway that I could guarantee would stay patent from the whole ride. If she woke up and started breathing to beat the band in the ED, then they can extubate her.

As an aside, I'm not a "GCS less than 8, intubate" kind of guy. There are plenty of folks that I put off tubing in the truck because I thought it would be okay or thought it wasn't necessary. (Or because I wasn't sure I'd be able to place the tube once I RSIed them). This isn't one of those. This woman should have a tube.
 
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teedubbyaw

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This.

The patient is managing just fine without intubation, and in fact seems to be improving.

Intubation & mechanical ventilation is not a benign procedure. It should only be done when really necessary.

Sorry, but if CVA is on your differential for this pt, and I'm sure it is, then they need a tube.
 

Carlos Danger

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She has a poor respiratory drive, but it seems to be improving. They are managing her airway fine with a BVM.

Folks like this are transported everyday by BLS crews and do just fine.

Maybe she will end up needing a tube. I don't see why she needs one right now.
 

MS Medic

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PT remains stable but unresponsive in transport. Spontaneous respirations improve to around 16 with BVM assistance, fall back to around 8 if BVM is withheld.
She has a poor respiratory drive, but it seems to be improving. They are managing her airway fine with a BVM.

I don't consider a respiratory rate that drops from 16 to 8 when ventilations are withheld to be improving. Sorry I don't feel this to be stably self-maintaining an airway and I would tube the pt.
 

reaper

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Why hold off on securing an airway, that you know will be done as soon as you roll into ED? If she has a true GCS of 3, then she cannot protect her airway. Secure it. If you do not have RSI then drop a NTI.
 

DesertMedic66

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Why hold off on securing an airway, that you know will be done as soon as you roll into ED? If she has a true GCS of 3, then she cannot protect her airway. Secure it. If you do not have RSI then drop a NTI.
We don't don't have nasal as an option here.
 

medicsb

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To intubate or not really depends on skill and experience of the crew. BVM will be sufficient, but I would not fault a well trained and experience crew with attempting to intubate. In the ED, experience, skill, etc. is the difference between "why didn't you intubate" and "thank you [for not intubating]".
 

MS Medic

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Why hold off on securing an airway, that you know will be done as soon as you roll into ED? If she has a true GCS of 3, then she cannot protect her airway. Secure it. If you do not have RSI then drop a NTI.
Just because the pt has a GSC of 3 doesn't necessarily mean they can't protect their airway, in fact they quite often can, but in this case the pt has problems maintaining a "decent" (I'm intentionally avoiding using the word adequate) respiration rate. Personal experience has taught me that you are on the front end of real respiratory compromise. You can start down the road and the pt goes into respiratory arrest or even worse, she starts vomiting.

In the first case, you still have to get a tube but rather than setting the situation to give you every advantage you can take, your now having to intubate in an emergent situation. In the second case you're actually having to stop ventilations in order to suction. This is a situation where if you get behind, playing catch up can have significant consequences for the pt.
 

zzyzx

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What if she vomits? That's not unlikely considering how long she's been bagged and that she may have a CVA.
 
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