ROSC intubation scenario

[Akulahawk]

For that patient, intubating her would be high on my list of things to consider. Sacramento County's protocols state that because the BLS airway management is adequate, that the BLS airway should be continued as this patient is not apneic and the County doesn't have an RSI protocol for Paramedics. If the BLS airway couldn't be adequately maintained, then intubation is directed by protocol. I would imagine that the patient also didn't have a gag reflex, or at least didn't for quite a while.

 

[TF Medic]

Update:

The crew for this call elected not to intubate. The scene time was quite short, and almost all assessment other than cardiac monitoring and initiating the BVM were done enroute. By time the necessary assessment/interventions were performed, the truck was about 5 minutes from the ER. They decided to keep the functioning BLS airway until arrival.

The PT was RSI'd in the ER upon arrival. ER pushed another 1mg Narcan without effect. I'll see if I can get further on etiology.

Thanks for the discussion.

 

[triemal04]

What other interventions and assessments were being done for 10 minutes?

 

[TF Medic]

I wasn't in the back, so I don't know exactly what happened. Based on the report, I gather:

BP/Pulse ox
Bag spike and IV start (2 attempts)
Glucose
D-Fib patches applied
12 lead
Narcan draw and admin

 

[triemal04]

I wasn't in the back, so I don't know exactly what happened. Based on the report, I gather:

BP/Pulse ox
Bag spike and IV start (2 attempts)
Glucose
D-Fib patches applied
12 lead
Narcan draw and admin

Oh, I thought you were actually on this call. From the original post it sounded like all that had been done prior to leaving; was curious what else was being done that took up 10 minutes of time.

And as to the original question, this patient does need to be intubated. Who does it and where it get's done is dependent on the capabilities and competencies of the providers. 15 minutes is a long time to have to hand ventilate someone, especially someone who is at high risk (higher risk with the BVM in a moving ambulance) for vomiting and aspirating.

Just to add another thought; did anyone ask the family what the patient's wishes were in a situation like this? See if she had any type of advance directives or if they knew how aggressive care she would want? The simple fact that they tried CPR (with prompting from a 3rd party no less) doesn't mean that is what the patient wants.

 

[Carlos Danger]

I don't consider a respiratory rate that drops from 16 to 8 when ventilations are withheld to be improving.

A couple issues here.

First, This patient was found apneic, then regained spontaneous respirations at a rate of about 6, and has since improved to a rate of 8. I think that qualifies as "improvement" by any measure. She is normocapneic and normoxic with minimal ventilatory support. Her hemodynamics have also improved. She is absolutely heading in the right direction. Could that trend reverse, and she ends up needing to be intubated in an hour or in 5 minutes? Of course. And it could happen in a hurry. If it does, we'll deal with it. But for right now, she is getting better with minimal intervention.

Second, this is an 84 year old cancer patient with DM2 and chronic pain issues. Putting her on a ventilator is pretty much the last thing I want to do, and I think it's the safe bet that the patient herself agrees. If the family insists that all measures be taken, then fine. But unless they have specifically instructed that, I think management should absolutely fall on the conservative end of the spectrum until that stuff can all be sorted out between the family and the ER physician.

Lastly, airway management encompasses much more than just intubation, and it isn't as if prehospital intubation is some magic panacea that solves all the problems and never causes new ones. There's actually a lot of risk associated with prehospital RSI. Sometimes people just need to be tubed, but other times discretion is the better part of valor. I think a scenario like this is one of those times.

 

[MS Medic]

First I think there was some missed information about opinions and second I think we are going to have to agree to disagree.

I stated in my original post on this thread that I would not RSI, only intubate if there was no gag reflex. I actually don't think the average prehospital personnel should be able to RSI. That should be reserved for CC personnel who have access to an OR if they don't meet minimum intubation requirements, neither of which applies to me.

As far as the pt goes, any respiratory effort is an improvement over apnea, but a pt who has AMS and requires ventilatory support isn't self maintaining an airway. If I could place this pt in a fowlers position with only a NRB and maybe an NPA then I would consider the pt self maintaining.

Second, you have a pt who was found pulseless/apnec and spontaneously converted with only CPR. This situation presents the real possibility of the pt going back into arrest. At this point, your in the position I mentioned of having to intubate in an emergent situation rather than in the more controlled situation I discussed earlier. You also have to worry about prolonged mask ventilations causing gastric distention and subsequent vomiting. At this point, you are suctioning and you're no longer supporting ventilations.

As for the statement that this should be sorted out by the family and the ER physician, standard of care puts the responsibility for this situation squarely on my shoulders. Issues of advanced directives should have been discussed on scene with the family and if they don't want the pt intubated, then that's that.

 

[SeeNoMore]

It seems to me the only argument in favor of intubation is protection against possible aspiration. I would certainly be expected to intubate this patient by my medical director, ED docs , QA folks etc. Of course that does not mean it is necessarily the right call. I have often wondered whether this risk is given undue emphasis vs the risks of prehospital RSI. I've intubated many patients with an adequate respiratory rate , ventilation and Sp02 for this reason, even when the ED Physician has opted not to. One would think that if lots of patients were suffering negative outcomes from aspiration from not being intubated then more studies would show improved outcomes from ALS airway management. Many of these patients were also encountered as ground or flight transfers of longer duration than the average 911 call. Would managing vomiting with positioning and suctioning be better than preemptive RSI for this patient? I don't have the data to say. Interesting discussion.

 

[MS Medic]

Concern over aspiration is a legitimate issue in the back of the ambulance, in cramped quarters, with a shortage of trained personnel and in a moving vehicle. But if a pt can be managed by positioning and doesn't require ventilatory assistance then they probably shouldn't be intubated.

 

[hogwiley]

15 minutes out, good ECO2 and spo2? this one is a no brainer to me. I would have done what that crew did. They got her to the ed with adequate ventilation and oxygenation and ed staff were able to rsi her in more favorable circumstances.

First rule, do no harm. What if they tried to rsi her to be proactive and things didn't work out as planned. Now 8 spontaneous respirations per minute are zero.

 

[NYBLS]

15 minutes out, good ECO2 and spo2? this one is a no brainer to me. I would have done what that crew did. They got her to the ed with adequate ventilation and oxygenation and ed staff were able to rsi her in more favorable circumstances.

First rule, do no harm. What if they tried to rsi her to be proactive and things didn't work out as planned. Now 8 spontaneous respirations per minute are zero.

And what if they leave her airway unsecured without protective mechanisms and she aspirates and dies?

 

[hogwiley]

And what if they leave her airway unsecured without protective mechanisms and she aspirates and dies?

Well there are risks either way. There is a legitimate case to be made for RSI. I think the case for not doing it in this situation is stronger though.

 

[DesertMedic66]

Also remember that in the ED patients are often left alone for periods of time on and off of ventilators whereas transporting this patient you are never more than 2 feet away.

 

[SeeNoMore]

This is a good discussion. I still struggle with decision making regarding airway management. I tend to be somewhere in the middle of the conservative - aggressive spectrum. I would have intubated this patient, but I can see the reasoning behind the arguments for BVM management en route. I have been trying to come up with a better knowledge base for assessing the need for intubation and from what I have read it seems the ability to spontaneously swallow and manage oral secretions is a good indicator of airway pateny. The problem is that many managers, docs etc rely heavily on the notion that GCS <8 requires intubation. Period.

As we have discussed here the argument always goes "they could aspirate and die if you don't intubate them." I've always felt that this was a little overstated given you are at their side able to manage positioning and suction but obviously it is a concern.

In addition the placement of an ETT is no guarantee that aspiration will not occur, and many providers seem to avoid putting in OG tubes despite their concerns over possible aspiration of gastric contents.

 

[Carlos Danger]

It seems to me the only argument in favor of intubation is protection against possible aspiration. I would certainly be expected to intubate this patient by my medical director, ED docs , QA folks etc. Of course that does not mean it is necessarily the right call. I have often wondered whether this risk is given undue emphasis vs the risks of prehospital RSI. I've intubated many patients with an adequate respiratory rate , ventilation and Sp02 for this reason, even when the ED Physician has opted not to. One would think that if lots of patients were suffering negative outcomes from aspiration from not being intubated then more studies would show improved outcomes from ALS airway management. Many of these patients were also encountered as ground or flight transfers of longer duration than the average 911 call. Would managing vomiting with positioning and suctioning be better than preemptive RSI for this patient? I don't have the data to say. Interesting discussion.

Great points. We are trained to be way too aggressive with airway management, and go to intubation way too quickly, IMO. We tend to approach airway management as though not intubating will almost certainly result in serious problems for the patient, and in order to justify/support that thought process, we simply ignore both the high rate of complications and proven lack of benefit involved with prehospital intubation. We get it almost exactly backwards.

 

[Brandon O]

Two useful but opposing airway principles could apply here:

1. If they need a tube, sooner is better than later.
2. If they need a tube, ask whether you're the right person to do it and they're in the right place for it to happen.

In other words, it depends on your comfort, resources, and patient factors (difficulty of the airway, etc). It also probably depends on whether you stayed to play or are already halfway to the ED by the time it comes up.

 

[SeeNoMore]

The issue is I still face a little uncertainty regarding whether some patients need to be intubated. It's not an issue of comfort. I intubate regularly in the field, OR and lab and while everyone has room to grow I am not generally overly worried about not being able to either intubate or otherwise manage the airway. To be clear I'm not trying to sound overconfident. I know that there are many possible negative consequences of intubation and that I like any other provider can certainly run into airway problems I did not anticipate.

The issue really is whether the threat of vomiting and subsequent aspiration is worth intubating a patient who is GCS <8, ventilating appropriately with an adequate 02 sat. A secondary issue is that where I work this type of patient would be immediately intubated by the ED team and I would be disciplined/educated for poor decision making. I would be more inclined to fight the good fight and argue the case if I could find better info on the true value of intubation in this type of patient (or lack thereof) and had a better approach to deciding whether aspiration was a significant risk, whether patient's managed via positioning and suction did as well as those intubated etc. Studies don't seem to indicate that lots of patients are dying from aspiration from BLS vs ALs transport, at least as far as I can tell. Reading studies is still an area I am shamefully deficient in.

Of course some presentations are easier than others. If someone is obtunded with vomitus or pooled secretions than your choice is not as hard.

 

[Brandon O]

You also need to consider that while you may be able to squeeze air into a patient's lungs with a mask, that is not a reliably controlled situation in the same sense as a tube. How long can you do that for? How much stock would you place in it -- in other words, are you confident mask ventilation will be easily achievable and remain that way without change or issue all the way until transfer of care?

It's true that the problems many people have with the BVM come from inadequate skill, but it's also true that it will never be as certain as plastic in the airway. Masks leak, bellies inflate, and yes, people vomit. (Oh, and maintaining a good mask seal will be extra fun while you carry them down some stairs or across a field.)

 

[SeeNoMore]

I don't disagree Brandon. I would have intubated the patient in this scenario. I was referring to the patient who does not need BVM ventilation but has a questionable capacity to maintain a patent airway due to altered mental status.

 

[SpecialK]

Based on history and presentation my diagnosis is a cerebral haemorrhage.

My reasoning for not performing RSI would be

1. Ventilation and oxygenation are being managed satisfactorily with bag-mask and an NPA
2. It will be faster by at least 10 minutes to continue to hospital vs. stopping and performing RSI
3. Given age and comorbidities, she is most likely to be palliated and not admitted to ICU or given neurosurgery

Having said that, this is a good case for RSI because

1. Allows definite protection of her airway
2. It may speed up imaging (e.g. going to CT directly upon arrival)
3. Is standard care in hospital
4. She can be easily extubated and allowed to ventilate spontaneously if palliated

Despite being quite torn on this one, I am fairly confident I would not perform RSI If hospital was a little further away and if she had a poor airway and/or poor oxygenation with basic airway care I would be more inclined to do it. Also, I would not perform the procedure in the back of an ambulance, I would stay on scene and perform it given our scene is a regular family home which has much better space, lighting etc than the back of an ambulance.

Given she is unconscious with a GCS of 3 I would also very likely only use suxamethonium for the initial intubation and not utilise rocuronium for post-intubation management unless she became unmanageable despite a fentanyl/midazolam infusion.

Finally, while an NPA appears to be working well in this scenario, I would change it over to an LMA.