Scenario-ish: To intubate or not to intubate?

[Handsome Robb]

Ran this call recently, I wanted some opinions and thoughts about how you would handle this.

Backstory: 1430 in the afternoon, heavy traffic conditions. We were 4 blocks north and the other unit was 2 blocks south when the call dropped, came out as a priority 2 (still lights and sirens response but able to divert) traffic collision given to the first unit then upgraded to a priority 1 extrication and we were added as a second unit, P1, at that point. First unit arrived on scene and requested we continue, we arrived 30 seconds later. T-bone accident to the passenger side door at >50mph. My pt was the passenger, unrestrained, 25-30 inches of intrusion into his seat which displaced his seat into the driver's seat. His window and passenger side windshield severely spidered.

When I got to him he was unresponsive, GCS 4 (1/1/2) (you could argue 3 but he did display a little bit of decerabrate posturing but not very obvious.) but was breathing adequately with a patent airway, no signs of cyanosis. No real outward signs of trauma besides a few lacs and a busted ankle. At this point it was only the two units on scene and fire was fighting traffic so we decided not to wait for them due to his status. I peeled the door back as best I could and climbed in next to him with my partner in the back seat maintaining manual c-spine. I placed a collar and with the help of one crew member from the other unit and a bystander holding the foot of the board for us we extricated him out the driver's side door onto a board right as fire arrived. Trauma naked, c-spine and to the ambulance.

Once in the ambulance vitals were:
162/70
Sinus with inverted p's and t's in II with a rate from 40-90 bpm
respirations were beginning to shallow at a rate of 22 and slightly irregular,
SpO2 of 86%,
GCS now a "solid" 3
CBG 106 mg/dL

I dropped an OPA which he tolerated and began bag assisting with ETCO2 in place targeting 30mmhg. Had a good EtCO2 wave form and great compliance and chest rise, only required a little suctioning, lung sounds were clear and equal bilaterally. With the bag assisting his SpO2 was now 97-99%.

This is where the question is. I had a 13 minute scene time including the 5ish minutes it took us to extricate him from the car and a 7 minute transport time to a Level II TC, no Level I available.

Do you intubate? If yes do you use drugs? If so which drugs and why? What if you don't have the ability to RSI?

I'll tell you what I did after some respond.

 

[Tigger]

Given the timing I think you present a reasonable case.

Even if you could RSI, by the time everything is setup you would be getting close to the hospital anyway.

 

[emschick1985]

Ran this call recently, I wanted some opinions and thoughts about how you would handle this.

Backstory: 1430 in the afternoon, heavy traffic conditions. We were 4 blocks north and the other unit was 2 blocks south when the call dropped, came out as a priority 2 (still lights and sirens response but able to divert) traffic collision given to the first unit then upgraded to a priority 1 extrication and we were added as a second unit, P1, at that point. First unit arrived on scene and requested we continue, we arrived 30 seconds later. T-bone accident to the passenger side door at >50mph. My pt was the passenger, unrestrained, 25-30 inches of intrusion into his seat which displaced his seat into the driver's seat. His window and passenger side windshield severely spidered.

When I got to him he was unresponsive, GCS 4 (1/1/2) (you could argue 3 but he did display a little bit of decerabrate posturing but not very obvious.) but was breathing adequately with a patent airway, no signs of cyanosis. No real outward signs of trauma besides a few lacs and a busted ankle. At this point it was only the two units on scene and fire was fighting traffic so we decided not to wait for them due to his status. I peeled the door back as best I could and climbed in next to him with my partner in the back seat maintaining manual c-spine. I placed a collar and with the help of one crew member from the other unit and a bystander holding the foot of the board for us we extricated him out the driver's side door onto a board right as fire arrived. Trauma naked, c-spine and to the ambulance.

Once in the ambulance vitals were:
162/70
Sinus with inverted p's and t's in II with a rate from 40-90 bpm
respirations were beginning to shallow at a rate of 22 and slightly irregular,
SpO2 of 86%,
GCS now a "solid" 3
CBG 106 mg/dL

I dropped an OPA which he tolerated and began bag assisting with ETCO2 in place targeting 30mmhg. Had a good EtCO2 wave form and great compliance and chest rise, only required a little suctioning, lung sounds were clear and equal bilaterally. With the bag assisting his SpO2 was now 97-99%.

This is where the question is. I had a 13 minute scene time including the 5ish minutes it took us to extricate him from the car and a 7 minute transport time to a Level II TC, no Level I available.

Do you intubate? If yes do you use drugs? If so which drugs and why? What if you don't have the ability to RSI?

I'll tell you what I did after some respond.

I think you did great, vitals show the bagging was effective at the time. RSI and intubation would have delayed transport time, I think you did a great job.

 

[teedubbyaw]

Agreed with tigger. Given those specific issues, I'd have kept with the bvm/opa.

 

[Handsome Robb]

Well thanks, I appreciate it. I'm just wondering other's thoughts. Like I said, would you? Which drugs? Why?

 

[chaz90]

With the time to the trauma center I don't think I would have rushed an RSI. With effective bagging and a 7 minute transport time I'd call it a day right there. For where I am though, I'd be intubating this patient and flying them out to the Level I. The local level IIIs wouldn't (and shouldn't!) have much to do with this patient.

If he tolerated the BVM and an OPA I'd likely consider intubating without drugs. Any signs of trismus or gag reflex though and I'd RSI with Lidocaine+Etomidate+Succinylcholine.

 

[Akulahawk]

Given the transport time to the L2 trauma center, I'd stick with BVM because it's clearly effective. The OPA isn't causing a response, so I might consider intubation, and certainly alert the ED that this patient will likely need to be intubated on arrival so they can prepare ahead of time. If everything else is going good and I have the time or the extra hands available, I might give the tube a go...

 

[emschick1985]

We don't have RSI capability at our service yet. I really wish we did because I have had several situations where it was very much needed.

 

[Tigger]

It's possible that this patient would not need to be RSIed as well. I guess if you had extra hands in back it would have been conceivable to try and intubate the patient, but if you were alone that seems like less than a poor idea.

The priority here is getting the patient to a trauma center, right?

 

[PotatoMedic]

Superglotic at most with a transport time that short. That is my opinion.

 

[DesertMedic66]

With that transport time I would have stuck with the BVM/OPA as long as ventilations were still efficient.

If the transport time was longer I would probably have intubated him. He is tolerating the OPA just fine so he may take the tube without issue. We don't have any RSI meds in my area so I would go without them.

 

[Tigger]

Superglotic at most with a transport time that short. That is my opinion.

This is a good point. If you are alone in back you could quickly place one and then not have to deal with a one handed mask seal.

 

[Burritomedic1127]

This is a good point. If you are alone in back you could quickly place one and then not have to deal with a one handed mask seal.

A great idea

Since the pt tolerated the OPA no prob, a quick King Lt some endtidal and you have a more "secure" airway than bagging. Along with the fact of not adding time away from the trauma center with intubating

 

[medicsb]

My general approach is to start planning the intubation as soon as it is determined that the pt. might need to be intubated. How far into planning you get will depend on resources. When I was still on the street I worked where we had to call for orders to RSI, which meant if possible one of us would go to the ambulance to call for orders and set up the equipment and draw meds. Once the patient was loaded into the ambulance, we'd proceed.

Sounds like you had limited personnel, but you or your partner could go to the ambulance to set-up as soon as the patient is extricated in order to expedite the process.

For this pt. you could probably go with ETI without meds, but I don't think I'd knock you for pushing etomidate and succs (or whatever you carry).

 

[Tigger]

My general approach is to start planning the intubation as soon as it is determined that the pt. might need to be intubated. How far into planning you get will depend on resources. When I was still on the street I worked where we had to call for orders to RSI, which meant if possible one of us would go to the ambulance to call for orders and set up the equipment and draw meds. Once the patient was loaded into the ambulance, we'd proceed.

Sounds like you had limited personnel, but you or your partner could go to the ambulance to set-up as soon as the patient is extricated in order to expedite the process.

For this pt. you could probably go with ETI without meds, but I don't think I'd knock you for pushing etomidate and succs (or whatever you carry).

No doubt a plan for additional airway compromise is always warranted, which I'm sure Robb had. Sometimes you just don't get to that point based on timing, which is likely here. I'm sure you were prepared to intubate if you were not able to bag him @Handsome Rob ?

 

[Carlos Danger]

Good call Robb. I don't think I'd have done anything different, other than perhaps drop an LMA instead of masking, just to make it easier on myself. As someone else said, with such a short transport you were likely at the ED before you would have had the tube secured, and the patient was able to be intubated in an environment with a lot more resources available. Even if the transport had been 10 or 15 minutes long, I'd say what you did would still be very appropriate.

What meds would I have used if I'd have tubed this guy? A large dose of etomidate quickly followed by some sux would work just fine. I'd prefer propofol over etomidate, but most of us don't have that in the field....etomidate is just fine; so is ketamine if it's all you have, though it'd be my last choice. If I had time, I'd cut the dose of etomidate in half, and give some lidocaine, fentanyl, esmolol, and glycopyrrolate (or a small dose of atropine) first.

As far as intubating without meds.....I would avoid that if at all possible. This guy's ICP is already approaching lethal levels, and the sympathetic surge that results from airway instrumentation without sedation is only going to make that worse. Some profound sedation and/or sympathetic blockade is highly desirable in this guy.

If you don't have RSI and he really needs to be tubed, then of course you just do what you can do, recognizing that airway takes priority. Maybe you could at least spray the airway and give some fentanyl or whatever beta blocker it is that you carry? Anyone have protocols for that, absent the ability to RSI?

 

[SandpitMedic]

Etomidate 20-40mg dependent on weight. Drop that tube en route; if I had 7 estimated minutes I could do that. This guy requires a secure airway. So I can do it in the field with sedation meds to reduce sympathetic response as noted earlier, sooner, and achieve the secure advanced airway. S/s of increasing ICP/multisystem trauma with airway compromise = buying plastic. Anything goes south and there is always the BLS/ILS airway options to fall back on.

I've ran similar calls like this, and while I am not afraid to bag someone in, I am pretty aggressive on airways.

 

[zzyzx]

I don't think you did anything terribly wrong, but i will have to disagree with you and the other posters and say that this guy needed intubation. All the talk in recent years about going from paramedics intubating should not distract you from situations where a patient needs an advanced airway immediately, and this guy needs a tube. He has no gag and is completely unresponsive, so why not just drop a tube? It should take you about one minute. And if you have trouble, just put in a King, which again should only take one minute. What was the very first thing they did when you arrive in the ER? Im sure they intubated. There are many downsides to BVM ventilations, including gastric insufflation, the fact that it is not an easy procedure, and requires 2 people. What if the guy had vomited after getting bagged for a few minutes? Again I'm not saying you handled the call badly but i do think this guy is like the poster child for that patient who needs a tube.

 

[DesertMedic66]

Good call Robb. I don't think I'd have done anything different, other than perhaps drop an LMA instead of masking, just to make it easier on myself. As someone else said, with such a short transport you were likely at the ED before you would have had the tube secured, and the patient was able to be intubated in an environment with a lot more resources available. Even if the transport had been 10 or 15 minutes long, I'd say what you did would still be very appropriate.

What meds would I have used if I'd have tubed this guy? A large dose of etomidate quickly followed by some sux would work just fine. I'd prefer propofol over etomidate, but most of us don't have that in the field....etomidate is just fine; so is ketamine if it's all you have, though it'd be my last choice. If I had time, I'd cut the dose of etomidate in half, and give some lidocaine, fentanyl, esmolol, and glycopyrrolate (or a small dose of atropine) first.

As far as intubating without meds.....I would avoid that if at all possible. This guy's ICP is already approaching lethal levels, and the sympathetic surge that results from airway instrumentation without sedation is only going to make that worse. Some profound sedation and/or sympathetic blockade is highly desirable in this guy.

If you don't have RSI and he really needs to be tubed, then of course you just do what you can do, recognizing that airway takes priority. Maybe you could at least spray the airway and give some fentanyl or whatever beta blocker it is that you carry? Anyone have protocols for that, absent the ability to RSI?

The county I did my medic internship at has protocols for 1.5mg/kg lido IVP for tube placement when there is suspected ICP.

 

[NomadicMedic]

Gotta say, after reading the scenario I was torn. I don't know if I would have intubated him or not. It might have simply depended on how lucky I was feeling that day… However, I've become a lot less cavalier about taking someone's airway. If BLS airway maneuvers were getting it done and you only had seven minutes to the hospital, good on you.

Putting a tube in the trachea is not what makes you a good paramedic, delivering a viable patient to the emergency department is.

...and to the person who said, "I'm sure the first thing that happened when they got to the emergency department is he bought a tube". I'm sure he did. And it's always, ALWAYS easier to do tube a trauma patient when the bed is adjustable to the optimum height, there's lots of lights, you're not bouncing down the road and you've got plenty of other people, a glidescope and the trauma doc standing by.