Scenario-ish: To intubate or not to intubate?

[Nova1300]

Difficult call when that close to the hospital. Head injuries with a GCS less than 8 are almost always intubated. If you guys are interested in a bit more reading on the topic, search the Brain Trauma Foundations TBI guidelines.

I agree with Remi. Those adjuncts, when used by skilled practitioners can really keep your hemodynamic swings in check when inducing a head injury. Especially short acting drugs like esmolol.

Again it is a hard call to make. Could that 10 minutes of mild hyperventilation enroute to the hospital be the one thing that keeps the patient from herniating until definitive therapy?

Looking further down the road, I will tell you that many of these folks have aspiration events after severe TBI and fluff out ARDS on hospital day number 3-4. Did they aspirate on impact, or was it the ventilation with an unsecured airway? Really tough to tell. I'm not sure there is a good answer in the prehospital setting.

 

[SeeNoMore]

It's not that he doesn't need to be intubated, it's a realization that intubation is not the be-all of his care.

Fair enough. I still feel intubation would be a good option prehospitally. Not the only option, but the one I would choose.

 

[PotatoMedic]

Again it is a hard call to make. Could that 10 minutes of mild hyperventilation enroute to the hospital be the one thing that keeps the patient from herniating until definitive therapy?

I believe PHTLS no longer reccomends hyperventilation of TBI's.

 

[SeeNoMore]

Controlled hyperventilation with a target of Pc02 26-30 is still the standard of care for pt's presenting with evidence of elevated ICP.

 

[Akulahawk]

Controlled hyperventilation with a target of Pc02 26-30 is still the standard of care for pt's presenting with evidence of elevated ICP.

Which is why it's good to get grumpy if all you have to detect EtCO2 with is a colorimetric device and not something spiffy that shows you the waveform and some numbers.

 

[SeeNoMore]

Do any US ALS services lack waveform Etc02? I thought that was the standard everywhere.[/QUOTE]

 

[Brandon O]

Controlled hyperventilation with a target of Pc02 26-30 is still the standard of care for pt's presenting with evidence of elevated ICP.

Most authorities are now suggesting this should be done only as a "rescue" intervention in the setting of active herniation, with the idea of temporizing until other interventions are available. In other words, when they blow a pupil and you're 5 minutes down the road from a guy with a big saw.

If there's nobody to catch what you're throwing it's probably worse than useless. I don't know if this scenario really qualifies. I would probably keep that gun in the holster for a bit.

 

[SeeNoMore]

True Brandon O , what I should have said was pt's presenting with signs of herniation/acutely elevated ICP and diminishing condition. As you point out the issue is still being debated. For the time being it's part of my practice.

Just to be clear, I am not saying this pt would have been hyperventilated, just intubated. And I do agree that hyperventilation is at best a temporary measure for severely ill patients.

 

[Akulahawk]

Do any US ALS services lack waveform Etc02? I thought that was the standard everywhere.

I would certainly hope that all ALS services in the US have waveform EtCO2. Quite frankly, I hope I never have to work for a service that doesn't...

 

[RocketMedic]

Lots still don't. "Our paramedics know how to place tubes." Which is an admission of both miserliness and stupidity. Quite effective at weeding out bad employers.

 

[Akulahawk]

Lots still don't. "Our paramedics know how to place tubes." Which is an admission of both miserliness and stupidity. Quite effective at weeding out bad employers.

That was my suspicion and also is exactly correct... Great way to weed out the bad places to work. Those would only use EtCO2 if their EMS Director made them and they'd only do that kicking and screaming.

 

[SandpitMedic]

If I don't use the EtCO2 waveform when I intubate, AND transmit it to my chart... It is an automatic 3 day suspension, and immediate termination the 2nd time!

 

[Shishkabob]

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.

I've never accepted that reasoning. 7 minutes to set up for an RSI for 7 minutes to transport... where they still have to set-up and do an RSI. You're now looking at >14 minutes. He needs an airway, he's going to get an airway ASAP, why prolong the inevitable and let the clinical course suffer? Not saying I'd have tubed in this situation, but the "Well you can get there quickly" line shouldn't be the sole determining factor.


Shoot, the two are not even mutually exclusive. Nothing says you can't intubate while headed towards the hospital and accomplish both tasks.

 

[DesertMedic66]

I've never accepted that reasoning. 7 minutes to set up for an RSI for 7 minutes to transport... where they still have to set-up and do an RSI. You're now looking at >14 minutes. He needs an airway, he's going to get an airway ASAP, why prolong the inevitable and let the clinical course suffer? Not saying I'd have tubed in this situation, but the "Well you can get there quickly" line shouldn't be the sole determining factor.


Shoot, the two are not even mutually exclusive. Nothing says you can't intubate while headed towards the hospital and accomplish both tasks.

Do hospitals not prep for patients when you do a call in? Ours will usually have everything laid out and meds drawn up. As soon as we move the patient over they get a quick set of vitals and then go to work.

 

[Tigger]

I've never accepted that reasoning. 7 minutes to set up for an RSI for 7 minutes to transport... where they still have to set-up and do an RSI. You're now looking at >14 minutes. He needs an airway, he's going to get an airway ASAP, why prolong the inevitable and let the clinical course suffer? Not saying I'd have tubed in this situation, but the "Well you can get there quickly" line shouldn't be the sole determining factor.


Shoot, the two are not even mutually exclusive. Nothing says you can't intubate while headed towards the hospital and accomplish both tasks.

I'm not sure RSI is an advisable procedure to do alone while moving, but to each his own.

 

[Carlos Danger]

Lots of posters here have said that the right thing to do in this scenario would be to intubate in the field.

For those who take that position, how do you square your opinion with the many studies that show that these patients actually do worse when intubated in the field?

Like this one from earlier this year: Is prehospital endotracheal intubation associated with improved outcomes in isolated severe head injury? A matched cohort analysis.

 

[triemal04]

Lots of posters here have said that the right thing to do in this scenario would be to intubate in the field.

For those who take that position, how do you square your opinion with the many studies that show that these patients actually do worse when intubated in the field?

Like this one from earlier this year: Is prehospital endotracheal intubation associated with improved outcomes in isolated severe head injury? A matched cohort analysis.

I'm absolutely not going to discount the results of that retrospective analysis; nobody should. But I would ask that you explain something to me: How is that people can, on the one hand, go off on the poor quality of prehospital medical care in southern Cali, specifically LA, and talk about how it is worthless and needs a complete overhaul, and yet on the other hand, hold up a study that (most likely; I only have access to the abstract) was done in LA as a reason for all prehospital providers to do something?

Something just doesn't add up.

There are similar analysis's from systems that are the polar opposite of LA that have come up with entirely different results.

Should those results be ignored because they don't match what people want to hear or do?

Should we pick and choose what "study" or analysis to believe in? Should we only read abstracts and only learn what the stated conclusion is?

Or should we really look at the data that's presented?

Prehospital intubation can be done, and done properly. And when it is, it can be beneficial. The problem is that not every system is set up to really perform intubation properly. That is the take away message from all studies like this is what I said earlier:

Are you (and this isn't meant in a personal way, but something that to many people don't really understand and think about) truly competant at intubation and equipped to do so? Which includes everything that comes before, and after the act of placing a tube in the trachea.

If the answer is yes, then he should have been intubated. If the answer is no, (and there's no shame in that) then he shouldn't have been, and what you did was fine.

People, and systems, need to know what their limitations are, and if a study done in a specific area applies directly to them. Problem being, most don't understand this.

 

[luke_31]

From research I did towards my degree one of the things that I found was that the trauma severity on these patients was significant enough that the mortality rate was relatively unaffected by the prehospital intubation. That is to say I found that most of the patients that were intubated in the prehospital setting probably we're not going to survive regardless of who and where did the intubation. Multiple meta-studies showed that the typical trauma patient intubated in the prehospital setting had significant comorbidity factors in relation to the traumatic injuries that it was hard to say for certain that it was the paramedics who intubated these patients that caused the patients to die more frequently. The hardest part of looking at these studies I found was the people doing the study acknowledged that there was a possibility that the injuries alone would kill the patient. A good example of this is the mortality rate of patients intubated in a cardiac arrest of medical nature. Looking at the rate of cardiac arrest saves versus deaths you could infer that it was the intubation that caused the increase in mortality, reality speaking we are trying to bring back someone who is clinically dead a heroic task to begin with.

 

[Carlos Danger]

How is that people can, on the one hand, go off on the poor quality of prehospital medical care in southern Cali, specifically LA, and talk about how it is worthless and needs a complete overhaul, and yet on the other hand, hold up a study that (most likely; I only have access to the abstract) was done in LA as a reason for all prehospital providers to do something?

The study was indeed done in LA.

Are you saying that studies done in LA are impertinent because standards there are significantly different than the rest of the country? Are paramedics in SoCal not trained to the same national standards as other places in the US?

FWIW, the findings here were not unlike the those from the San Diego trial whose results were published in 2002.

There are similar analysis's from systems that are the polar opposite of LA that have come up with entirely different results.

Should those results be ignored because they don't match what people want to hear or do?

Should we pick and choose what "study" or analysis to believe in?

No on is picking and choosing here. There are some studies that show mildly improved outcomes with intubation (I would not say "the polar opposite"), but those tend to be in select systems with much higher standards than normal, and therefore can't really be extrapolated to the majority of EMS agencies. One example that comes to mind is a retrospective analysis done in Seattle a few years ago.

Even the Bernard study done in Australia, which is the only prospective, randomized trial done on prehospital intubation of TBI's, showed only moderate rates of improvement in neuro status at 6 months with prehospital intubation as compared to those intubated in the hospital. There was no difference in mortality, ICU, or hospital stay, and there was something like a 5-fold increase in cardiac arrest among those intubated prehospital. Overall, the trial did show RSI to be an statistical success, but hardly the clinical game changer that it's proponents want it to be. And at any rate I don't think those results can even be extrapolated to the US, given the large difference in the way paramedics are trained there.

Overall, the aggregate of the data shows success rates that are lower, complication rates that are higher, and outcomes that are generally worsened when patients are intubated in the field as compared to in the hospital.

 

[triemal04]

The study was indeed done in LA.

Are you saying that studies done in LA are impertinent because standards there are significantly different than the rest of the country? Are paramedics in SoCal not trained to the same national standards as other places in the US?

FWIW, the findings here were not unlike the those from the San Diego trial whose results were published in 2002.

Well...actually...

I'm absolutely not going to discount the results of that retrospective analysis; nobody should.

What I am suggesting, in fact demanding, is that what any self-respecting individual should do, is look at more than what the conclusion in an abstract says, and look at how the data used was obtained, which includes looking at the services involved. Questions should be asked, like "Is that service the same as the rest of the country? Is it the same as mine? How comparable is it? Is that a service that should be emulated? Have other services come up with different results? If so, why? How did they differ?"

What national standards do you speak of? Do you mean national registry? Does Cali/LA require that? Is this the same national registry that doesn't require any live intubations to become a paramedic? Seriously, what kind of answer was that?

A co-worker worked in San Diego during the trial you mentioned; I'll just leave it out there that they weren't exactly a high-speed system either, and there were some inherent...flaws...in how that study was run within the department.

No on is picking and choosing here. There are some studies that show mildly improved outcomes with intubation (I would not say "the polar opposite"), but those tend to be in select systems with much higher standards than normal, and therefore can't really be extrapolated to the majority of EMS agencies. One example that comes to mind is a retrospective analysis done in Seattle a few years ago.

Of course they can be applied to other EMS systems! That is the true take home for studies like this. It doesn't matter where you work; Australia, King County, LA, the real conclusion for all these airways studies is very simple: IF prehospital providers are really taught how to intubate, they can do so safely, effectively, and in a way that is beneficial. And prehospital providers in fact CAN be taught to do so. IF they don't learn, it's a bad idea. Every department that intubates should be considering this, and thinking about which applies to them, and if the latter, if they can change to the former, or if it's worth changing to the former. Not everyone can, or really should.

All the data has really ever showed is that if you aren't really ready to intubate, don't do it.

Edit: I'm in a hurry, more tommorow.