Trauma Scenario: Thoughts? RE: RSI/Intubation

[CANMAN]

Nasal tube perhaps?

Certainly not to replace RSI, but an option for those that don't have it.

Yeah perhaps if we had to manage this guys ventilations for an extended transport time, but if we were close to the hospital I would defer if I didn't have RSI. Nasal intubation can cause pretty dramatic spikes in ICP and for the guy with a potential head injury idk if I would venture down that path or not personally. But a great idea and glad people still think of it. Definitely a lost art and a lot of medic schools don't even teach it anymore...

 

[DesertMedic66]

Out here it's code to the closest ED. We don't have RSI, nasal intubation, or even crics.

 

[medicsb]

I generally agree with the notion that soot in the airway and/or singed facial/nose hairs should not be an indication for intubation. Nor should isolated facial burns. Add on respiratory distress, voice change, sloughing of oral mucosa, etc. and then you have some solid reasons to intubate. I do, however, think that if you are on the fence, it is probably better to intubate. Having spent 4 weeks working in a Burn ICU, I've seen the sort of damage to the tracheal and oral mucosa that can occur - swelling and sloughing of necrotic mucosa. I've seen patients go extended periods of time with no cuff leak due to swelling. And there were a few who were extubed the next morning after positive cuff leak and negative bronchoscopy and then sent home directly from the ICU. In the ED, I have the benefit of having an NPL, so I can look directly at the vocal cords and hypopharyx to eval for edema. We frequently brought patients in for "airway watch" and then D/C'd to home when everything was fine the next day. We probably do "over intubate" burn patients, but I'd never want to be behind the curve of an airway burn.

 

[Nova1300]

Nasal tube perhaps?

Certainly not to replace RSI, but an option for those that don't have it.

It's funny, the only time I ever placed a nasal ETT in the field was a burn. Fire pulled a gentleman out of a house with 100% full thickness from the top of his head to the bottom of his feet. He was still moaning, but otherwise non-communicative.

Having never placed one, and frankly never even seen one, I used a trigger tube (some of you may remember those), down the nose, watched for mist, synchronized my own respirations with the patient's, prayed, here we go, on the next breath we are going for it.....another quick prayer.... bam! A few joyous expletives and an ambubag later I emptied the morphine and the Valium tubex into his IV and pedal to the floor.

18 years old, brand new cardiac tech (probably now equivalent to an intermediate), absolutely terrified. It was certainly one of those calls that sticks with you the rest of your career.

Somehow we managed pre-RSI. But, wow would I never like to do that again. I still don't know how that tube ended up in the trachea. Beginners luck, 100%.

Now that I have a substantially larger knowledge of airways, I would be way too chicken to attempt a nasal intubation on a burn. But, it can work in a pinch.

 

[CANMAN]

Guessing you guys didn't have BAAM's then Nova? Before the days of CPAP a lot of our tanking CHF'ers would buy a trigger tube and a BAAM and those things work like magic!

 

[Carlos Danger]

Whenever someone says "RSI isn't an option for me", someone else always pipes up an says "well, what about blind NTI?" and then they or someone else goes on to explain how they've done many of them and how they are a really feasible alternative to RSI.

I'm not disagreeing or saying I don't believe those who say that've done them, because I've never done one myself. I'm just wondering....are they really that easy? Do you still not encounter a violent gag reflex? And if they do work well, why aren't they done more?

I was taught how to do them years ago in paramedic school, and it was touched on again in my anesthesia program. We carried BAAM's several places that I worked, but I don't recall ever even attempting a BNTI.

I emptied the morphine and the Valium tubex into his IV

That's like a blast from the past, because when I was a new paramedic, the only analgesia and sedation we carried was morphine and valium.....both in 1ml tubex's. I recall a few times getting orders to combine those with brutane in order to facilitate intubation. It was always ugly, but sometimes it worked.

 

[CANMAN]

Whenever someone says "RSI isn't an option for me", someone else always pipes up an says "well, what about blind NTI?" and then they or someone else goes on to explain how they've done many of them and how they are a really feasible alternative to RSI.

I'm not disagreeing or saying I don't believe those who say that've done them, because I've never done one myself. I'm just wondering....are they really that easy? Do you still not encounter a violent gag reflex? And if they do work well, why aren't they done more?

I was taught how to do them years ago in paramedic school, and it was touched on again in my anesthesia program. We carried BAAM's several places that I worked, but I don't recall ever even attempting a BNTI.



That's like a blast from the past, because when I was a new paramedic, the only analgesia and sedation we carried was morphine and valium.....both in 1ml tubex's. I recall a few times getting orders to combine those with brutane in order to facilitate intubation. It was always ugly, but sometimes it worked.

Well I don't believe they are an ideal replacement for RSI by any stretch, but they aren't overly difficult to place if you have the right gear.

Right gear being Endotrol "trigger tubes" and a BAAM. Alternatively you could use an in line end-tidal but the BAAM is a nice audible confirmation with spontaneous respirations. I have never put larger then a 6.0 in due to nare size, and obviously they require copious lube. I have had people with a strong gag, and some without a gag, or very weak all accept a tube. Most of the people with a strong gag were CHF patients before the days of CPAP that were so air hungry they literally would suck the tube down. That being said I have done about 7 in my career, all but one successful with relative ease.

Biggest issue I have had is making sure the ET adapter is pushed down tight enough in the tube so it doesn't come out, and securing it, which can be done with IV tubing.

I think they aren't done as frequently now a days because of the introduction of Narcan and CPAP. Also the increase in ICP is a concern with head injured patients as we know.

 

[Akulahawk]

I've seen NTI done and was trained in the technique in Paramedic school but I've never done one. This is mostly due to the fact that most of the systems I worked in did not authorize NTI. Since some did, we were trained in how to do it though. My observations are pretty much what CANMAN stated. It's not too difficult as long as you have the correct tools, one being an Endotrol trigger tube ETT and the other being a BAAM device. The intubations were generally well tolerated.

Even in this age of RSI, it's not a bad idea to have this in your toolbox, so to speak, though I would expect it to be rarely used these days. One other technique I was trained in was digital intubation... but generally speaking, I'm not too keen on the idea of putting my hand/fingers into someone's mouth and working entirely by feel.

 

[Carlos Danger]

Even in this age of RSI, it's not a bad idea to have this in your toolbox, so to speak, though I would expect it to be rarely used these days. One other technique I was trained in was digital intubation... but generally speaking, I'm not too keen on the idea of putting my hand/fingers into someone's mouth and working entirely by feel.

I've done several digitals in messy airways. THAT is a great technique to stay comfortable with. Along with retrograde. Those are my old-school party tricks.

You damn kids these days have it so easy with your bougies and your VL's.

 

[Akulahawk]

I've done several digitals in messy airways. THAT is a great technique to stay comfortable with. Along with retrograde. Those are my old-school party tricks.

You damn kids these days have it so easy with your bougies and your VL's.

I was also trained to do retrograde... Because of VL and bougies, I've yet to see any of my ER Docs have to use that technique, let alone doing a cric.

 

[Tigger]

Whenever someone says "RSI isn't an option for me", someone else always pipes up an says "well, what about blind NTI?" and then they or someone else goes on to explain how they've done many of them and how they are a really feasible alternative to RSI.

I'm not disagreeing or saying I don't believe those who say that've done them, because I've never done one myself. I'm just wondering....are they really that easy? Do you still not encounter a violent gag reflex? And if they do work well, why aren't they done more?

I was taught how to do them years ago in paramedic school, and it was touched on again in my anesthesia program. We carried BAAM's several places that I worked, but I don't recall ever even attempting a BNTI.



That's like a blast from the past, because when I was a new paramedic, the only analgesia and sedation we carried was morphine and valium.....both in 1ml tubex's. I recall a few times getting orders to combine those with brutane in order to facilitate intubation. It was always ugly, but sometimes it worked.

We still learn them in our program and it isn't a "this is a skill that you'll never use but we have to teach it" sort of thing. We carry the trigger tubes and BAAMs and while I would never say I am comfortable in doing something I have never done to a live patient, I do feel that I was educated to the point of being willing to attempt it, especially with a long transport (minimum of a half hour for us).

 

[ERDoc]

I agree that we do go a little overboard about tubing these sorts of pts, but I think the pt in the original scenario has shown us that she is one of them that needs a tube. Anyone inside a fire is more than likely to have soot in their nose, throat and everyone else but it doesn't mean they inhaled hot gasses so you have to look at the soot in the full, clinical context.

 

[Doczilla]

I agree that we do go a little overboard about tubing these sorts of pts, but I think the pt in the original scenario has shown us that she is one of them that needs a tube. Anyone inside a fire is more than likely to have soot in their nose, throat and everyone else but it doesn't mean they inhaled hot gasses so you have to look at the soot in the full, clinical context.

I agree both to this, and your previous sentiment about taking minimalist approaches to airways that need tubes.

Not everyone needs a tube, or RSI for that matter. But when you need RSI, you NEED it. Over the years there's been many more "risk adverse" adjustments to airway guidelines (which are actually protocols lol) in response to the overwhelming notion that prehospital tubes are causing further harm.

Yeah, some of em are. But we've gotta use the same solvent analysis that we use for other stuff and address deficiencies in ourselves before we downgrade airway management resources in a knee-jerk, blanket fashion.

We owe it to our patients, and ourselves as clinicians.

 

[MackTheKnife]

I'm trying to wrap my head around one of the scenarios we recently did in medic school, so I figured I'd run it by everybody here (I'll try to remember it the best I can. It was a few days ago so I can't remember a lot of the information):

Dispatched for an explosion at a building. Upon arrival, you have one patient (middle-aged male) found laying on the ground. Going head to toe: decreased level of responsiveness (can't recall exact GCS, but 12-13 range maybe?), singed nose hairs, mucous membranes intact. Burns to chest, forearms. I don't remember much about the respiratory rate, but I remember that we did place an NPA and provided ventilation with a BVM. Lung sounds clear and equal. Bilateral lower leg fractures. I don't recall exact vitals, but I believe they were relatively stable (with exception of resps).

I wish I could remember more of the scenario and paint a better clinical picture, but unfortunately I'm lacking on the details.

My question is this: would you consider RSI for this patient? I wasn't the team leader, but I was arguing that the patient should be intubated: decreased level of responsiveness, multi-system trauma, and potential airway burns. Others were saying that you shouldn't RSI in this situation due to the fact that lung sounds were clear (they were arguing that you don't RSI without stridor or wheezing in a case like this) and because BLS airway interventions were working.

I've been thinking about this scenario for a few days and have convinced myself that I'm on the right track saying that this patient needs a tube. However, I'm obviously open to having that belief changed.

Anybody have any thoughts on this?

If you're having to bag him, you need to tube him.

Sent from my XT1585 using Tapatalk

 

[Melbourne MICA]

The question is, what proportional correlation is there between certain visible airway burn markers and the need for prophylactic intubation? Well, the juries still out. A large proportion of airway burns intubations whether done in the field or at the ED/burns unit are extubated in the 1st 24hrs. I'll hunt up some references, but current evidence does support any particular combination of airway signs as a reliable model for ETT decisions. Like so may paramedic decisions, it's a judgement call - a balance between potential serious risks from RSI and whatever benefits we suspect may be derived from an early intubation.