Trismus Intubation

Rangat

Rangat

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Hey all

So what are your opinions on a PVA pt with a clenching jaw and a GCS of 5?

What happened was after 20mg of Morphine and 20mg of Midazolam he was unconscious, but still clinching too much to get a proper view of the cords.

A good candidate for blind nasals, i know.

So would you give him even more sedation until you can intubate him, or turn lateral until they can RSI him in the ER?:ph34r:
 
The problem is he had a sedative, not a paralytic (which would had reduced muscle tension). Whenever 20mg of Morphine is given, I would wonder about the dangers why, anyone would administer such a high dose with associated Versed.

Face it, you are not going to knock them down if M.S. (10mg) and especially Versed (20mg). Now, you might have a potentially dangerous situation with lowering the blood pressure (since both will), potential bradycardia and inducing coma state unnecessary.

This part of the problem with partial RSI or induced medicated intubation techniques. I would say the paramedic should had protocols permitting paralytic (muscle relaxer) such as succinylcholine or another; but judging by the amount or sedatives given, I can see why. As well, it is now being demonstrated induced narcotic unresponsiveness has a higher percentage of laryngospasms, and inability to intubate. Thus, the reason I will no longer use just pharmacological methods for < LOC without paralytics.

There are tons of articles in regards to this type of scenario.

R/r 911
 
3 words............Etomidate and Succinylcholine................Problem solved!
 
Flight-LP said:
3 words............Etomidate and Succinylcholine................Problem solved!
Click to expand...

I have to agree with you on that one, give those two drugs and your pt will clentch no more!
 
4 words 'round here. BNTI. At least for those of us that learned how to do it.

What is PVA?

Egg
 
PVA- Pedestrian Vehicle Accident

What is BNTI? Another word for RSI?



I agree that paralytics or inducers are the way to go. And luckily when I graduate in 2 years Ill have paralytics on a stand alone protocol.

I deduct from you guys that you wouldn't give more sedatives coz of the side effects? So turning lateral until hospital was ok?
 
I am supposing Blind NasoTracheal Intubation.. which could be considered, but if you are going to sedate, then one might as well paralyze. My view point is if you trust your medics to intubate and administer sedatives, one might as well give authority to paralyze.

Bil-lateral NPA's with normal suctioning and removing of secretions PRN. Sure, laying lateral is okay, but now you have probably knocked down some of the respiratory rate.. Closely monitor and assist ventilation's PRN with BVM, etc.

R/r 911
 
RSI vs. blind nasal intubation has been shown to be safer, more successful, and quicker. Not to mention the possible ramifications of sticking an ET tube up someones nose with a potential closed head injury. BTNI was great in its day, but now has really fallen to the wayside with the progression to NMBA induction.
 
OK well an OPA was in place and he was still breathing at a good depth and rate.

Advice appreciated.

Thanks
 
What I would give for RSI. One would think that it simply does not exist in the EMS realm here. Granted, we have a very high success rate w/ nasal intubation but what a drag. I got got my practice and got it out of my system and now wish we had something else. BNTI is not fun (to say the least) for your pt.

Egg
 
We dont have RSI in GA, at least for street level medics. Flight Medics can, but no EMS system that I know of allows it.

As for BNTI, we had it up until this summer, but our Medical Directors in all their insightfulness removed that protocol from our skill set. They said that it caused too much naso-pharengeal trauma when not done properly. Also, supposedly we were sitting on scene too long instead of trying to get to the ER for definitive tx. To that degree I can understand as our average Emer. transport time is 5-6 minutes, but there are however a few areas of our zone and MA response area that are 20+ minutes emergent drive from an ER.

We are only allowed to call the whirleybird if we are way-way-way out and the pt is a pediatric pt. That just started being allowed about 4 months ago and no crew that i know of has utilized it yet.
 
This is something that I am rather torn about. I dislike BNTI but I think there may be a place for it. I feel that under the right circumstance it is a good thing but without practice on real people you can never really become good at it. I also think that you should not practice it on real people. So where do we go from here? Last year we kicked down a study going on about how great we are at dropping nasal tubes. Big deal, I kinda thought the more progressive systems are into the RSI thing. If you are face to face with a silent chest I think being able to drop a nasal tube smartish is a real good thing. However I say this having NO experience with RSI in the field. I will steer off for a moment and thank the inventor of CPAP. Anyway, not having experience with RSI and having more than enough with BNTI I think you should have at least one of the two. Why would your boss doc not give you either (not sure how GA rolls)? Long story short I am glad I can nasally tube most if I have to but I would love to have a much better option at hand.

Another option would be to do as your "Gaurdian" would do. Chuck your "common sense" and maybe get a real detailed hx on that silent chest and them come up with 19 things for your diff/dx (never mind the 1 word dyspnea, that would imply using common sense). After that you may want to consult with your partner for a spell if you are still unsure about the etiology of the s/sx (god forbid you act like a "cowboy" and move fast on this one). Some time after that you might wish to state "Holy S**T!!!! I am way out of my league and should just flake out and let someone with some idea of how to manage a call take this person to the hospital". Goodness!!! I am sorry for that! A bit childish eh? So sorry. Really I am. Just kinda thought that if I am to be called a b**ch on the PM maybe I should respond in kind here.

A bit of advice for new medics that do BNTI.
DO NOT tell your pt. that there will be some "pressure" in their nose or something along those lines.
DO NOT tell them it will be "uncomfortable".
In fact DO NOT tell them ANYTHING short of "it is terrible and you will hate me and ALL paramedics after this".
I used to say these things, things that I heard other medics say. This was until I was told these things prior to ME "buying plastic".
It is nothing short of a very bad thing to endure.

Egg
 
eggshen said:
This is something that I am rather torn about. I dislike BNTI but I think there may be a place for it. I feel that under the right circumstance it is a good thing but without practice on real people you can never really become good at it. I also think that you should not practice it on real people. So where do we go from here? Last year we kicked down a study going on about how great we are at dropping nasal tubes. Big deal, I kinda thought the more progressive systems are into the RSI thing. If you are face to face with a silent chest I think being able to drop a nasal tube smartish is a real good thing. However I say this having NO experience with RSI in the field. I will steer off for a moment and thank the inventor of CPAP. Anyway, not having experience with RSI and having more than enough with BNTI I think you should have at least one of the two. Why would your boss doc not give you either (not sure how GA rolls)? Long story short I am glad I can nasally tube most if I have to but I would love to have a much better option at hand.

Egg
Click to expand...

Well I looked at the protocol again, and we still technically have BNTI, but we have to call and get orders. Isked our training guru yesterday and they said only one person has called and asked for orders and it was denied (not sure on circumstances) in the 4 months since it changed. She said prior to that we were doing 10-15 or so a month as an agency (300 employees, 100k calls annually).

We do have CPAPs coming hopefully faily soon, once some financial issues are cleared up with the parent hospital. It will be great once they are all up and going.

As for GA, we are just a**backwards when it comes to lots of things. Still dont have a regulated/funded statewide trauma system. One of the level I trauma centers is $50million in the hole, and scheduled to start cutting services after Thanksgiving barring and infusion of cash. Two of the other three Lvl I centers are contemplating dropping trauma status. No RSI for street medics. NREMT-I85 not I99 level...the list goes on
 
Grady_emt said:
Well I looked at the protocol again, and we still technically have BNTI, but we have to call and get orders. Isked our training guru yesterday and they said only one person has called and asked for orders and it was denied (not sure on circumstances) in the 4 months since it changed. She said prior to that we were doing 10-15 or so a month as an agency (300 employees, 100k calls annually).

We do have CPAPs coming hopefully faily soon, once some financial issues are cleared up with the parent hospital. It will be great once they are all up and going.

As for GA, we are just a**backwards when it comes to lots of things. Still dont have a regulated/funded statewide trauma system. One of the level I trauma centers is $50million in the hole, and scheduled to start cutting services after Thanksgiving barring and infusion of cash. Two of the other three Lvl I centers are contemplating dropping trauma status. No RSI for street medics. NREMT-I85 not I99 level...the list goes on
Click to expand...

That is horrible that you have to call and ask someone if you can secure a patient's airway! I truly hope things better for you................

And don't hold a lot of hope on CPAP. Everyone is lovin' the CPAP and most are giving it at the wrong time! Think about this for a minute. You generally have three types of pts. medically that you would need to intubate; Asthmatics, COPD'rs, and CHF'rs. The CHF'rs will benefit from CPAP, but did you know that in "dry" pts. i.e the other two, CPAP is actually contraindicated? All too often I see pts. brought into ER's from other services with their Asthma pts. being CPAP'd instead of being intubated. They find out quickly that they have wasted their time and possibly worsened their pts. condition.

You have to have something available for these pts. to secure their airway and get them to ventilate. RSI, PAI, BNTI, something. But CPAP is not the answer.
 
I have one very quick question:

How were the pt Sa02 on a NRB mask to start with? Did they need to be intubated? I know it's a more secure airway but did they NEED it?

OK well an OPA was in place and he was still breathing at a good depth and rate.
Click to expand...

Again SaO2?

I agree with Egg, Load'n Go. (Or call for Air if you need to)

I tell my students all the time BLS before ALS.
 
ASTMedic said:
I have one very quick question:

How were the pt Sa02 on a NRB mask to start with? Did they need to be intubated? I know it's a more secure airway but did they NEED it?



Again SaO2?

I agree with Egg, Load'n Go. (Or call for Air if you need to)

I tell my students all the time BLS before ALS.
Click to expand...


Acute traumatic injury with altered mentation reducing the GCS to a 5, and a clenched jaw. He needs to be intubated, period. SPO2 is irrelevant. The question here is more the methodology associated with the intubation. Perfect example of when RSI is indicated.
 
ASTMedic said:
I have one very quick question:

How were the pt Sa02 on a NRB mask to start with? Did they need to be intubated? I know it's a more secure airway but did they NEED it?



Again SaO2?

I agree with Egg, Load'n Go. (Or call for Air if you need to)

I tell my students all the time BLS before ALS.
Click to expand...

I hope you tell your students it is SpO2, not arterial saturation, and that one should be treating the patient, NOT the monitor. Personally, I could care less what the SpO2 numbers say!

Are you going to await to secure an airway on a patient with a "clinched jaw"? Allowing aspiration and hypoxia to occur before you take action? Remember, it may take up to 3-4 minutes of hypoxia before the tissues start to desaturate. If the patient has already desaturated, and you awaited for the numbers to fall, your NEGLEGENT.

As well WHY DOES THIS PATIENT NEED AIR TRANSPORT? What does an aircraft have to do with any treatment? Why is this a common response? It has been proven air transport does not change outcomes, unless one is very rural > 30 minute transport time. Sorry, if you are able to provide ALS and did not, your negligent in care.

You describe Load-n-Go.. again why? Yes, do not delay transport, but take care of the patient. This patient needs an secure airway.

Administer some Versed nasal, then intubate them. If the trismus has decreased and has relaxed and if one is able to place an oral airway in, one should be able to intubate. If you can't; then place an alternative airway.. i.e. combitube.

Now, I have not read of the detailed assessment, but this is a trauma patient? Is there facial fractures, or potential palatine fractures blind nasal intubation is contraindicated. Again, if they have a GCS of 5 and they are able to communicate and are alert enough to fight, we have a problem. Either because the medic does not know how to calculate a GCS appropriately, or the patient is not as represented with "clinched jaws".

One better decide which airway (such as BNI) way before administering narcotics, which decreases respiratory drive. Ever BNI a non-breathing patient? Especially trauma without manipulating the neck? I have and it is HE*L! Yes, it can be done but very tricky!

I suggest that many read current literature on airway management and if possible take a course such as SLAM to be proficient.

R/r 911
 
Ok sorry about the spelling (SaO2) I was writing that after a 13hr day. FYI I'm writing this on my iPhone at work so you might want some of that nasal Versed cus i may have made some spelling errors.

Whoa guess I hit a hot subject for someone! Also when did i say sit and do nothing. You keep using the neglegent statement. Some of us in the world cant give medication to allow for intubation. None Nada Zip Zero! I was making a loose statement and not writing protocols here. So are you saying that I should BNI this pt? A trauma pt with poss fractures? Or stick a little straw in their neck and hope that does the trick?

I will answer this in parts:

Load and Go- What is the point of sitting on scene just to provide ALS care. I'm 4 min from the hospital. Do I sit on scene to do ALS care or load the pt with a BLS airway, drop a line enroute, and get to the hospital where 10 times the hands are ready with 20 time the tools? It used to be done ALL the time.

Air ambulance- You must work in an area that has short transport times or a nice scope. I am anywhere from 5-90 min from a level 3 that wants nothing to do with a head injury that has a GCS of 5. So I have two options: 1) Load and Go and make a 30-45min drive to one of the two closest level 2 or 2) Think ahead and call for an air ambulance to take the pt to one of those two hospitals. An air ambulance that can also RSI and I can't.
 
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