Trismus Intubation

[eggshen]

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

We CPAP asthmatics using in line nebs. Can you hook me up with the info somewhere stating that it is a bad idea. We have been doing it for about 18 months or so and I have seen more than one asthmatic turn around. Anything I can find regarding this would be terrific.

Egg

 

[Mr. Anderson]

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!



Huh? I'm assuming by BNI you are refering to blind nasotracheal intubation. If that's the case, I'm eagerly awaiting the story behind how you did this with a non-breathing patient.

 

[Ridryder911]

Simple, one introduces into the trachea without the aid of respiratory movement. One can feel tautness, and "pop" as it goes through the glottic opening. Just blind intubation.

Like I described not easy, but can be accomplished.


R/r 911

 

[eggshen]

I have done it a few times. Not easy but it can be done. Where nasal intubation in a breathing pt. is a combination of skill, technique, finesse and cooperation of the pt. the same in an apneic pt. is mostly luck and some decent anatomy.

Egg

 

[Flight-LP]

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

We CPAP asthmatics using in line nebs. Can you hook me up with the info somewhere stating that it is a bad idea. We have been doing it for about 18 months or so and I have seen more than one asthmatic turn around. Anything I can find regarding this would be terrific.

Egg

Yea, I'm trying to find a study I read recently...........I'll get back to you.

The issue that I have and the view of our medical director is that Asthma being an obstructive issue vs. an air exchange issue would be better served by focusing on the inflamation (i.e. steroids, b2 agonists), instead of increasing the probability of barotrauma. If they are going into failure and are inflammed, CPAP will do nothing for the inflammation. Therefore, do you really believe it will help slow their breathing to the point where they can control their respiratory cycle? More often than not, the answer is no. In fact the mask itself usually produces further anxiety. If it hits that point, they need to be intubated. They need to give their lungs some much needed rest. CHFr's onn the other hand can and usually do show an immediate improvement to the forced opening of the alveoli. Thats our take on it anyways..............

We do inline treatments through the BVM. Usually works wonders.................

 

[eggshen]

Eagerly awaiting.

Thank you
Egg

 

[natrab]

In respect to RSI, I wish we had it. The patient described is exactly who needs it.

As a fellow California medic, I understand the air ambulance thing. Let me explain. I work on the coast and my transport time by ground to a trauma center is about 30-50 minutes. Granted, it usually takes an air ambulance 20 minutes to get to scene (and for some stupid reason the auto-launch protocol is not being followed in comm.), 10 minutes to load, and 20 minutes back to the trauma center. With this pt in particular, I would wait the extra 10 minutes for the air ambulance simply because they can RSI and protect the pt's airway and it will happen in 20-30 minutes rather than at the end of the golden hour when we finally get to the hospital. I think it's ridiculous that we're forced to think that way (who wants to sit on scene or at an LZ with a severe trauma pt?), but they just don't allow us to RSI. Typically we'll get the equipment set up, a nurse from the chopper will jump in with a drug bag and do the RSI before loading up. Could have happened 10 minutes ago and we'd have beat them to the trauma center anyways.

I don't mind if they put limitations on RSI, but please give us the option so I don't get stuck watching my patient lose their airway on a winding road in the mountains on the way to a hospital.

 

[burntbob]

blind nasal

As they always say, BLS first-- good airway, 02, careful ventilation, cautious suctioning and good C spine control. Last thing you want is an airway full of blood and a vomiting patient.
Then ALS--If you don't have an ALS backup Plan B for when you've snowed them and taken away their breathing centre you better be good at BLS airway.

Blind nasal is contrindicated up here for traumatic head injuries due to the risk of cranial intubation ......It's still a great skill and useful when you need it, we still get the old CHF'ers who point at their nose when you come in since they know what will buy some time when they are all tired from fighting the fluid in their lungs.
theres a neat gadget that fits on the tube and whistles when you get into the trachea called the BAM. Some guys here swear by it.

 

[emtd29]

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.

OK I know this is off topic but...

WHAT?

OK let me get this straight...

you're way way way ( ie 20 miles the other side of nowhere ) out with an adult pt that would more than likely benefit from air transport vs. ground, you CANNOT call for a bird???

However, if you have a kid in the same situation, you CAN call for the bird??

I don't get it.


Something fishy there....

 

[Ridryder911]

.
theres a neat gadget that fits on the tube and whistles when you get into the trachea called the BAM. Some guys here swear by it.

I posted a training video, that uses the "whistler" used to be known as the BAM.
http://www.youtube.com/watch?v=HXjPdNSL96c

Grady: "We are only allowed to call the whirleybird if we are way-way-way out and the pt is a pediatric pt."

That is a dangerous movement. Age discrimination is definitely noted, if you recognize the reason is needed for rapid transportation to a more definitive center. I highly suggest, that the EMS and Hospital legal team review this policy. It is a setting time bomb, one I would not want to be involved in.

R/r 911

 

[natrab]

I'm hoping he meant or the pt is a pediatric. That would make more sense in both trauma and medical scenarios. It would make no sense to require a long ETA and the pt to be pediatric.

 

[pa8109]

I know that this is a late post, but reading about a pedestrian struck with a GCS of 5 and a clenched airway I had a few things come to mind. PA does not allow ground units, except a select few, to carry paralytics. Some services carry Etomidate which it sounds like that in this case would work perfectly. Now I realize that every patient is different, and its easy for one to sit and discuss how to treat a critical patient after that fact. I was just suprised to hear that in regards to the increase risk of intracranial trauma from BNTI that no one mentioned a surgical airway. If there was any doubt that a BNTI would cause more harm than good because of head/facial trauma, why not perform a cricothyrotomy? Maybe I may have misread a thread or two, but I got the impression that this patient had some pretty severe head/facial trauma. If it was my last resort, I'd look at a surgical airway.

In regards to the CPAP on "dry" patients, i.e. COPD patients, I find it interesting that there is debate about this. I understand both sides of the arguement. Our statewide protocols place strict warning on intubating patient with exacerbations of asthma and COPD without attempting CPAP first. I will quote, not to say its right or wrong but this is straight from the book "WARNING: Although sometimes needed, intubation further narrows the airway restriction in a severe asthma exacerbation, and this may worsen some cases. Aggressive use of bronchodilators is generally the most important therapy for severe asthma exacerbation" I have used CPAP on several asthma patients with in-line albuterol treatments and found marked improvement. Every patient I've known to have been intubated has died. Not to say that I've completed a research study on it, but in this area CPAP is beggining to take precedence over intubation in severe COPD exacerbation. Any thoughts?

 

[bonedog]

Intubation of asthmatics is great as long as you pay strict attention to your e time. Having the ability to recognize the patient that needs it is the biggest key. Any decreased LOC or tachypnea with a unexpected CO2 level points that way. Personally I have tubed a few, proper sedation and as stated careful attention to e time and mechanics, and fortunately have yet to have a morbid outcome. I have heard of a few though, usual cause is iatrogenic barotrauma. Acidosis is not to be feared in these broncho spastic patients, also with intubation, suctioning is targeted to the airways, as mucous can be half the problem.

CPAP is great for CHF.

Also as a great intensivist once told me, I'd rather Roc than suc.....

 

[MSDeltaFlt]

Back on track with the original post, also. A clinched jaw, a GCS=5, and appartently no paralytics available but you could get an OPA. I'm hoping that you have another aiway option on the truck: as in Combitube or King LT. That will provide at least some airway protection.

GCS=5 and dropping with clenched jaws is an airway problem plain and simple. Be aggressive. And, in the immortal words of Snoop Dogg, "Drop it like it's hot!"

 

[paramediclori]

Wow, I couldn't even finish reading all of the responses, I was getting so mad. You have a person that was in an MVA, and you are giving them high doses of morphine? Maybe it's just where I live, but has anyone thought about the fact you don't give that drug to someone who has any possible bleed or a head injury, which sounds like this patient had a very good possibility. :unsure: The fact that you gave THAT MUCH of seditives blows my mind. I absolutley would have tried a nasal intubation, and OPA, NPA, Combitube. Where I work, we do not do RSI do to the dangers of it, which I absolutly agree with. I don't think we are ever in a controled enough enviorment to preform that.h34r:

 

[Ridryder911]

I absolutley would have tried a nasal intubation, and OPA, NPA, Combitube. Where I work, we do not do RSI do to the dangers of it, which I absolutly agree with. I don't think we are ever in a controled enough enviorment to preform that.h34r:

Wow! You would nasal intubate a head injury, but NOT perform RSI?

Nasal intubation should be used very, very cautiously in those with traumatic head injuries if ever. Personally, I find nasal intubation much more risky and dangerous than any assisted or even RSI procedure. If the patient truly does have clinched jaws, it is obvious that one cannot assess for internal maxillo fractures. As well, RSI has a double beneficial effect of lowering ICP in head injuries and is highly recommended per neuro's.

Personally, if one cannot control airway enough for RSI, then one should not even be able to intubate. RSI, if properly educated and controlled is the best and least traumatic to an already traumatized patient. Apparently, you never have seen a palatine fracture with the ETT going into the brain stem, then you would change your mind.

Time to step up and increase the education level....

R/r 911

 

[paramediclori]

HAHA, ok good point and thanks for making me eat my words,... I guess I wasn't thinking about that, I got side tracked with frustration you would give so much Morphine to a possible head bleed, or even internal bleed, and you are right, I would not do a nasal intubation in that situation. I guess as far as RSI, it really isn't done in the field in the state of michigan. I have always been taught more the dangers of RSI then the benifits, not to mention I have watched an ER doc do an RSI, things went bad and ended up with alot more problems. Maybe the education I recieved about RSI could use some improvment, but like I said, I have always been taught the downfalls and dangers.

 

[Ridryder911]

The problems with RSI is not the procedure, rather the persons performing or using it incorrectly. The main problem now, is Paramedics abusing it.

I have been performing RSI since the late 80's in the field, so I don't see the big deal. For as your ER Doc, sounds like it either was an airway from he*l or they need to review. If one cannot tube, either ventilate with BVM, combitube, or crich them... again, no big problem.

We RSI at least weekly here, and in ER usually at last every other day (and its a rural/urban ER). It is not uncommon to knock someone down for respiratory disorders (COPD, CHF-although CPAP has reduced our #'s) and definitely head injuries.

Let me ask, how do you control respiratory patterns such as in head injuries, COPD or combative TBI patients? Even non head injury combative patients?

R/r 911

 

[paramediclori]

I can see people abusing it, and as far as the ER doc, she did crich. Well in a combative I will take a few extra FF's with me for extra hands, we have restraints. As far as if I need to intubate right away and need some way of knocking them out, then I would use MS for pain, and Versed as sedation, which is what our locol protocols call for. If at all possible though, I try to hold off on intubations IF i can, and hope they can hold out for cpap. No I do not depend on it, and I will and have intubated when needed. I hope this answered your quetion, I wasn't 100% sure the specific of you quetion.