Unconscious 64 y/o

[teedubbyaw]

Good point, I'll pass on BVM for 70 minutes. What about an LMA or other BIAD though? I guess we really don't want to have to depend on one of those for that long?

The two biggest factors are that they can't protect their airway, and that is an incredibly long transport time. Neither a king or LMA will truly protect the airway as well as an ET tube, and a hemorrhagic stroke pt will benefit from an advanced airway for a couple of reasons.

 

[Carlos Danger]

Good point, I'll pass on BVM for 70 minutes. What about an LMA or other BIAD though? I guess we really don't want to have to depend on one of those for that long?

I would certainly avoid the use of an extraglottic airway for a long transport if at all possible, but for a short one I think they are highly appropriate.....probably even more appropriate than intubation in many cases.

Vomiting and aspiration is a risk, of course, but is frankly a bit overblown in the prehospital world, IMHO.

What frequently seems to be missing from discussions on the risk of aspiration when using an LMA or King is acknowledgement of the risks involved in prehospital intubation, which are not at all insignificant.

 

[LACoGurneyjockey]

The patient was intubated and transported code 3 to the local hospital. CT showed a subarachnoid bleed, and later that night she was flown just under 200 miles to the nearest neurosurgery specialty facility. Could she have made it to the stroke center, probably. But they would have ultimately shipped her out to the same specialty center.

 

[Angel]

darn, bleed from what?

 

[LACoGurneyjockey]

Docs best guess was chronic untreated HTN...

 

[NPO]

The patient was intubated and transported code 3 to the local hospital. CT showed a subarachnoid bleed, and later that night she was flown just under 200 miles to the nearest neurosurgery specialty facility. Could she have made it to the stroke center, probably. But they would have ultimately shipped her out to the same specialty center.

Knowing where you work/having familiarity with your protocols/area etc I would have called medivac for access to the higher level care facility and to get the CCT crew on scene.

BUT.... That's easy for me to say now, after the fact.


EDIT: and I just realized this thread is old. Meh.

 

[LACoGurneyjockey]

Knowing where you work/having familiarity with your protocols/area etc I would have called medivac for access to the higher level care facility and to get the CCT crew on scene.

BUT.... That's easy for me to say now, after the fact.


EDIT: and I just realized this thread is old. Meh.

Only problem is medevac would have flown to the in county stroke center, who ultimately couldn't handle it and refused the transfer. That, and out where we are the airships flight time, scene time, and transport time is about the same if not slightly greater than our transport time to AV. Unless there's some reason we can't leave scene immediately (entrapment, off-road), we can go by ground quicker than by air.

 

[Handsome Robb]

I wouldn't trust most providers to be able to effectively ventilate via BVM for a long transport.

And that's why I love my ReVel. Originally we could only use it on CCT/SCT transfers but now vent cleared medics can use them for any patient.

Screams bleed to me. Acute ALOC, hypertensive, risk factors...

 

[BlueJayMedic]

In our area this patient would be managed with airway control and transport to local facility. We do not have RSI. I would have started with our King LT and only intubated if airway was lost. I am not sure if I would waste time with cardioversion here, maybe a call to base hospital physician for consult on that. I feel as if the pulmonary edema is a rate problem and may benefit from the pressure and rate of proper vent illations. I am absolutely not driving by a building with a big H on it to go to another one with this patient. She is far too unstable for me to make the decision to risk her life to a tertiary care centre. This patient needed intervention, stabilization and transport by professional transport staff. Personally I think you made the right decision here, interesting to see the different views on this one.

 

[LACoGurneyjockey]

In our area this patient would be managed with airway control and transport to local facility. We do not have RSI. I would have started with our King LT and only intubated if airway was lost. I am not sure if I would waste time with cardioversion here, maybe a call to base hospital physician for consult on that. I feel as if the pulmonary edema is a rate problem and may benefit from the pressure and rate of proper vent illations. I am absolutely not driving by a building with a big H on it to go to another one with this patient. She is far too unstable for me to make the decision to risk her life to a tertiary care centre. This patient needed intervention, stabilization and transport by professional transport staff. Personally I think you made the right decision here, interesting to see the different views on this one.

I'm interested as to why the King tube? Here it's more of a last resort/rescue airway when ET fails, or if BLS arrives first by quite some time they can place one. But what advantage would you have in placing a king in this patient instead of an ET?

 

[BlueJayMedic]

I'm interested as to why the King tube? Here it's more of a last resort/rescue airway when ET fails, or if BLS arrives first by quite some time they can place one. But what advantage would you have in placing a king in this patient instead of an ET?

10 minute transport time and less invasive, I think ETT has its place and I am glad its a skill I can use however if I can manage with a less invasive airway device I will. Personal preference really, I would just rather allow that to be done in the ED where they have more sterile equipment and more personnel to help with the procedure. I guess this patient would have a higher chance to vomit now knowing about the increased ICP. keeping my scene time short would be my highest priority in this situation. In my area we have two on a truck and are lucky to get FD, and when we do often times it is volunteer around here who have low training as far as medicals go. Tubing in the back even and needing cric pressure may not be an option. That being said we also cover a ton of ground and if the transport time was longer that may change my mind.