Was intubation indicated or appropriate?

Handsome Robb

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So it appears I am the low man on the totem pole here but I am always looking for critiques on my thoughts so I'll give it a shot. In my county ET tubes are not in the scope for an I, so I'll look at it from an NREMT standpoint if thats ok?

With the fact that his sats are dropping I'd drop an NPA and start with an NRB to try to improve them and start the pre oxygenation for the tube in the event he becomes unresponsive, and call for the flight intercept and head towards the LZ. This guy needs fluids as well, so I'd start an NS drip and call MC for a pain med order. With the potential for lower airway burns this guy NEEDS the burn center, the quicker he gets there the better. As I am not allowed RSI procedures I would monitor the pt and if he becomes unresponsive I would go ahead and drop the tube with a king as plan b.

Ok let the critisim begin...
 
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Linuss

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The flaw with your concept is that the potential for laryngeal edema is very high, which is very possibly the reason why the pt is now coughing and desatting. An OPA / NPA / supraglottic airway will do NOTHING to help if this is the case, and a tube, or even a needle cric, past the area of edema is needed.


If you try to do just an OPA/NPA/SGA, you're wasting valuable time in which the airway can close more, essentially making an ETT impossible and probably necessitating a crich.
 

Handsome Robb

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So then with my scope would it be better to use the NRB or even attempt bag assisting to keep the sats in the >90 since I am unable to sedate the pt to drop the tube?
 

Linuss

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At the EMT and Intermediate levels, your one and only choice is to get to the closest hospital that has a doctor as fast as humanly possible. You don't have the luxury of time time.
 

Smash

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I'm aggressive with burns that have any kind of airway involvement. Sedate, paralyze and intubate now, rather than wait for things to get worse and make the ETT harder to place. An edematous airway is not a happy place to be fossicking around in if we leave him too long.
 

MSDeltaFlt

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With steam being blasted to the face, a barky cough, c/o SOB with decreasing sats, you my friend are stuck on airway. This pt needs to be tubed. However, your only backup airway device remotely close to being usable is a NEEDLE cric which is a temporary airway on an airway that is already closing off. If, and I do mean IF, you decide to tube this man, you have one shot. Just one shot before his airway closes completely off, for all pretensive purposes. A needle cric won't cut it. You'll need a surgical cric. I personally would call for the bird, or someone who can cut this mans throat open if sugar turns so sh*t.
 

gicts

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Interesting scenario.

Before he complained of difficulty breathing did you begin some sort of pain management?

I would have gone to the trauma hospital and given a report and let them make the call if they want to call in a helicopter. I'm not sure why you would call for additional resources unless you just wanted someone to bag for you.

While I agree he will be intubated, had the trauma hospital been the same distance as the closest hospital I'm not sure I would have tubed him. By the time you set everything up, let the drugs work, delay transport, and get the tube you would have been well into the ER. Others thoughts?
 

MSDeltaFlt

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OK, read more thoroughly the scenario.

First, define DAI. Do you have paralytics? If you don't, then leave him alone and transport to the Level II and have them have anesthesia on standby. A Mallampati 3 with super heated air and a worsening airway makes for a VERY difficult intubation. Enhance his calm as best you can and transport.

If you do have paralytics, remember you have one shot. If you decide to tube, failure is not an option.
 

DrParasite

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as an uneducated one, I would say tube him.

facial burns, possible airway burns (high probability based on the scenario), and now he's having more trouble breathing? if the burns are going to cause more airway swelling, and it's going to get worse, then what? it's going to make tubing him even harder, and even worse if he loses this airway completely.

Let the hard rigid tube ensure that he maintains an ability to breath at least until until you get to the hospital.

Again, I am uneducated, but I would imagine it's better to tube the patient who has a high chance of deteriorating from burns, than not tube the patient, than not tube the patient and then have to play catchup when he stops breathing.

is there a downside to being too aggressive and intubating a patient that may not have needed to be intubated int he field?
 

Linuss

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They'll need to be weened off the tube in the hospital, which takes times, and you could cause some damage.


But with how this is presenting, that's the least of your worries. Hindsight is 20/20, but we don't have the luxury of it in the field.
 

abckidsmom

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as an uneducated one, I would say tube him.

facial burns, possible airway burns (high probability based on the scenario), and now he's having more trouble breathing? if the burns are going to cause more airway swelling, and it's going to get worse, then what? it's going to make tubing him even harder, and even worse if he loses this airway completely.

Let the hard rigid tube ensure that he maintains an ability to breath at least until until you get to the hospital.

Again, I am uneducated, but I would imagine it's better to tube the patient who has a high chance of deteriorating from burns, than not tube the patient, than not tube the patient and then have to play catchup when he stops breathing.

is there a downside to being too aggressive and intubating a patient that may not have needed to be intubated int he field?
It is not benign, by any means, to intubate someone. There is a significant risk of infection, injury, and complications of mechanical ventilation. Additionally, prehospital providers continually fail to recognize esophageal intubations. Not that I think that the people posting in this thread would fail to recognize an esophageal intubation, but we're talking about the least common denominators, who increasingly have been given the discretion to paralyze and sedate their patients and intubate based on their judgment.

This study showed that 31% of all prehospital intubations could be considered "failed intubations." An additional 12% were unrecognized esophageal intubations, which is the shocking part.

Moving intubated patients is a very risky endeavor, especially if the tube is not properly secured. Without the proper monitoring (ETCO2) and assessment, it actually CAN be life-threatening to intubate someone un-necessarily.

As several posters have pointed out, with this guy and his delicate airway, you only get one shot at this intubation before his vocal cords spasm and swell shut. Depending on the swelling in his trachea, a surgical cricothyroidotomy may or may not be possible or successful. He will die if he falls into that 31% of patients who experience a failed prehospital intubation.

A 1 in 3 chance, just on the basis of being out of the hospital. I wouldn't take that chance lightly, but I can completely support the idea of taking control of this airway. It's just one of those times when you're either going to do really, really well, or you're going to kill the guy.
 

Linuss

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I hate studies about pre-hospital intubation.


Until they send anesthesiologist out into the field and find out THEIR averages, I pretty much won't trust the studies. Totally different monster intubating in a clean OR against in a ditch.


Let's send medics to ORs and record the success rate there, as that'd be a lot more viable and realistic in determining the success rate of medics, to which you can extrapolate out into the field and why things don't always go right.





That, however, doesn't excuse not noticing a wrongly places tube, just the "missed" tubes everyone complains about. But also, I'm weary about how many are "placed wrong" and how many shift during the move from the cot to the ER bed (which should be noted BEFORE it happens)
 
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abckidsmom

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I hate studies about pre-hospital intubation.


Until they send anesthesiologist out into the field and find out THEIR averages, I pretty much won't trust the studies. Totally different monster intubating in a clean OR against in a ditch.


Let's send medics to ORs and record the success rate there, as that'd be a lot more viable and realistic in determining the success rate of medics, to which you can extrapolate out into the field and why things don't always go right.





That, however, doesn't excuse not noticing a wrongly places tube, just the "missed" tubes everyone complains about. But also, I'm weary about how many are "placed wrong" and how many shift during the move from the cot to the ER bed (which should be noted BEFORE it happens)
I don't put this against medics in general, but it needs to be noted that out of hospital intubations are more difficult and have more risk based on the fact that the patient is going to be moved a number of times before he comes to rest in the ER.

Given this risk, the fact that medics everywhere do NOT continually reassess and document tube placement, especially with almost universally available ETCO2 waveform technology is inexcusable, regardless of how weary we are of the stereotype.

I agree with you, take an anesthesiologist and have him intubate in the ditch (the numbers would likely be really similar to medics intubating, I would think) then move the patient to a backboard, then to the stretcher, then to the truck, then out of the truck and walk into the ER and transfer onto their bed, all while manually ventilating with a BVM. The anesthesiologist, knowing the extreme risk of every one of those moves, would spend most of the ride reassessing the patency of the tube, and glancing at the waveform on the monitor.

Why aren't medics everywhere doing the same?
 

MasterIntubator

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Bravo Linus! I agree with you on this one. Working in the field and past in hosp surg, they compare quite similar... of course, no one wants to compare in hosp and out of hosp stats.... but I would be fairly confident they are close.
The difference... of the 43% above stated failure, 95% of those were probably inexperienced medics who were not calm and rushed thru it trying to beat a time curve. I watch adrenaline high medics rush thru things, forget landmarks, etc... not cool.
Ever watch an anethesiologist miss? Its like another day in the park... "Ohh hum... guess I better try again. They recognize it quick, and fix it quick. And heck... when the first attempt fails, you have fiberoptic assisted direct larygoscopy... with those tools.... the chances of a failure can be dimished greatly. Yeah, they have $$$$ tools, but we do too.

Side effects.... the current outcome outwieghs the side effects of intubation. Infection, irritation and weaning is an easier chore. Just remember.... deep breath.... gooseflava... and relax with good thoughts of girls on trampolines. ( or guys..... ). Can't be a total sexist. ;)
 

Linuss

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I can pretty much guarantee we'll be hitting 95%+ success rates once video laryngeoscopy becomes standard. No reason it shouldn't be, people just don't want to spend the $$$... which can be somewhat understandable in rural areas where they get 1 tube a month but not in cities.
 

abckidsmom

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I can pretty much guarantee we'll be hitting 95%+ success rates once video laryngeoscopy becomes standard. No reason it shouldn't be, people just don't want to spend the $$$... which can be somewhat understandable in rural areas where they get 1 tube a month but not in cities.
But capnography hasn't even become standard...how can we look for a new toy that may help if the standard for now isn't even being met?
 

Linuss

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Leaving the DoT and getting with a agency that actually makes sense to run EMS, and then get on them about enacting laws.
 

Fox800

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But capnography hasn't even become standard...how can we look for a new toy that may help if the standard for now isn't even being met?
Waveform capnography needs to be required for any agencies with tracheal intubation equipment. If it comes to a state DOH regulation that requires it, so be it. Having ETCO2 equipment available and not using it to verify tube placement should be grouds for loss of certification/licensure.
 

terrible one

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Seems we are getting a little sidetracked here,
back on topic - pt needs a tube. Lower airway burns, c/o SOB, with a bark like cough = RSI ETT. Cases can be made for and against the helicopter, with the ETA of the truama center almost identical to HEMS ETA it is a difficult choice. I'm curious as to find out from the OP the decisions made (if it was a real call) and outcomes.
 

FLEMTP

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ok... im glad to see that a majority of you are on the same page with intubation.


This scenario is based on a patient i had in the not to distant past. I changed some minor details but the basic concept and presentation was the same.

I too opted for a drug assisted airway, and intubated the patient.

After initial contact, the patient was medicated with fentanyl for pain, prior to complaint of shortness of breath, which initially only brought the pain level to a 7/10. The patient was checked for signs of allergic reaction to the fentanyl and ruled out as a cause, just FYI

During laryngoscopy some mild redness was noted to the area above the glottic opening. the cords did not appear swollen or burned. There was some slight swelling of the airway.

Intubation was performed on the first attempt with minor difficulty. The patient was adequately preoxygenated with a NRB mask for 5 minutes prior to induction, and was ventilated via BVM post induction for approx 2 minutes.

The intubation attempt took approx 15 seconds, and the tube was visualized passing the cords, and placement was confirmed via waveform capnography.

The patient was transported emergently to the trauma center 15 minutes away.

The ER later complained that intubation was inappropriate as they felt the airway did not have sufficient edema or swelling.

I was called on the carpet to explain my "actions" and I wanted to make sure I was not alone in my choice to be aggressive with this particular patient.
 
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