Was intubation indicated or appropriate?

[Smash]

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.

While I agree that 12% of ETI being unrecognized as oesophageal is pretty uninspiring (and totally unacceptable) I have to take issue with 31% of all prehospital intubations being considered as "failed". More properly, what this study shows, is that in a limited timeframe, in one particular geographical area serviced by different prehospital care providers, a post-hoc study showed that in 31% of patients presenting to a single hospital, passing of an ETI was unsuccessful when attempted by paramedics in severly injured patients.

This really doesn't come as a shock, given that these paramedics only average 1-3 intubations per year anyway! If I didn't average 1-3 intubations per week it would probably be because I was driving a desk somewhere.
What's more, as the authors concede, these patients are pretty mashed up anyway with a mean ISS of 40.

Most importantly though we also see in this study some of the same factors that were in Wang's oh so brilliant study a few years back, although at least these authors admit to them.

To wit: Patients with traumatic injuries in whom an airway can be placed, without the use of appropriate pharmacology (sedation and paralysis) are not going to do well anyway. They must have absent airway reflexes for ETI to be achieved (or even attempted in most cases). So what we see is that patients that are so severely injured as to have absent airway reflexes and thus are able to be intubated without drugs, do very badly. Does this really surprise anyone?

The authors acknowledge this to some extent with their comments on the differences between road and flight based medics success at intubation. However I disagree that succinylcholine is solely a safety thing to prevent an agitated patient being flown. Succinylcholine, along with appropriate sedation, is an absolutely vital part of managing the airway of brain injured patients. It not only allows the best possible intubating environment, it also directly mitigates many of the deleterious effects of both the inital insult to the brain, and the subsequent assault on ICP that would otherwise be mounted during intubation.

There certainly seems to be issues surrounding prehospital intubation in North America. My own personal feeling is that this is due more to the woeful levels of education and exposure (1-3 tubes a year!) rather than any inherent problem with the procedure itself. To be fair, there may be a problem with the procedure itself, but so far all we know from the research is that a procedure done poorly is bad for patients.

Interestingly enough, in Australia, where they do not seem to have the same problems with intubating that North America has, and where actual randomized, intention to treat studies have been carried out, there are favourable outcomes reported with prehospital intubation and RSI.

 

[Smash]

Sorry, posted while I was ranting.

Sorry FLEMTP, your post appeared obviously while I was typing my rant.

It's very nice that the patient didn't deteriorate between you intubating him and arrival at hospital. I always envy ER staff with their perfect 20/20 hindsight of scenes they were not at and situations they have no experience of...

I would rather be criticized by an ER person for treating a patient, than by the coroner or the courts when the patient died due to me not intubating him.

 

[ccfems540]

I too have transported to Lee Memorial Hospital and caught flack for intubating and not intubating. I was scolded by a trauma surgeon for not intubating a patient with a GCS 14 that was confused. This patient had minor lacerations to the face. I have very mixed reviews about that facility.

 

[JeffDHMC]

Once his voice changed indicating airway burns....nasal tube. Not the most fun method of airway mgmt, but he needs it. Sitting on this guy for more than a minute once you determine the need is likely going to result in a surgical airway.

Jeff

 

[DrParasite]

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.

hmmm 1 in 3 chance that he might have a failed airway, vs a 98% chance of dying when his airway swells shut and you are digging for an emergency surgical airway..... which would you prefer?

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

hindsight is always 20/20. They are forgetting the whatif factor; whatif the swelling increased, then what do you do in the field? this isn't an ER, with lots of docs, lots of nurses, resp, anesthesia, light and space, all who can be waiting for you when for when you walk in the door.

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.

ehhh, getting called on the carpet isn't too bad, assuming you can defend your actions. Based on what you said, I would say your actions were in the best interests of the patient. and if someone disagrees, just ask: if the swelling got worse, and we couldn't intubate, then what?

 

[usalsfyre]

FLEMTP, who is calling you on the carpet? Is it the ED, or your medical direction. We have a local facility that does not like EMS doing pre-hosiptal pain control and/or sedation. For anything, at all. You could have a femur sticking out of your thigh and the physicians and nurses will give you a hard time for an appropriate opiate dose and complain to the medical director. Our medical direction tells them politely to $crew off and the cyle is repeated. Unless my medical director or clinical education team is hassling me, I pretty much ignore it.

 

[usalsfyre]

hmmm 1 in 3 chance that he might have a failed airway, vs a 98% chance of dying when his airway swells shut and you are digging for an emergency surgical airway..... which would you prefer?

While I agree intubation was approprite here, I'm not sure I agree with this statment. This is not a case where the cric kit can stay in the bag, a choice of last resort. Even though I know the sucker is 100 bucks plus, you better believe before I attempt to maniplulate this airway the ability to do a surgical airway will be out, ready and the skin over the neck preped. I've been lucky and haven't had to do a cric. I've been present for two, both in the ED, and both were faster than a conventional orotracheal ETI attempt. Hopefully some people who have done surgical airways for real can confirm or deny.

An additional consideration is if I don't have paralytics or surgical airways. I'm not 100% on initially paralyzing this guy, but my Rocc would be ready to push in case I encountered or caused layrengospasm (one of the few cases where I would prefer succs, as the onset is slightly faster). As mentioned before, I'd be ready to do a surgical airway as well. If I can't do either one, I'm hauling *** to the closest facility that will accept me, espically if I think there is anesthetists in house, as most facilties would have during the day or if they have OB services. I would notify the facility very early with what I had, and let the place that has the meds, equipment and training to deal with a potentially unstable airway take care of it.

 

[FLEMTP]

FLEMTP, who is calling you on the carpet? Is it the ED, or your medical direction. We have a local facility that does not like EMS doing pre-hosiptal pain control and/or sedation. For anything, at all. You could have a femur sticking out of your thigh and the physicians and nurses will give you a hard time for an appropriate opiate dose and complain to the medical director. Our medical direction tells them politely to $crew off and the cyle is repeated. Unless my medical director or clinical education team is hassling me, I pretty much ignore it.

Neither.. its our agency administration. They promoted a friend of our chief from a road paramedic to captain in charge of QA/QI issues. He has been with our dept about a year or so, tops. He was hired with a sense of entitlement because he is friends with the Chief, and seemed to exude the attitude that he should have been hired directly into a command position and becaues he wasnt, he now has a chip on his shoulder. He has character issues, and its nothing but rude and condescending to people when he "discusses" a call with him... its more or less him saying "this is not how *I* would have handled the call, so you're going to change your behavior.

If you challenge him, his ideas, or his "authority" at all, then he takes measures to have you clinically restricted in your practice as a paramedic. He has also taken to referring to our guidelines (which are just that.. guidelines) to protocols, and he can't seem to get through his head that we have always been encouraged to think outside the box, and to do what is appropriate for the patient vs what the book says.

He was told by the last agency he worked at that it was time he retire before they assisted him with his moving into retirement.

He needs to go. He's been in EMS 30+ years and that's always his rationale for why he is right.

If something isnt done soon, our agency is going to lose some good people.. myself included.

 

[usalsfyre]

FLEMTP, without knowing how involved your physician medical director is, or how well you know him, is there anyway to get him involved in this case? Overzealous, disciplinary QA/QI is a fast road to no good, including poor retention of medics and inaccurate (read, lying so you don't get hassled) doccumentation. I very seriously doubt he would support this. Of course this may also paint crosshairs on your back.

Remember folks, 30+ years in EMS could mean an experinced 30 year medic, or a medic with 1 year of experince, 30 times...

 

[FLEMTP]

FLEMTP, without knowing how involved your physician medical director is, or how well you know him, is there anyway to get him involved in this case? Overzealous, disciplinary QA/QI is a fast road to no good, including poor retention of medics and inaccurate (read, lying so you don't get hassled) doccumentation. I very seriously doubt he would support this. Of course this may also paint crosshairs on your back.

Remember folks, 30+ years in EMS could mean an experinced 30 year medic, or a medic with 1 year of experince, 30 times...

I have a meeting with our medical director on Monday, a one on one. Im going to voice my concerns with him then. Our MD is a very reasonable and very understanding guy...but he also expects you know your job and do it appropriately.

I will be bringing this up. The higher ups look at more QA/QI as a good thing.. but the problem is, if its not the way THEY would have ran they call.. the pull you in for a meeting. Not everyone practices medicine in the same way.. and micromanaging a paramedic on a medical treatment level isn't going to go over well... and its just not going to work. No 2 medics run the same call the same way.

I really like your statement at the end of your post. Im going to thieve that for future use!B)

 

[rhan101277]

I have a meeting with our medical director on Monday, a one on one. Im going to voice my concerns with him then. Our MD is a very reasonable and very understanding guy...but he also expects you know your job and do it appropriately.

I will be bringing this up. The higher ups look at more QA/QI as a good thing.. but the problem is, if its not the way THEY would have ran they call.. the pull you in for a meeting. Not everyone practices medicine in the same way.. and micromanaging a paramedic on a medical treatment level isn't going to go over well... and its just not going to work. No 2 medics run the same call the same way.

I really like your statement at the end of your post. Im going to thieve that for future use!B)

My company can have meetings with me all day long. It is like you said every paramedic will treat every call differently. That does not mean you made bad decisions on your call. If the patient was treated appropriately that should be all that is needed to be known. I know some medics that don't take vitals until patient is in truck. I like to get mine when I lay eyes on the patient. It only takes a couple minutes.

Trauma patients are different ABC's. Do they have a radial pulse etc.

 

[firetender]

Sorry; GROSS overtreatment!

21 yo male with facial burns

He states his face burns.

(paraphrase) an hour ago he returned to an overheated car that sat about half an hour

a burst of steam hit him in the face. his face is

red and slightly swollen, with some small blisters forming on his lips.

changed his mind because of the pain (and called ambulance)... about 15 minutes ago. (Response time not noted, lengthening time of non-emergent symptoms prior to presentation to medic)

He denies any medical history, medications or allergies.

there was only water in the radiator

His only complaint is pain to the face

no soot, redness or irritation to the muscosa in the throat

5-10 minutes into transport he begins to complain of shortness of breath, and you notice he is coughing quite a bit.

states he is scared because he cannot breathe.

Nearest hospital to your location is 7-10 minutes away. The nearest trauma center is a Level II trama center 15 minutes away. The nearest burn center is an hour away by air, and 2 hours away by ground.

I'm interested to see some responses & ideas.

#1. Mechanism of injury; blast of steam to the face from a radiator of a car that had ALREADY COOLED DOWN for 1/2 hour. No prolonged exposure, not a direct hit into mouth/trachea

#2. Alert, conscious, talking 1/2 hour AFTER the fact, Minimal visible signs of injury, only complaint of pain...AROUND THE EYES!

#3. Time elapsed w/o incident; at least 40 minutes from time of incident until medic feels need to take action

#4. chief complaint of patient? "states he is scared"

Where in the protocols does it say "intubate for fear"?

No kidding, I'm sorry...ALL OF YOU, this is absolutely ridiculous
and shows WHY everybody is watching and waiting for you to screw up and is ready to pounce when you do!


You DO NOT get a 45 minute DELAYED REACTION from burns (with negligible signs of trauma) that would come close to warranting SEDATION and INTUBATION in a case with such a limited impact.


The patient had NOTHING to warrant intervention other than taking the time to provide reassurance and support during a time when he was alarmed.

What you did was not really intervention; it was placing the patient at risk. To be blunt, you made such poor judgment on this one, I'm amazed you didn't screw up the sedation/intubation. Your safety net was less than 10 minutes away, my friend for a patient that was in ZERO danger, as evidenced NOT ONLY by subsequent examination, but by the very case you presented.

FIRST WORK WITH YOUR PATIENT! You missed the most important thing and it really could have cost this patient his life.

Here's where you get to really learn. This suggests to me you need to take a real good look at what you know, what you don't and why you jump to extreme paramedic/Doctor when being a humble EMT would suffice.

Please, look at this all carefully. Good luck on your review, but I wouldn't advise resistance.

 

[medic417]

Fire this could be a chemical reaction as much if not more than a steam burn and thus could be slower in developing the edema in the airway or worse fluid filling the lungs as a reaction to the toxins.

Don't blindly say over treated. To many possibilities that could make this nothing but a panic attack or an actual death eminent call.

 

[Veneficus]

Firetender,

I have the highest respect for your opinions and input, but I respectfully disagree this time.

I think early intervention in the form of RSI was absolutely the best choice and I would have done the same.

From the initial discription I think due caution and an attempt to go without the advanced airway was properly made. Upon reassesment of the patient, and the potential for a catestrophic decompensation, which may have required a surgical airway, which may have been too little too late anyway, the decision to intervene was the only logical one.

In addition to the rather minor burn, it is importsnt to remember in the oral cavity, there are microbes that that potentiate an inflammatory and immune response which would cause additional swelling.

I would rather err on the side of intubating an not needing it in this case than not being able to intubate later or making it considerably more difficult.

Just my take on it.

 

[MrBrown]

We had a guy like this the other week who had a face full of second degree burns.

He had no signs of any difficulty in breathing, increased work of breathing, normal breath sounds, no soot in the mouth, throat or nose, no singed nasal hairs or really anything that wpuld be problematic other than he was in a lot of pain.

Neither us nor the hospital intubated him (we did call for an RSI capable Intensive Care Paramedic) but the ICP gave him a lot of ketamine and we went off into space on what was hopefully a nice journey.

 

[Akulahawk]

Just remember, this was a steam event, not a flame event. You won't see singed hair or soot because nothing was on fire.

 

[dmiracco]

RSI absolutely

 

[Smash]

Just remember, this was a steam event, not a flame event. You won't see singed hair or soot because nothing was on fire.

Water also holds and transmits thermal energy more effectively than gas/air, so one must assume that the potential for lower airway injury would be greater.

 

[firetender]

I think early intervention in the form of RSI was absolutely the best choice and I would have done the same.

I'm thinking I'm so damn old that I'm the only one who remembers that cars used to have fragile radiators that boiled over and it was COMMON for people to get 2nd degree burns exactly as the victim of the OP got!

Vene, it was a radiator-boiling over FLASH of steam, NOT prolonged causing MINOR irritation to the eye area which, clearly, took the HIT. In the absence of the pt. directly INHALING the steam blast, his eyes would have to have been bubbling mush before his airway would be affected.

One fatal flaw in the narrative, which now makes me wonder how legit the post is, when was the last time you got a conscious patient to okay you to intubate him?

Let me make it perfectly clear to all of you, Under NO circumstances will you intubate me while I'm conscious and can keep enough air moving to stay conscious. Got it?

How did the OP talk this guy into getting tubed? Answer me that, and then, I'll ask you another question.

 

[Veneficus]

One fatal flaw in the narrative, which now makes me wonder how legit the post is, when was the last time you got a conscious patient to okay you to intubate him?

Actually it has been a while, but I did have a frequent flyer asthma patient that when she would go into extremis she would actually ask to be intubated and tell us if it didn't happen she would crash. Which was actually true.

Aside from that, people get knocked own and intubated all the time in same day surgery.

Patients in extreme pain are intubated in order to be able to better control the pain. Most patient requests are denied, but it does happen.

How did the OP talk this guy into getting tubed? Answer me that, and then, I'll ask you another question.

I can't answer that for him, but I can offer how I would have approached it.

"Sir, there is the possibility that you suffered an injury and the effects of such that may compromise your airway which will leave you unable to breath. Should that happen it maybe difficult to insert a breathing tube if not impossible. If that happens we may need to cut a hole in your neck in order to make sure you can breath."

"I would ask your permission to give you some medication to knock you out and insert a breathing tube now. The procedure is not benign and there are several complications that may result. These include infection, damage to the airway/vocal cords, medication reactions, and can possibly result in a longer hospital stay or even death."

"In my opinion, inserting the breathing tube is the best option right now to both manage your airway and relieve your pain. However you are free to choose to permit me to do this, refuse to have this procedure, or tell me what you would like and if possible I will do my best. At anytime prior to the procedure you may change your mind. Howver, once we give you the medication you will be unable to convey your wishes."

"How would you like to procede?"