Was intubation indicated or appropriate?

[firetender]

"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?"

Honestly? If I was still alive by the time you got to the end of your pitch, I'd know I'd last long enough to get to the hospital without you messing with me. And Jesus! Quit talking and get me there.

And Vene, Really, a simple steam burn?

 

[Veneficus]

Honestly? If I was still alive by the time you got to the end of your pitch, I'd know I'd last long enough to get to the hospital without you messing with me. And Jesus! Quit talking and get me there.

And Vene, Really, a simple steam burn?

"5-10 minutes into transport he begins to complain of shortness of breath, and you notice he is coughing quite a bit. You note his Sp02 is now 95% on room air, and when he coughs he has a slight barking quality to it. His respirations are now 28, and he does appear to have some mild difficulty breathing. He is becoming anxious, but has no history of anxiety, and states he is scared because he cannot breathe."

Barking, usually describes the upper airway obstruction of croup. So it sounds as if there is some sort of inflammatory process going on in the upper airway.

There is no way for either of us to know just how much of an inflammatory response there will be.

What happens if I intubate and I am wrong? The tube gets yanked in the ED and the drugs wear off.

What happens if I don't intubate and I am wrong? I lose the airway or such a sizable portion of it that it is no longer patent. Now I have to cut with a knife.

Despite the fact I like cutting, and I am always happy to get a chance, my favoritism is not always best for the patient. Sometimes decisive surgical intervention is the proper/only treatment, but if it can be reasonably avoided, why shouldn't it be? If a properly timed intervention could potentially stop the use of a knife, why shouldn't it be used?

It all boils down to potential and risk stratification. Your assumption is that the patient will not deteriorate. My assumption is it could stay the same or get worse.

I am not really a fan of Spo2, I find its usefulness rather small, so the number doesn't really concern me. But a patient getting anxious because he feels like he can't breath and a barking caugh.

I am sure we have both on many occasions seen patients who appear stable with a sense of impending doom just prior to things taking a turn for the worse.

I cannot explain how they have this forsight, or wavelength, but experience has taught me to take it very seriously.

Might the RSI be an over reaction, sure, but with the info presented here, I would do it.

As an alternative, perhaps some albuterol or some recemic epi. But I think if EMS is trying to reduce inflammaton on a burn victim, the question becomes "why didn't you intubate?"

Having the pt tubed and mechanically ventilated can also protect the airway and take away pain/anxiety until some longer term anti inflammatory treatment can be performed.

 

[Charmeck]

Worse case, You can always call the bird. I dont know of any flight services that dont have advanced airway abilities and a vent. This is of course, if you dont have the ability to procure any advanced airways.

 

[Akulahawk]

Worse case, You can always call the bird. I dont know of any flight services that dont have advanced airway abilities and a vent. This is of course, if you dont have the ability to procure any advanced airways.

Charmek: I wouldn't call the bird. Why? The closest ED is about 7 minutes away, the L2 Trauma Center is 15 minutes away and the Helo is 10 min away. The Helo crew is NOT going to be able to just hop out and drop a tube. You go to the pad to wait for them, when they land, they still have to gather their equipment and exit the ship, walk over to your ambulance and begin doing their assessments. Then you still have the transport decision: air or ground and you're no closer to the ED than when you first started, and probably "further" as you'd still have to load the patient into the helo if air transport was chosen, even though flight time would be short: maybe 2-3 minutes.

While it's a great asset, in urban areas, a helicopter usually does not make sense.

At least the ED (any of them) would be able to have some kind of pre-arrival warning of a patient that may be in dire need of a surgical airway and be ready for your arrival.

 

[Veneficus]

Worse case, You can always call the bird. I dont know of any flight services that dont have advanced airway abilities and a vent. This is of course, if you dont have the ability to procure any advanced airways.

??? I am lost.

The OP was presenting a case in which he was faced with the decision to RSI a patient or not. The OP also has a circ away available.

What is the point of calling a helo or how did a discussion on this develop from the post?

 

[Akulahawk]

Vene: in the original post, there was mention of a helo being available in 10 minutes and an LZ 5 minutes away (you go there, you wait 5 more minutes for the helo...) Nice asset, but the nearest basic ED is about 7 minutes away. Real difficult failed airway decision... ED or Helo...