Does he need to be intubated?? - page 2

An 18 year old male is transported to the ED after being involved in a rollover motor vehicle crash. The paramedics report that he is unresponsive, respirations are rapid and shallow, and his skin is... Read More

  1. by   gregemt
    This patient needs a protected airway ASAP. I would RSI on scene, unless for some reason it seemed like a difficult airway (extremely anterior,etc.). I have never had much of an issue intubating a patient with a c-collar on, and according to new PHTLS guidelines a c-collar can be removed for intubation as long as c-spine immobilization is held manually.
    There are other factors to take into consideration, the ED two minutes away, is it a trauma center, if not how far is the nearest center? How much assistance do I have on scene (Fire rescue)?
    If for some reason I couldn't get the patient intubated, I would proceed to drop a King Lt, or OPA and BVM to the ED.
    Now if my service didn't have RSI, only sedation I wouldn't attempt to intubate and would bag the pt. to the ED. This patient could still have an intact gag reflex, might start to clench down during laryngoscopy. Of course it depends on how unresponsive the pt. is, what was the GCS?
    Last edit by gregemt on Sep 26, '07
  2. by   APNgonnabe
    Was the ambulance crew paramedics? Just asking because sometimes they aren't. With the term unresponsive...? GCS? Does the blood in the OP indicate that there was no gag? Was this evident on scene were their lighting isnt quite like the ER. Was there scene help. How were the other VS? Do we know what their SMO's are. Do they have RSI? What is they comfort with tubing a trauma pt w/o back up?
    My treatment...Scene safety, check for radial while Cspine w/ airway in same step (is it clear, does it need to be suctioned, if gag no OA indicated, consider NA, We dont carry RSI, rapid extrication possibly and most likely before airway if pt is as critical as indicated), check neuro, backboard/ccollar, cid, move to rig, recheck neuro/ABC. If rapid transport indicated-transport. If airway remains unchanged, NRB @ 15L, consider large bore IV, continuously monitor for radial pulses, neuro and airway changes, if only two min out treat w/ diesel, give quick inbound that paints a clear pic that ER needs to be ready. Something I think we forget is that prior to the hospital is totally different than once they come to us.
    ~PHRN
  3. by   GilaRRT
    RSI: Rapid sequence intubation. Some people no longer use the term induction outside of the anesthesia environment. When nuckleheads such as my self perform the procedure, we do so as non-anesthesia providers, so some people like to leave out the induction part to prevent mis-interpretation problems.

    RSI is a procedure that involves giving medications in rapid sequence followed by intubation. Typically, a sedative is given followed by a neuromuscular blocking medication. The types of meds vary highly. My guidelines call for Etomidate as the sedative and Anectine as the paralytic. We also give 1/10 a standard dose of Vecronium about 2 minutes prior to the anectine to blunt fasciculations. This results in sedation and muscle paralysis. This can produce optimal intubating conditions and decrease the chances of patient injury and aspiration. However, you are taking all of the patients protective reflexes away and producing allot of stimulation not to mention producing apnea. The consequences of RSI gone wrong can be quite devistating. Following the procedure placement is verified and the tube is secured. In addition, ongoing pain control, sedation, and paralysis is often required.

    If you mess up, This is one of the few times that you have a chance at getting a "clean kill."
  4. by   ready4crna?
    Quote from GilaRN
    RSI: Rapid sequence intubation. Some people no longer use the term induction outside of the anesthesia environment. When nuckleheads such as my self perform the procedure, we do so as non-anesthesia providers, so some people like to leave out the induction part to prevent mis-interpretation problems.

    RSI is a procedure that involves giving medications in rapid sequence followed by intubation. Typically, a sedative is given followed by a neuromuscular blocking medication. The types of meds vary highly. My guidelines call for Etomidate as the sedative and Anectine as the paralytic. We also give 1/10 a standard dose of Vecronium about 2 minutes prior to the anectine to blunt fasciculations. This results in sedation and muscle paralysis. This can produce optimal intubating conditions and decrease the chances of patient injury and aspiration. However, you are taking all of the patients protective reflexes away and producing allot of stimulation not to mention producing apnea. The consequences of RSI gone wrong can be quite devistating. Following the procedure placement is verified and the tube is secured. In addition, ongoing pain control, sedation, and paralysis is often required.

    If you mess up, This is one of the few times that you have a chance at getting a "clean kill."
    OMG sooo funny!
  5. by   shenanigans327
    Quote from APNgonnabe
    Was the ambulance crew paramedics? Just asking because sometimes they aren't. With the term unresponsive...? GCS? Does the blood in the OP indicate that there was no gag? Was this evident on scene were their lighting isnt quite like the ER. Was there scene help. How were the other VS? Do we know what their SMO's are. Do they have RSI? What is they comfort with tubing a trauma pt w/o back up?
    My treatment...Scene safety, check for radial while Cspine w/ airway in same step (is it clear, does it need to be suctioned, if gag no OA indicated, consider NA, We dont carry RSI, rapid extrication possibly and most likely before airway if pt is as critical as indicated), check neuro, backboard/ccollar, cid, move to rig, recheck neuro/ABC. If rapid transport indicated-transport. If airway remains unchanged, NRB @ 15L, consider large bore IV, continuously monitor for radial pulses, neuro and airway changes, if only two min out treat w/ diesel, give quick inbound that paints a clear pic that ER needs to be ready. Something I think we forget is that prior to the hospital is totally different than once they come to us.
    ~PHRN

    My 2 cents would find the use of a nasal airway adjunct contraindicated in this case because of blood in the mouth and nose, I'd think that coupled with a decreased LOC would be cause to believe a head injury where the NPA might enter into where it's not supposed to be :wink2: I agree with one of the previous posters, watch the sats, suction as necessary, and bagging, I believe the pt. needs a trauma bay more than a tube with only a 2 minute ETA to the hospital.

    My rationale for this is a failed intubation, what's the next step? Are these providers that can do a surgical cric if necessary? Would that warrant a cric if the trauma center is only 2 minutes away? I agree that if the closest trauma center is 15-20 minutes away, definitely protect the airway, but with aggressive suctioning and bagging, I don't see why one wouldn't be able to keep the sats up and lessen the time to more advanced care...
    Sidenote, I really like these discussions about what should be done...they're really helpful to people like me who are new to the ED. Let's keep it going...
    Last edit by shenanigans327 on Sep 27, '07
  6. by   emtnursingstudentguy
    I'm looking at this from both perspectives, the medics bringing the kid in, and the ED staff that will be working him up.

    The top priorities for this patient (whether you're in or out of the hospital) are: IVs and fluid for shock, O2 and potential assistance with a bvm and consider an expedient intubation, RSI would be ideal. DON'T sedate/paralyze this guy before you get a good neuro exam. "Unresponsive" is too vague. Get a good GCS and try to determine if he has any extremity motor/sensory deficits.

    From the medics' perspective, transport time <10 min my pt is probably not getting a tube for rapid/labored breathing. I will be wasting time if I tube this guy in the field, and I don't have the resources on hand to tube him in my truck. I'm going to try my best to hold off on an ET tube till I make the hospital and the pt has a ED doc, a handful or nurses, an RT, etc. as opposed to me and maybe my partner (if I'm lucky). I will call ahead and prepare them for the fact that this pt may need a definitive airway fast but I'm probably not going to have time and hands.

    From the ED perspective, after I assure his ABCs and get him on my monitors, get him off the backboard if I can, I'll start shooting some films and get my FAST to determine the extent of any internal injuries and draw my baseline labs and blood gases. I'll also want that neuro exam to determine any extremity/spinal injuries and figure out if this guy needs to go to surgery or not.

    Lemme know what you think of the approach.
  7. by   usalsfyre
    Generally I'm going to RSI this guy. Two minutes from a tertiary ED however, I'm not. An RSI generally takes at least 5-7 minutes, which if he's not hypoxic and I can maintain his airway via suctioning and positioning for two minutes is wasted time. In the ED not only are more resources available, other things can be happening than just airway control.
  8. by   usalsfyre
    Quote from shenanigans327
    I believe the pt. needs a trauma bay more than a tube with only a 2 minute ETA to the hospital.
    Not even a trauma bay. He needs a neurosurgeon and a trauma surgeon evaluation and possibly an OR. The tramua bay is just another delay, albeit a necessary one.

    Quote from shenanigans327
    My rationale for this is a failed intubation, what's the next step? Are these providers that can do a surgical cric if necessary?
    There's back up options besides a scalpel now, most of which work well.

    Quote from shenanigans327
    Would that warrant a cric if the trauma center is only 2 minutes away?
    I could be 15 seconds away from the ED and might have a patient that warants a cric, or even an RSI. You can't base an airway decision solely off of distance to the ED.

    Quote from shenanigans327
    I agree that if the closest trauma center is 15-20 minutes away, definitely protect the airway, but with aggressive suctioning and bagging, I don't see why one wouldn't be able to keep the sats up and lessen the time to more advanced care...
    Based off your later comment that you new, my guess if you've never encountered a true nightmare airway that can't be suctioned fast enough, or bagged with any degree of success. Sometimes you run into the patient that needs a tube two blocks from the ED to even get to the truck, or the patient that gets a surgical airway right off the bat. These are VERY rare cases, but they do exist.
  9. by   akulahawkRN
    Quote from KenCCRN
    I agree with Dixielee.....Paramedics are being cautioned to avoid going right for the ETT nowadays. I am a critical care transport nurse on an SCTU and am housed with the medics. We frequently discuss patient care from each of our perspectives.
    If the airway is manageable with a bag valve and you are 2 minutes away...why would you spend those 2 minutes trying to secure an airway that can be managed....once in the hospital setting and c-spine is cleared...then you can have the ER doc or anesthesia intubate for airway protection......just my 2 cents.
    Ken
    As usalsfyre indicates, in a true nightmare airway situation, that patient may need a secure airway just to get to the truck. If I can manage the airway adequately without resorting to advanced airway procedures, I'd be inclined to use them in such a short transport time. I'd advise the ED to be ready for this patient though... However, if the patient needs an advanced airway right now, the patient needs it right now. That doesn't matter if you're 10 seconds from the ED or 20 minutes.

    And the ED Doc or Anesthesia Doc (or whomever else) will intubate before c-spine is cleared if the patient needs that level of airway management right then. They'll just adapt to keep things inline during the attempts...
  10. by   Pixie.RN
    Just FYI, this thread is from 2007 ... some of the original contributors might not be around to respond.
  11. by   akulahawkRN
    Not that I'm all that worried... but we can still learn from the thread!
  12. by   TinyRNgrl
    Given the mechanism of injury and the pt's condition and symptoms, this is a trauma pt and nasal airways are CONTRADICTED! With any evidence of head, or nasal injuries NEVER attempt a NPA.
    And Lunah, I always was taught the less than 8, intubate.
  13. by   usalsfyre
    Quote from TinyRNgrl
    Given the mechanism of injury and the pt's condition and symptoms, this is a trauma pt and nasal airways are CONTRADICTED! With any evidence of head, or nasal injuries NEVER attempt a NPA.
    Chances of passing a NPA into the cranial cavity are probably way overstated. I would be more cautious in the case of maxilofacial injury, but the general category of "head injury"' isn't really a contraindication and shouldn't deter you from using an NPA if appropriate. Most importantly, you should use gentle technique and stop immediately if resistance is met. Not only does this keep you from putting anything through a basilar skull fracture, it minimizes trauma to the nasal passages as well.

    Quote from TinyRNgrl
    And Lunah, I always was taught the less than 8, intubate.
    The problem is this is a blunt tool that can push people into bad situation, as well as not capturing everyone that needs a tube. I've taken airways at a GCS at 13 in cases where they were headed down, and left patients unintubated at a GCS of 6 or 7 with a short transport and anticipated difficult intubation. One of the issues with prehospital airway has been reliance on canned rules such as above rather than doing a real airway assessment and basing decisions off that assesment.

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