Does he need to be intubated??

[InmyblooD]

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 cool to touch. The paramedics did not initiate treatment, other than spinal immobilization, since they were only 2 min. away from the hospital.

On assessment of the patient's airway, blood is noted in his mouth and oropharynx. Respirations are present.

What would you're interventions be??

[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.

[usalsfyre]

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.

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.

[mwboswell]

The ABCs are always, always first. If he is unconscious due to trauma he may not be able to protect his airway, so intubate would be the first intervention.

Well nowadays there is nothing that is "ALWAYS", even the ABC's!

If you're in a combat theater it's "C" always first...

Well, that comes after "X" (IE: get off the "X") then CBA.

[Roy Fokker, BSN, RN]

Well nowadays there is nothing that is "ALWAYS", even the ABC's!

If you're in a combat theater it's "C" always first...

Well, that comes after "X" (IE: get off the "X") then CBA.

It ain't just 'combat theater' anymore! Everyone from providers to laypersons... :)

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.

Agreed.

These are VERY rare cases, but they do exist.

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.

Don't mean to ask a retard question but - how many "questionable airway" cases do you folks opt to manage with ....say BiPAP?

I guess the reason I'm asking this question is because I'm just curious.

I hear the call on the radio, I "know" who is bringing the patient in and I usually end up calling RT based on who the medic is on duty - because some medics tube a pt. at the drop of a hat... while some will bring some in who needed to be tubed.

Now, please, before y'all kill me with attack posts - this is NOT an indictment.

Heaven knows that pre-hosp care is difficult.

And as an ER nurse, I totally understand that "patients presentation changes on a dime". Heck, you guys have less toys to play with than we do! This isn't a 'blame the other party' post.

cheers,

[TinyRNgrl]

"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."

I was always taught NEVER to attempt a NPA in pt's with obvious or suspected head injuries. I don't have radiology in the back of my truck to rule out a basilar skull fx. Why would you even risk it? I personally would not take the chance of passing a nasal airway, even with "gentle technique" in any pt I suspect of having a head injury. If that is your choice to pass one, that is your personal preference. I am just stating what I was taught in my area. It is contraindicated.

And as for the "less than 8, intubate"That was just the going statement in PHTLS. Never have I seen someone NOT intubate a pt with a compromised airway because the GCS was a 10. GEEZ, give us the benefit of the doubt. We aren't incompetent providers.

[Lunah, MSN, RN]

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.

Just a guideline, not a rule ... no cookbooks allowed!

[ERjunkie81]

YES!

IF he is truly unresponsive with shallow respirations.

[usalsfyre]

Been meaning to answer a couple of things here....

IDon't mean to ask a retard question but - how many "questionable airway" cases do you folks opt to manage with ....say BiPAP?

I guess the reason I'm asking this question is because I'm just curious.

I hear the call on the radio, I "know" who is bringing the patient in and I usually end up calling RT based on who the medic is on duty - because some medics tube a pt. at the drop of a hat... while some will bring some in who needed to be tubed.

Now, please, before y'all kill me with attack posts - this is NOT an indictment.

Heaven knows that pre-hosp care is difficult.

And as an ER nurse, I totally understand that "patients presentation changes on a dime". Heck, you guys have less toys to play with than we do! This isn't a 'blame the other party' post.

As you note, it's highly dependent on the medic sometimes. Most of my respiratory failure patients get at least a trial of CPAP before moving onto intubation unless their LOC or respiratory effort is so far gone I have to take control of the airway immediately. If I'm tubing for airway protection and not respiratory failure then CPAP would obviously be inapproprite.

[usalsfyre]

"I was always taught NEVER to attempt a NPA in pt's with obvious or suspected head injuries.

Never's a dangerous word in medicine.

I don't have radiology in the back of my truck to rule out a basilar skull fx. Why would you even risk it?

You don't need radiography. You need a good understanding of trauma kinematics and what injury paterns typically produce basilar skull fractures. Like I said, with good assesment the risk is entirely managable.

I personally would not take the chance of passing a nasal airway, even with "gentle technique" in any pt I suspect of having a head injury. If that is your choice to pass one, that is your personal preference. I am just stating what I was taught in my area. It is contraindicated.

So what do you do with the patient who has a closed head injury, is a poor candidate for prehospital intubation, is slightly obtunded but still has a gag reflex? Tie youself up at the head holding the patinet's airway open to the neglect of anything else? Or "risk" passing an NPA?

And as for the "less than 8, intubate"That was just the going statement in PHTLS. Never have I seen someone NOT intubate a pt with a compromised airway because the GCS was a 10. GEEZ, give us the benefit of the doubt. We aren't incompetent providers.

I have. I've also seen patients who's GCS was 7, were poor candidates for RSI but could have been managed with basic techniques become airway nightmares because someone followed the cookbook. There's a whole lot of incompetent providers out there. EMS, for all its bluster often does a poor job of teaching airway management and assesment. We're taught an ETT is the gold standard instead of whatever makes the chest go up and down and keeps blood, boogers and puke out of the lungs.

[usalsfyre]

Just a guideline, not a rule ... no cookbooks allowed!

Exactly! But then you probably think like me because you sat in the same classes as I did ...

We need to move beyond cookbook terms like "always" and "never" and into "at times" and "perhaps".

[mmutk, BSN, RN, EMT-I]

I wonder if TNCC and ENPC will come out with updates or new editions that embrace the new AHA guidelines of CAB instead of ABC?

Does trauma get a different set of guidelines or will the new CABs be incorporated?

[usalsfyre]

I wonder if TNCC and ENPC will come out with updates or new editions that embrace the new AHA guidelines of CAB instead of ABC?

Does trauma get a different set of guidelines or will the new CABs be incorporated?

Remember, CAB only applies is cases of cardiac arrest (and really more medically oriented arrest) and massive uncontrolled hemorrhage. Everyone else still gets their airway taken care of first.