Does he need to be intubated??

  1. 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??
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  2. 38 Comments

  3. by   EricJRN
    Let us know your thoughts, then we can help you from there. What are your initial priorities in managing any traumatic emergency?
  4. by   InmyblooD
    Pt. with a compromised airway. Suction first with a Yankaur, jaw thrust to maintain airway, then consider advanced airway such as an OPA or NPA to maintain C-spine immobilization.
    Since he's unresponsive and respirations are shallow and rapid but present, would this indicate intubation? I'm thinking he's having spontaneous respirations so no need to intubate yet as long as airway is patent.

    Also, how do you insert endotracheal tube with someone who is in C-collar if indicated?
  5. by   traumaRUs
    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.
  6. by   ready4crna?
    Given his hx, and being in a hospital - I would do either a rapid sequence with DL or an awake fiberoptic intubation depending on his hemodynamics. If I was in the field and had no toys with me, and he took an OA, I would use a combitube as a temporary measure until I could get tools to place a definitive airway. C-spine precautions could be maintained with manual stabilization until an airway is secured.
  7. by   Pixie.RN
    A good rule of thumb is something that medics are taught, in reference to a patient's GCS: "Less than 8 = intubate." It sounds rather cookbook when you say it like that, but it's usually pretty accurate! A patient with a GCS that's less than 8 is probably not protecting his/her airway.
  8. by   RN1989
    He needs intubation as he is unable to protect his airway. However, it may be better to tube him ASAP on arrival to ED since it may be a difficult intubation. As long as he was getting O2 enroute - better to not try to tube him and risk problems with c-spine, long intubation due to c-collar on, bumpy ride to ED etc. When I first took ACLS many moons ago - back when one little thing failed you - we had to practice tubing successfully in less than 30 seconds. If we couldn't then we failed. Since that is not how ACLS is done today, the medics may not have gotten all the practice to intubate in such a short period. And since this one sounds like it may take a little longer to avoid other injuries - best to do it in controlled environment unless the patient was not moving any air at all. A BVM can get the extra O2 needed when done right.
  9. by   GilaRRT
    Primary interventions would include:

    Suction and position with a jaw thrust.
    Drop an airway adjunct.
    Begin 2 person BVM technique with cricoid pressure.

    Next:

    Somebody can work on a primary assessment and vitals.
    Establish IV lifelines
    Prepare for RSI and have backup options ready
    Try to obtain more info on the patient
  10. by   Dixielee
    We see this scenario every day in our ER. Generally, he would be intubated in the field under these circumstances as well as at least one large bore IV with fluids. Being only 2 minutes away, they may have elected to scoop and run. If they assumed a difficulty airway, they may have decided the chances were better to bag the patient, keep the airway clear with suction and get them to the trauma bay sooner.

    That is why good communication with the ER is important so they know to have the airway cart open, RT at bedside and all available personel ready when they roll in.

    Depending on your hospital level of care and your EMS experience, there are variables. Yes, with a GCS of maybe 5, this guy needed emergent intubation, but it doesn't matter where it is done, in the field or in the ER, it needed to happen soon!
  11. by   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
  12. by   InmyblooD
    "Prepare for RSI and have backup options ready"

    What is RSI??
  13. by   LeesieBug
    Rapid Sequence Intubation ( or Rapid Sequence Induction)
    Last edit by LeesieBug on Sep 26, '07
  14. by   InmyblooD
    If the patient is intubated out in the field with with the c-collar on.......is it basically just jaw thrust and visualization with the laryngoscope?
    And is visualization any more difficult with the c-collar on?

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